"Food"

In case you missed it -- and I must say it's gotten remarkably little attention -- David Barboza and Alexei Barrionuevo report in the NYT that Chinese manufacturers routinely add melamine to protein products for export to the U.S. In case this is at all confusing to people, the reason is essentially to commit a fraud. Buyers assess the quality and price of these products by measuring their nitrogen content, which they assume corresponds to their protein content. Nitrogen is an important constituent of protein, but not of the other major constituents of living things -- carbohydrates and lipids. Melamine contains a lot of nitrogen, so it fools the tests.

Now, the people who do this are dishonest but they aren't murderers at heart -- they appear to honestly believe that melamine per se isn't harmful, although the adulterated product is of low nutritional value. What we still don't know is whether substantial amounts of this stuff have been used to make products intended for human consumption. So far, we're only aware of melamine entering the human food supply through feeding of "salvaged" melamine-contaminated pet food to livestock. But there is certainly no reason to think that Chinese manufacturers have limited this practice to the pet food market.

Is it harmful to humans to chronically consume small amounts of melamine? Well, we can't actually answer that question. But the real issue is that the U.S. does very little to inspect imported foodstuffs at all. This may be only a very small part of a much bigger story. When you go to the grocery store, you buy what purports to be food, but you don't really know.

Weekend in the country

I'm going to be out amongst the cornfields and the cows for a couple of days, so if you're lucky (Hah!) I'll get something up here Saturday afternoon, but maybe not till Sunday. Meanwhile, I'm very pleased to announce that Missy will be posting on the Dialogue blog, offering a take on the Bible and matters philosophical from a religious point of view. It was our hope in establishing the blog to have such dialogue, of course, and I know we'll have a very worthy interlocutor. (No pressure Missy, but I will hold off on my next post until she has a chance to get started.)

For today's Stayin' Alive, I will just say that the Democratic presidential debate last night signaled that substantial health care reform will be on the campaign agenda. However, the front runners are still rather vague. Sen. Clinton, of course, is once bitten and twice shy, and she largely discussed health care in terms of her regrets about the failure of her effort in the her husband's first administration. Good luck finding anything about health care on her campaign web site. Obama, as usual, is rather more full of stirring rhetoric than precise policy proposals. (I'm sorry Senator, but this is largely bullshit. His most specific promise is that he "wants to hear" from us.) John Edwards proposes an incremental reform similar to the Massachusetts state plan, which includes an employer mandate, expansion of publicly financed insurance for low income people, creating large community-rated pools, and ultimately an individual mandate. It is far from clear that these steps can truly contain costs and make insurance affordable for middle income people, but the incremental steps could help and will provide a basis for more fundamental reform should it become politically possible.

Bill Richardson wants to establish some (unspecified) employer mandates, and more important, let people buy into the federal employee's plan, let people 55-65 buy into Medicare, and he wants to offer some subsidies, characterized as an "advanced, refundable tax credit." I actually think this is one of the most meaningful proposals -- it represents genuine progress toward a single payer system and does not require that private corporations skim profits from expanded coverage.

Joe Biden is watching reform efforts at the state level and waiting to see what he likes. Chicken shit. Christopher Dodd is proud of his record but what he plans to do as president is still a secret. We all know that Dennis Kucinich is for universal, comprehensive, single payer national health care but I'll be president before he is. And, uhh, there's some guy from Alaska.

So, as of now, I'm putting Richardson in first place and Edwards in second. Obama has barely gotten out of the blocks and the rest of them haven't even heard the starting gun yet. We're really going to have to make this into a powerful grassroots movement, I think, if we are to move from rhetoric to substantive progress.

Does your government work for you?

Well duhhh. One salient area in which we frequently discuss this question is, of course, pharmaceutical regulation, and as long-time readers know, the answer in this case is doubly no because the drug industry not only controls the Congress through its powerful PhaRMA lobby, and the FDA Commissioner's office through crony capitalism, (both of which are typical of regulatory practice in the current era), but the industry actually funds the drug approval process directly through "user fees," under the Prescription Drug User Fee Act (PDUFA) bequeathed to us by George Bush the First. He who pays the piper calls the tune, of course, and as Jerry Avorn writes in the new NEJM:

User fees now account for more than 40% of the budget of the FDA division that reviewsnew drug applications. ... Colleagues at the FDA have told me of a worrisome side effect of the PDUFA: the growing sense that the organization is accountable to the industry it regulates. One FDA scientist who was often criticized for being too concerned about drug-risk data was told by his supervisor to remember that the agency's client was the pharmaceutical industry. "That's odd," he replied. "I thought our clients were the people of the United States."

What a naif. Anyway, the PDUFA is up for its five-year reauthorization and, given all the controversy over the past years, there are proposals for some reforms. Continuing its ignominious retreat before the ever-growing power of Stayin' Alive, the New England Journal of Medicine is making more and more of its public affairs-related content available to the masses,* and this week they have done good, I tell yuh, they have done good. You can not only read Dr. Avorn's essay, you can also read an analysis by former Bushista FDA Commissioner Mark McLellan, who not surprisingly is far more sanguine about the current situation, and a third take by Sean Hennessy and Brian L. Strom, who I would classify as responsible insiders who work for the industry and FDA but who recognize the public interest. (And, in a gesture of utmost munificence, the exalted pooh bahs of NEJM will also allow you to read this tangentially related report on drug industry influence over your personal physician. It will be a miracle if it isn't substantial.)

I won't try to make up your mind for you, but . . . oh, what the hell. Proposals for reform don't go nearly far enough. The amount that would be allocated to post-marketing surveillance, post-marketing safety studies, and developing an adequate infrastructure for safety monitoring is a mere pittance compared to what is necessary. Far too little is being done to reduce conflicts of interest in the agency and to reform the standards for approval so that drugs which are no better than, or even inferior to current standard products, with inadequate evidence of safety, are not approved. Nothing is done to redirect resources in drug development toward the public interest rather than industry profit. And so on.

But read the experts, and decide for yourselves.

*NEJM continues to hide its medical research behind the subscription wall, however. Oddly, the British Medical Journal has done the precise opposite. Its research reports are open acccess, but its public affairs reporting continues to be subscription-only. So they're both half wrong.

Give me liberty and give me death?

I'm a great admirer of Glenn Greenwald, but he put up one post recently that I found quite odd -- not to mention outside of his usual bailiwick. He doesn't understand why there are drugs that are available only by prescription. Why shouldn't a competent adult be free to consume any pharmaceuticals she or he chooses, without having to get permission of a physician?

This is a rather surprising question that I can't recall ever seeing a serious person ask before. That doesn't mean it isn't a good one -- there are plenty of unexamined assumptions in our culture and law. But I think this is pretty easy to answer. I wrote to Greenwald, but he didn't care to answer. This is what I wrote, slightly edited for presentation here:

Dear Mr. Greenwald:

You write:

“Adults have the right to do all sorts of things that other people, including experts in a particular field, think are stupid and self-destructive, even when the person's livelihood or even life are at stake. That is, more or less, a defining attribute of being an adult.

What is the difference between the attorney-client and doctor-patient relationship, where the former is purely advisory but the latter becomes parental? And other than consumption of medicine which can actually affect the public health (such as excessive consumption of antibiotics), why should an adult be deemed a criminal for using a particular medicine all because a doctor (for whatever reasons, including self-interest) will not give permission?”

First, of course, as commenters have already suggested, you conflate some issues, in both law and public health, when you move between the issues of so-called controlled substances, and prescription drugs in general. Not all controlled substances are prescription drugs, and the overwhelming majority of prescription drugs are not controlled substances. With rare exceptions – which I will discuss at the end – most so-called abuse of controlled substances is not done with a motive of treating disease, but for recreational purposes, or to satisfy the compulsions of addiction.

Controlled substances, such as morphine, that also have approved medicinal uses, are therefore made available by prescription only because the Congress (and for the most part the state legislatures as well, although there are some conflicts here) has judged that it is in the public interest to prohibit their non-medicinal use. I happen to be opposed to the criminalization of illicit drug use, although there are some pretty strong arguments in favor of restricting distribution, and that is what the prescribing system does.

One problem that we have in continuing the discussion from this point is the double-meaning of the term “drug.” It means an illicit substance of abuse – we do not call alcohol or tobacco “drugs” in this sense, because they are not illicit, but they are nevertheless addictive and potentially harmful to their users – and it also means a pharmaceutical product intended to treat, cure or prevent disease.

So, let us now continue with the non-“drug” drugs, such as antibiotics, cold remedies, NSAID analgesic-anti-inflammatories, laxatives, anti-diarrheals, anti-depressants, blood pressure medications, cholesterol medications, cancer chemotherapy, etc. Many of these, as you know, are indeed available without a prescription. Your local CVS has literally hundreds of feet of shelf space filled with nothing else. (Some of these do happen to have potential recreational uses, but the government hasn’t gotten around to making them controlled substances. An example is the antitussive dextromethorphan. But that’s a digression.) For other remedies, you have to go to the pharmacy counter and present a prescription from a physician. You are asking, “Why is this?”

While I share with you a strong proclivity to favor the liberty interest, it seems not to have occurred to you that government restricts it in many areas other than drug prescribing for the sake of the welfare of the individual. For example, while adults can drive, if they demonstrate proficiency, they are not allowed to exceed the speed limit, blow through red lights, or operate motor vehicles which have not passed safety inspections. In most states they are required to wear seat belts. I am not allowed to build a house, or to rent out an apartment, that does not conform to the building code. I cannot purchase clothing that does not meet flammability standards, or children’s toys which have been found to be unsafe. And there are innumerable other examples. If you object to making certain drugs available only by prescription, you will have to think through hundreds of such analogous situations and see why they are the same or different.

Now, as for the prescription drug regime, the fundamental rationale has to do with the observation of Paracelsus: “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison…” Since his day we have learned even more, of course, and we now know that different people react differently to the same substance, and what is more important, that chemicals have multiple biological effects. Harmful effects may emerge immediately (acute poisoning) or become evident only after exposure over days, months or years. In the case of substances intended to treat disease – pharmaceuticals – beneficial effects must always be weighed against harmful effects.

These calculations are often very complex, and require inputs of knowledge which are quite diverse, along with sophisticated decision making models. Even a small mistake can kill you -- for example, taking certain anti-depressants and then eating fava beans or drinking coffee.

At the same time, as you well know, drug manufacturers are eager to sell you their products, and any viewing of prime time television will make that abundantly clear.

The fundamental reason why many drugs are available by prescription only is that you, Glenn Greenwald, are simply not competent to decide whether you ought to take them, when you ought to take them, how much of them you ought to take, whether you ought to take them in combination with certain other drugs, and so on and so forth – in other words, you are not in a position to make use of your liberty should it be granted to you. That would be equivalent to the liberty to run into the middle of the interstate highway, or sunbathe on the railroad tracks. It is not a liberty that most sensible people would want to have.

Your desire to take opioid analgesics against your doctor’s advice is a very special case. Many people try to wangle prescriptions for opioids in order to sell them on the street; others are addicts. Doctors are required to be vigilant about such people and can even be prosecuted for prescribing these drugs irresponsibly. That in fact troubles me. However, in the case of drugs which are not controlled substances, doctors are not criminally liable, although they may be liable for civil malpractice. But the reason you can’t get these drugs without a prescription is similar to the reason why you can’t fly an airplane without a license or build a house that is not approved by the building inspector.

Now, there is the very special case of controlled substances which doctors are not allowed to prescribe, but which some people think should be permitted, of which marijuana is the most commonly debated. Medical marijuana laws, as generally proposed, would require a physician's prescription to possess marijuana. So this is quite separate issue.

I hope these observations are helpful to you.

What do you think? Is this a question that should be seriously considered? Should all approved drugs be available without a prescription? That strikes me as a fairly nutty idea, but Greenwald is a smart guy who is right about most things. Is he as far off base on this as it seems to me?

Aww, shucks

Missy nominated us for another one of those blog awards, and of course I couldn't decline such as flattering gesture. Click on the icon just under Chimpy if you want to vote. (You have to register to vote in this one, but as far as I can tell they aren't trying to sell you anything.)

Thanks Missy, we are not worthy.

The dark horizon

Watching the hairhatted elocutionists blathering on the TV last night got me to thinking. One of the problems with the news is that most of it consists of, well, news. It has to be about distinct events that happened in the past 24 hours, and even more recently if possible, so that, for example, if some soldiers were killed in Iraq yesterday, but too late to make last night's broadcast, they won't mention it today.

The exceptions, of course, are events that based on some mystical alchemy they all decide need to be talked about incessantly for anywhere from 4 days to a week, even though there isn't actually any new information and their import is largely local and temporal. The Virginia Tech shooting is obviously in this category, as have been other events of even less importance such as the missing young white woman phenomenon.

But the biggest part of what we need to be thinking about, and worrying about, and doing something about, as a nation and as a society, does not turn on immediate events. Most of our important problems are chronic, not acute. So, hardly anybody is talking about what will be the ruin of this country, and I don't mean global climate change or World War III or the death of the constitutional order. I mean ruin as in broke, busted, going through the trash for deposit bottles.

In accounting terms, the United States is bankrupt. And it's not because of the $2 trillion liability for the war in Iraq, and it's not because of Social Security. Even though the Deceiver in Chief threatened us with Social Security bankruptcy in his attempt to eliminate the program, Social Security has only a modest deficit which could easily be fixed -- in fact, just eliminating the cap on earnings subject to the payroll tax would just about do the trick, and make the tax structure more progressive at the same time. Nope, the problemn is Medicare. You think $2 trillion is a lot of money? Try $27.8 trillion, which was the projected 75 year Medicare deficit two years ago. (I believe it is more now, but I didn't have time to find a more recent projection.) And Bush was yelling about Social Security with a $3.7 trillion projected shortfall.

Many people have held out hope that this won't actually be such a big problem because the retiring baby boomers are going to be healthier than their parents and so will consume less in Medicare spending. Sadly, very sadly, no. Or at least the proposition is in grave doubt. They -- we, well hopefully not me personally but us not-quite-yet-fogeys -- are less healthy than our parents, according to self-reports. Now, maybe we're just a bunch of whiners, and maybe we're just getting diagnosed more, and we aren't actually sicker, but either way, we're still going to consume more health care.

But, there's a good chance that in some important ways we are less healthy. Yes, we smoke less, but we are -- and you know what's coming -- fatter. Physical inactivity and obesity mean heart disease, diabetes, and osteoarthritis. That would save Medicare money if it would just go ahead and kill us, but what's actually going to happen is that we'll soldier on with drugs, surgery, and ultimately nursing care.

And, once our kids hit later life, they'll be doomed because they're going to be even fatter than we are. For that we can thank the TV and the "food" industry, which are conspiring to keep them zombified on the sofa and guzzling the sucrose.

So who is going to pay for all these bypass grafts and lower extremity amputations and bedpan changes? Where is that $27.8 trillion going to come from? It's not a fit topic for the nightly news, because it didn't happen yesterday. But somebody needs to talk about it.

Let me go off topic for a moment

I don't really feel like posting today, but you know, duty. So I'll just muse a bit about something I really don't know anything about -- hey, if the folks on teevee can make a million dollars a year doing it, at least the price is right here.

In all the discussion about whether consigliere Gonzales will resign, I don't see many who even hint at what seems to me to be the central issue here. If Gonzo goes, there will have to be a new AG, who will have to be confirmed by the Senate. True, Joe Lieberman would go along even if Chimpy nominated Karl Rove himself for the job, but at this point there are at least 2 or 3 Republican senators who would probably not vote to confirm a partisan hack whose only qualification was an evident unwillingness to investigate any elements of the criminal conspiracy currently running the country. Or, to spell it out for you, there is too much information within the DoJ, that would be available to a new AG, that they cannot allow anybody outside of the conspiracy to have.

So, I try to steer clear of predictions but I think Gonzales will stay if there is any way for them to make it possible. Judging by the announcement this morning, about how pleased Chimpy is with yesterday's testimony, that appears to be the plan.

Donning the ALCOA sombrero, however, I can imagine a Plan B: Yup, Joe Lieberman again. The Senate will always confirm a club member, no matter what; the CT Governor is a Republican, so the Senate will tip (which will also please Joe); and Holy Joe can be counted on to keep his lips firmly glued to the Chimpoleon posterior because he doesn't want anything to jeopardize his precious war against the A-rabs.

Anybody got a Plan C?

I'll bet you haven't heard about this

While the media freak show was going on, the FDA was conspiring with Sanofi-Aventis to kill you. Dr. David Ross tells the apalling, little-known story in the new NEJM, and bless their normally greedy little hearts, this of sufficient public importance that they've made it available free to the common rabble.

I wrote recently that we have a looming crisis of microbial drug resistance, and that the drug companies aren't investing enough in developing new antibiotics. But that didn't stop S-A from getting approval for a useless, dangerous new antibiotic, called Ketek. Initially, FDA reviewers had safety concerns about it, so they asked S-A to conduct a new clinical trial. The company then set up what amounted to a phony trial, one guaranteed to get favorable results, but that wasn't good enough: they conducted the trial fraudulently. One physician involved in the trial, as a matter of fact, is currently doing 57 months in federal prison for fabricating data.

The FDA learned this before presenting the trial results to its advisory committee, but presented them anyway, without mentioning the fraud. They claim they couldn't discuss it because of the ongoing criminal investigation -- but then why present the results at all? Knowing nothing about the fraud, the committee voted to approve the drug. FDA managers realized they might get in trouble in the long run for this, so as Ross writes, they "proposed using foreign postmarketing reports on Ketek as evidence of the product's safety, despite the unreliability of such data. . . The postmarketing data submitted by Sanofi-Aventis were reivewed by the FDA without any verification of their accuracy or completeness, even though 3 months before the third review, FDA criminal investigators recommended examining whether Sanofi-Aventis had been involved in systematic fraud . . . " The FDA did not investigate.

Not only was Ketek not safe, it was worse than existing alternatives. But the trial design did not require that it be found to be superior. The FDA had already decided that these "non-inferiority trials" no longer be used, but they justified approving Ketek on the basis of such a trial because of prior agreements with the industry. Isn't the welfare of patients more important than inappropriate agreements that may have been made in the past with manufacturers? Not to Bush's FDA.

Seven months after Ketek had what S-A bragged was the "most successful launch of any antibiotic in history," the FDA got a report of the death from liver failure of a patient treated for a mild respiratory tract infection. They did nothing. A year later, they learned that a report was about to be released of 3 deaths associated with Ketek, so they held an emergency meeting of senior managers, which resulted in an announcement that Ketek was safe -- based on the fraudulent study.

Dr. Ross, in February 2006, alerted the FDA to concerns about the Ketek case. The FDA did nothing. They finally got around to removing mention of the fraudulent study from their web site after a congressional hearing. In June, facing subpoenas and bad press (at least a little bit -- as I say, this was largely ignored by the corporate media), FDA Commissioner Andrew von Eschenbach finally took action. Specifically, he forbade FDA reviewers from discussing the matter publicly. By now, there were 23 cases of liver injury, 12 cases of liver failure, and 4 deaths associated with Ketek known to the agency, and by the end of last year, there were 53 known cases. Approval of Ketek for two indications -- indications for which it had never been shown to be effective in the first place -- was withdrawn in February of this year, the day before a congressional hearing.

In the same issue of NEJM, also free to the masses, is a report that has gotten some attention on your teevee, about the decline in breast cancer incidence following the news that hormone replacement therapy (HRT) was dangerous. Now, the approval of HRT wasn't based on outright fraud, but it was based on speculation rather than solid evidence. This report doesn't quite hammer in the final nail, but it's looking pretty solid that the increasing incidence of breast cancer starting in the 1980s -- the increase that had women marching, and blaming everything from pesticides to PCV piping -- was largely caused by drugs prescribed to women by their doctors.

In this case, I think, the manufacturers were more well-meaning, and the approval process was misguided rather than criminal. Nevertheless this should serve as a powerful reminder that we tinker with our bodies' fundamental processes at our peril, and we need to be much more careful, much more diligent, and much more conservative about pharmaceutical intervention. Yes, it does save lives, and relieve suffering, but it also makes big profits, and there is no doubt about it: our regulatory process is deeply corrupted.

Too easy for a hint

I don't know why I bother to point this out, but it seems a sort of duty. Sure enough, last night the network news broadcasts did it again: all 22 minutes, or whatever it is they have left over after commercials, dedicated to the VT massacre.

Okay, sure, it's a dramatic event and it hits close to home for a small percentage of Americans, at least. But was it the only important thing that's happened in the past two days, or even among the most important? Obviously not. It goes without saying that comparable events happen in Iraq two or three times every day, and then there's some placed called, what was that again? Darfur I think it was. Speaking of Iraq, today they had at least a half dozen pretty impressive massacres. And, the WHO reminds us that it's no fun to be a kid in Iraq right now, because in addition to the unpleasant probability of getting blown up or shot, you have a more than 20% chance of starving, and a 70% chance that you're drinking contaminated water, which means you have chronic diarrhea. Then there's that uncomfortable fact, God forbid the news readers should remind us of it, that the United States is currently being run by a criminal conspiracy.

But, of course, the problem with all that is that it's meaningful. There are important implications for us as citizens. We need to think about these problems, and what ought to be done about them, and how we got into such a fix.

In contrast, although it was very disappointing to the wingnuts, Cho Seung-Hui turns out not to be a Muslim, or an anarchist. He didn't kill people because of the theory of evolution, or because they didn't post the Ten Commandments in his classroom, or because his mother put him in day care, or because of violent rap lyrics or video games or the homosexual agenda. He did it because, to use the technical term, he was fucking nuts. He might have had a brain tumor, or a brain injury, or been psychotic, or who knows what. But there isn't any moral or political lesson here at all. This was essentially a natural disaster. It's appropriate for the police and experts to study the case and learn what they can, that might help prevent future incidents, but there is nothing to be gained by instant data-free pontificating.

In 2005 there were 16,692 homicides in the United States. That means that if April 16 was an average day, there were about 46 murders in the U.S. in addition to Cho's 32. And there were 46 the next day, and the next, and the day before, and there will be tomorrow as well. The vast majority of these, probably all of them, unlike the VT shootings, were not the random acts of lunatics, but rather were related to domestic violence, robbery, organized crime, street gang feuds, and other matters for which there are indeed potential public policy and socio-cultural responses that we ought to be discussing.

But can we expect an even minimally reflective, informative, or proportionate response to reality from our corporate TV news industry? Of course not. Instead we had to endure the sight of Brian Williams staring adoringly into the Dear Leader's eyes last night and slobbering all over him as the mystical healer of the nation. I may vomit.

Idiotic Yammering

As I mentioned a few weeks ago, I have for the first time in my life acquired cable TV -- motivated by the unavailability otherwise of the Boston Red Sox, hey we all have our little vices.

Anyway, having noted (below) the pervasive ignorance of people who get their info from TV news, I figured I'd check it out. Last night was revealing indeed. The three broadcast networks nightly news programs, and the all-news cable channels, talked about pretty much absolutely nothing else but the Virginia Tech massacre -- the nightly news for the full half hour, and the cable news channels all evening long. I mean nothing else. Not for 10 seconds.

Here's what they knew during the half hour evening news shows.

Somebody shot and killed two people in a dormitory at a little after 7:00 am. About two hours later, a man entered a classroom building and shot about 50 people, about 30 of whom were dead. He killed himself as police closed in. Some witnesses had identified him as appearing "Asian."

That's it. I just told you 100% of the information that occupied the entire news broadcast.

After the responsible authorities held a press conference at 7:30, we learned the following additional facts.

The police still weren't sure that the classroom shooter was the dorm shooter, but they were working to confirm that. The classroom shooter used two weapons, a 22 caliber pistol and a 9 mm pistol. The classroom shooter had chained at least one set of doors shut. The university president also read out a brief timeline of the authorities' response to developing events.

In addition to these actual facts, there was a rumor (false, as it turns out), that the shooter was a Chinese national. That's it. All of the information could have been read out, slowly and clearly, in about 40 seconds. There was nothing else. Yet this is all they talked about for hours, from Lou Dobbs to Wolf Blitzer to Joe Scarborough.

Also yesterday, although none of these programs mentioned it, as far as I noticed, the U.S. military announced the deaths of 7 soldiers and marines in Iraq; the Sadrist bloc withdrew from the government; and dozens of people were shot to death around the country, including two university professors, as it happens. Currently, there are about 30 U.S. military personnel killed in Iraq every week -- the highest rate since the last few days of March, 2003 when the invasion was first launched.

Also, an e-mail showed unambigously that Alberto Gonzales had lied to Congress when he said he had no involvement in deciding which U.S. Attorneys to fire. He was closely involved in discussions about firing Carol Lam, prosecutor of Duke Cunningham. A big storm in the northeast caused a lot of flooding and power outages. A new installment of the report from the Intergovernmental Panel on Climate Change had a lot of bad news for coastal areas of the U.S. The Urban League issued a discouraging report on the state of Black America. And so on.

But, if you get your information from TV news, you don't know any of that. You are an ignorant idiot, and you're too ignorant even to know it.

By the way: The yammering heads repeatedly assert that the events yesterday at VT were "the worst mass shooting in U.S. history." Not even close.

We are so abysmally ignorant

The Pew Research Center for the People and the Press did a little news quiz for a random sample of telephone owners. The questions are pretty basic, e.g., "Who is the Vice President?" so I don't know that it's even getting at whether people have enough knowledge of public affairs to be trusted with the franchise, but it's already disturbing.

It turns out 69% could name the Veep -- down from 74% in 1989, when the occupant of that office was of far less importance. (For those of you who have gotten unstuck in time, back then it was a guy who couldn't spell potato. Now, the guy who can't spell potato is occupying the office of president. That's a kind of progress.) And only 66% can name their own state's governor. Etc. They didn't even bother ask who your representative or senators are, but anyway, only 15% of the people could correctly identify Harry Reid, although Peyton Manning and Beyonce Knowles did much better at 64% and 62%. (Who the hell is Beyonce Knowles?)

Anyway, that's not the sort of thing that bothers me the most. Almost everybody has a rough idea of who Hillary Clinton is, but only 24% of the people know that Congress passed legislation to increase the minimum wage, and only 37% knew that John Roberts is a conservative.

Yeah, yeah, let's all view with alarm and decry the state of the culture and so forth. But it's pretty obvious that the information sources that people depend on aren't giving them the information that citizens need to make any sense out of politics. It would seem to follow that more than half of those people who can identify Dick Cheney don't know about the minimum wage bill, and a good half of them don't know that the Chief Justice is conservative. Not surprisingly, the least well-informed people get their "info" from Fox News, and the best informed get it from fake news -- The Daily Show. This is actually not news, it's been found before. However, the other TV news shows don't do much better than Fox.

The really bad news is that, while knowledge of public affairs is, not surprisingly, correlated with the amount of formal education people have, rising educational levels in the past quarter century have not translated into a more knowledgeable citizenry. We're staying in school longer, but we're coming out more ignorant. And the reason, of course, is that TV news is sucking our brains out.

Plugola

Old friend Gary Greenberg has an article in the May Harper's Magazine that I commend to your attention. Sorry, no Internet availability but do check it out at your local library. Gary's writing is somewhat eclectic but he is interested in many of the subjects we obsess about here, including the reification of mental illness and the social structural determinants of psychopharmacology. I won't say much about the piece now because I don't want to spoil it for you, including the boffo ending, but maybe in a couple of weeks, once people have had a chance to read it (and certainly if Harper's does make it available on the web) I'll have more to say.

Meanwhile I'll just say that Our Hero suffers from the ineluctable pain of the human condition (which I will diagnose for him with the Buddhist label, dukha), complicated by insight and reflectiveness. Alas, the insight-reflectiveness syndrome causes him to give too many wrong answers on the Hamilton Depression Inventory, rendering him a victim of Major Depression. The doctors who deliver the bad news are not acting on behalf of greedy pharmaceutical executives, rather they are testing a natural substance, unpatentable, already available at the GNC. Nevertheless they perforce live in the the drug companies' universe, in which a disease process consisting of what the late K. Vonnegut famously described as "bad chemicals" in the brain maps onto the answers people give to a particular game of 21 questions, and that this disease is cured by ingesting good chemicals.

In return for the endorsement, Gary has agreed to pick up all the rocks on my property and pile them neatly along the creek bank.

In an unrelated development, I've resumed posting on the dialogue blog after a substantial hiatus. Anyone interested in why the pause and why the resumption can check it out.

No rapture in this apocalypse

This story hasn't gotten major attention, as far as I can tell, but CDC has just reported that 13% of new gonorrhea infections are ciprofloxacin resistant, which means CDC is now advising doctors to stop using cipro and other fluoroquinolones for the clap in California and Hawaii, and for gay men everywhere. There is only one class of antibiotics left for gonorrhea, called cephalosporins. (Here are the updated treatment guidelines for M.D.s.)

I have mentioned here previously the problem of methicillin resistant staphylococcus aureus. Here's another recent report from CDC: n January 2007, CDC received reports of 10 cases of severe methicillin-resistant S. aureus (MRSA) CAP, including six deaths, among previously healthy children and adults in Louisiana and Georgia during December 2006--January 2007. Other growing problems include drug resistant (and especially nasty) Clostridium difficile, which causes indescribably severe bloody diarrhea, and extremely drug resistant tuberculosis, which so far is a problem mostly in immunocompromised people, and specifically people with HIV in poor countries, but that can easily change.

Very few people these days appreciate how different our world is from that of our great grandparents, or even our grandparents when they were children, because of the conquest of infectious disease. In the old days, no-one could take life for granted. Death lurked in the shadows every single day, and few people lived out their three-score years and ten. At the turn of the last century, urban dwellers in the U.S. could expect to live into their forties, which means that half of them did not.

Our common expectation of old age rests on three pillars: public health measures, such as provision of clean water and sanitary codes for the food production, sale and service industries; immunization; and antibiotics. The Bush administration has substantially weakened the first pillar, which has already led to some minor disasters. That is reversible. But the third is in real danger.

If we lose the ability to treat common infections before they develop into toxic shock or necrotizing fasciitis or pneumonia, that we cannot treat; if children's sore throats start turning into rheumatic fever; if eye infections start to mean lost eyeballs; if we can no longer safely perform surgery; we'll be living in a fundamentally different historic era.

The drug companies aren't interested in developing new antibiotics because they aren't nearly as profitable as products that are taken for a long term by large numbers of people. Obviously there's no way to pump up sales of overpriced antibiotics by advertising. Either you need 'em or you don't. And they can still sell tons of existing antibiotics to the livestock industry. Here's one place, in addition to stem cells, that NIH should be putting more research dollars. It's insufficiently glamorous, however.

Meanwhile, most urgently, we've got to preserve the antibiotics we still have, as much as possible. As always, check out my friends at APUA for the straight dope.

Too much for one day . . .

I've always been a Vonnegut fan. When you're young, his writing goes down smoothly, despite the bitter herbs, but when you get older, there's still plenty there. He lived somewhere near the edge of despair, but he seldom crossed it. Well, there's Mother Night. But even the end of the world, in Cat's Cradle, was somehow redeemed by courage and laughter.

I feel particular affection for Vonnegut's alter ego, the pulp science fiction writer Kilgore Trout. Like Vonnegut, I loved that stuff from Astounding Science Fiction and the ilk, with its gothic prose and telegraphic allegories. No doubt the pulp sci-fi elements in Vonnegut's own work helped encourage the serious critics to look down their noses at him, but to me, he was like a great composer building on themes from folk and popular music.

These days, Vonnegut's method of laughing at the darkness instead of cursing it is about all we've got to keep ourselves going. I know one thing for sure, I can't handle any more "progress" in Iraq, or any more restoration of honor and integrity to the White House. Twenty two more months of this evil doofus are going to do us in, I fear.

Calling all blastocysts

So the Congress is going to make the Preznit (who consitutes the single most compelling argument against intelligent design) veto a bill allowing federal funding for embryonic stem cell research without the current disabling restrictions. They might even be able to override a veto on this one.

I know the entire world is breathlessly awaiting my personal opinion, so here goes. On the one hand, I think it's so absurd that it's grimly comical to argue that the sixteen-cell entities that are destroyed in order to extract embryonic stem cells constitute "human life" or have any moral status whatsoever. It is particularly baffling that the people who insist on this delusional proposition derive it from their "Christian" faith, when obviously there is no support for it whatever anywhere in the Bible or even in Christian tradition until the late 19th Century. It's positively enraging that these same people seem to ascribe little or no moral status to actual living human children, when they are killed and maimed in their Glorious Leader's wars, tortured in front of their parents to extract information, or allowed to die of starvation, HIV or malaria because God doesn't want them to pay taxes to help foreigners, or to have governments messing with His sacred Free Market.

Most people already agree with me, so I don't need to go into the ethical questions. We've already won that one, and we already know that this is about pandering to a very narrow group of religious fanatics.

But I do want to point out that many people have severely exaggerated expectations for embryonic stem cells. Scientists are excited about the basic knowledge they can gain about human development from research with Embryonic Stem Cells -- although to be honest we can learn almost as much from work with other animals. In the long term, the really big excitement is that by cloning an individual using somatic cell nuclear transfer, and then extracting stem cells from the resulting embryo, we could grow whole new organs, which are perfect genetic matches and therefore do not require any immunosuppression in order to implant them. In other words, you develop heart failure, we just give you a brand new one.

Yes, that might be possible. It might also be possible without having to create embryonic stem cells at all. Maybe there are already cells in our body that could be induced to become heart tissue, or a new kidney, or a brand new spanking clean plaque-free coronary artery, or a knee joint, or even brain tissue. But whatever turns out to be possible, it's going to be expensive. And so:

-- It will drive up health care costs in the rich countries, probably dramatically;
-- It will not be available to poor people, and perhaps not even to moderate income people;
-- It might extend your life (or that of your loved ones or descendants), but it won't stop you from growing older, so while that new heart may give you a new lease on life, everything else will just keep on falling apart around it, and it won't make yo live forever. So next you'll need new arteries, and new kidneys, and maybe a new colon, and some new muscles, and . . . well, you get the idea.

We'll have some rich people walking around into their nineties with a lot of replacement parts -- if that category of "rich people" is going to include most Americans, that means the rest of the population will be paying ever higher taxes to make it happen -- until the framework falls apart or the brain finally turns to mush. And we'll have the rest of the world, 90% or so, who get bupkis from the whole thing. So, is this necessarily the best investment for our research dollar?

Something to think about.

And now, for the press-bashing post

as promised below.

Ned Parker, doing the daily Iraq round-up for the normally half-decent LA Times, writes:

There was little violence in Iraq yesterday, as bans on vehicle traffic shut down Baghdad and Najaf. However, one person was killed and three wounded in a mortar attack in the Shi'ite section of the Baghdad suburb of Dora, considered a haven of Sunni militants. Two Iraqi soldiers and an oil protection guard were killed in a bomb blast north of Basra, the Iraqi military said.

Nine unidentified bodies were found dumped in Baghdad yesterday and two corpses were found in Babil Province, south of the capital.

Okaaaaaay. Here's what our friends Whisker and Dancewater managed to find for Iraq Today, referring to the same date, yesterday, April 9. I'm not going to reproduce the links here, but you can find them on the original.

Baghdad:

In southern Baghdad, a sniper killed a civilian and a policeman.

And a mortar round killed one person and wounded two others, police said.

Five bodies, four of them unidentified, were found by policemen on Monday in the district of al-Aamil in western Baghdad, a security source said. "Three bodies were found in al-Aamil and another in the district of al-Risala," the source, who did not want to be named, told the independent news agency Voices of Iraq (VOI).

Baghdad was under curfew on Monday, the fourth anniversary of the fall of the capital to U.S. forces, as Iraqis streamed to the city of Najaf for a big anti-U.S. protest. Iraq announced a 24-hour vehicle ban in Baghdad starting at 5 a.m. (0100 GMT) to prevent car bombers launching attacks on the anniversary. Thousands of U.S. and Iraqi troops are sweeping through the capital in a new security crackdown

Baghdad- Three U.S. soldiers were killed and another was wounded when an explosive charge went off targeting a U.S. vehicle patrol in Zaafaraniyah district, southwestern Baghdad, a security source said on Monday.

Baghdad- As many as fourteen gunmen were captured during crackdown operations launched on Monday in Baiji and Tarmiyah in north of Baghdad, the U.S. army said.

BAGHDAD - The bodies of 17 people, some bearing signs of torture, were found across Baghdad during the past 24 hours, police said. Many of the bodies are thought to be victims of sectarian violence.

Diyala Prv:

Gunmen assassinated Jalal al-Daini, a tribal leader, in the town of Khalis, 80 km (60 miles) north of Baghdad, police said.

Police in Buhriz, about 35 miles north of Baghdad, said clashes broke out between unknown gunmen and al-Qaida fighters — leaving 30 people injured.

Three civilians were killed and four others wounded when a car rigged with explosives blew up in central Muqdadiya district, 35 km northeast of Baaquba, an official Iraqi police source said on Monday. "The vehicle was parked near a compound of markets and was detonated by means of a remote control," the security source told the independent news agency Voices of Iraq (VOI) on condition of anonymity. He said most of the victims were local residents of Muqdadiya in Baaquba, the capital city of Diala province, 57 km north of Baghdad.

Baaquba – Five policemen were wounded when their patrol came under an armed attack in central Baaquba, an official Iraqi police source said.

Diala – A tribal chief from al-Qaysiya clan in Habhab city, Diala province, was killed by unidentified gunmen on Monday, an Iraqi police source said.


Hilla – Security authorities in Hilla imposed a curfew from 10:00 a.m. Monday as two explosive charges went off near two U.S. patrols in the city.

Muthanna – A judge from the court of al-Samawa was killed by unidentified gunmen, while three policemen were slightly wounded in a hand grenade attack in the city, a security source in Samawa said

Iskandariya:

Gunmen killed two Shi'ite protestors who were heading south towards the holy city of Najaf from Iskandariya, 40 km (25 miles) south of Baghdad, police said. Seven others were wounded in the attack.

Diwaniya:

A roadside bomb wounded four civilians when it exploded near a U.S. military vehicle in the southern city of Diwaniya, 180 km (112 miles) south of Baghdad, police and hospital sources said.

More than 60 Shiite militants have been killed or captured in deadly battle with Iraqi and US forces in the central city of Diwaniyah, milatary officials said on Monday. Since Friday, around 3,300 US and Iraqi troops have clashed with Shiite militants, largely believed to be from the Mahdi Army militia controlled by firebrand cleric Moqtada al-Sadr, in Diwaniyah, south of Baghdad.

Hit:

Iraqi police killed two al Qaeda militants in the western Iraqi town of Hit, police Lieutenant-Colonel Ahmed Hameed said.

Mahaweel:

Police found the blindfolded and bounded body of a man in the town of Mahaweel, 75 km (50 miles) south of Baghdad, police said. The body had apparent torture marks on it.

Basra:

Three Iraqi soldiers were killed in an explosive device attack in northern Basra, a police source in the province said on Monday. "An explosive charge killed two Iraqi soldiers and a third from the oil installations guard force when it went off near a joint patrol in Bahla district in northern Basra," the source, who asked not to be named, told the independent news agency Voices of Iraq (VOI).

Kirkuk:

Police said they found the body of a member of the Kurdistan Democratic Party (KDP) who was stabbed to death near the northern city of Kirkuk, 250 km (155 miles) north of Baghdad.

Al Anbar Prv:

Unknown gunmen on Monday blew up the house of an officer from the current Iraqi army in Haditha, one of the cities of Anbar province, but no casualties were reported, said eyewitnesses from the city. "Unidentified gunmen blew up the house of Lt. Khaled Milhan Al-Jaghifi in al-Aaskari district, south of Haditha, by planting an explosive charge at 11 a.m. on Monday," an eyewitness told the independent news agency Voices of Iraq

Also:

The DoD has also announced another three deaths not previously reported by CENTCOM. These were three U.S. Navy casualties who died in enemy action near Kirkuk in northern Iraq on Friday, April 6th:
Chief Petty Officer Gregory J. Billiter, 36, of Villa Hills, Kentucky
Petty Officer 2nd Class Curtis R. Hall, 24, of Burley, Idaho
Petty Officer 1st Class Joseph A. McSween, 26, of Valdosta, Georgia
All three men were assigned to the Navy's Explosive Ordnance Disposal Unit Eleven based at Whidbey Island, WA.

Listen folks, it's like this every day. The corporate media will give a report from Iraq in which they list two or three violent incidents, and leave you to think they have described the day's events comprehensively. In fact, they usually mention only 25% or fewer of the events which have been publicly reported. That is a form of lying. Why don't they want you to know the truth?

The Zombie analgesic

Yup, Pfizer has decided it would be a crime to not to keep raking in the bucks from it's former blockbuster, which ought to be spelled Sellebrex. They've even gone so far as to take out a two and one-half minute long commercial on the ABC nightly news, which makes the claim that SellCelebrex may not pose a higher risk of cardiovascular events than other pain killers. Avenging angel Sidney Wolfe has asked the FDA to ban the ad, in part because of that claim, which is, er, uhh, well, a lie.

Credit where it's due, NBC science correspondent Robert Bazell does a pretty good job with this story here. I know, I know, I'm supposed to bash the corporate media, and for my next post, I plan to do just that, but there's no use doing that if I don't give the occasional example of getting it right.

As Bazell makes clear, there was never any reason for Sellebrex to be a blockbuster drug in the first place. Those ads with the vigorous old folks doing Tai Chi in the park very clearly suggested that it was a superior pain reliever, but it was in fact no better than aspirin -- which by the way is what I take when I have a headache or other transitory pain -- but it cost about 100 times as much. The only argument for anybody taking this stuff in the first place applied only to that very small minority of people who suffer gastrointestinal side effects from aspirin-like drugs -- but now it appears that Sellebrex may not even have a lower risk for those complications, while it is indisputable that it raises the risk of heart attacks and strokes. So, Pfizer is inviting you to die for the privilege of spending 100 times as much money to accomplish the same relief you get from aspirin.

What Bazell does not say, which I will, is that the FDA should not only ban the ads, but should also ban the drug. I say this because they have no legal mechanism for restricting its use to that tiny minority of people who truly cannot take NSAIDS but who have chronic pain and inflammation. When doctors are allowed to prescribe a medication, they can legally prescribe it to anyone, for any reason. That doesn't necessarily make sense, but there it is. And Pfizer is obviously absolutely determined to sell this drug, no matter what, including a willingness to expose themselves to legal liability. So, as long as Sellebrex is legal, they are going to find ways to get doctors to prescribe it. Ergo, ban it. Human life is precious, but your life is the last thing the executives at Pfizer care about, which is pretty obvious since they are trying to kill you for 3 bucks.

Bush's FDA works for the drug companies, of course, so it's feckless for me to write this.

A couple of observations from work in progress

You aren't supposed to say too much publicly about research that hasn't been completed, but I think it's okay for me to talk here about some informal observations and hypotheses that are coming out of work I'm doing now. This involves a method for coding and analyzing physician-patient interactions. I believe I've alluded to it in the past but I'm not going to search for it right now.

The key point is that our new method lets us separate out what the people are talking about from how they are talking about it. It turns out that if you give physicians independent information about how well their patients are adhering to a medication regimen -- based on a device that records when pill bottles are opened, for example -- the doctors generally end up spending more time talking with the patients about adherence. The bad news is -- and I'm sure this will come as no surprise to our friend Dr. Showalter -- this doesn't have any discernible effect on how well the patients adhere. They have the conversation, but they just go on not taking their pills.

Another disappointement? Well, yes, but also maybe a clue toward a more productive path. Most of this additional talk is more or less like most of the adult voices on South Park -- a lot of scolding noises. It's take your pills, you have to take them on time, if you don't take your pills bad things will happen to you, why don't you take your pills, I'm telling you to take the pills, you must take the pills, yadda yadda yadda. I expect it turns into "meepmeepmeepmeepmeep" in the listener's cortex and that's all it's worth. What you don't get is a talk with Chef -- what is the problem and how can we solve it?

As I said in one of the interesting background conversations that are going on regarding this topic, people who don't "adhere" aren't generally being "irrational." It's just that they aren't investing all their effort into maximizing their acturial expectation for Quality Adjusted Life Years. People's self-adjustment for their own quality of life includes items like not having to deal with the constant hassles of refilling prescriptions and remembering to take pills that remind them that there is supposedly something wrong with them; not having to pay $45 in copayments every month; not having to explain to co-workers (or their kids) why they are taking an anti-retroviral at 2:00 every afternoon; and so forth.

Doctors get frustrated when their patients don't comply but if they want to do something about it, I suspect it would help if they would learn to listen more and talk less. I can't prove that yet -- but it's worth investigating.

A Self-Fulfilling Prophecy?

That would be the apocalypse. For those of you who haven't had a chance to read Michelle Goldberg's Salon article on the Left Behind books and the belief system behind them, please click the link.

Unfortunately, we are not talking about a harmless fringe group. Tim LaHaye, co-author of the Left Behind series, is powerfully influential. As Goldberg writes:

After all, Tim LaHaye isn't merely a fringe figure like Hal Lindsey, the former king of the genre, whose 1970 Christian end-times book "The Late Great Planet Earth" was the bestseller of that decade. The former co-chairman of Jack Kemp's presidential campaign, LaHaye was a member of the original board of directors of the Moral Majority and an organizer of the Council for National Policy, which ABCNews.com has called "the most powerful conservative organization in America you've never heard of" and whose membership has included John Ashcroft, Tommy Thompson and Oliver North. George W. Bush is still refusing to release a tape of a speech he gave to the group in 1999. . . .The Left Behind series provides a narrative and a theological rationale for a whole host of perplexing conservative policies, from the White House's craven decision to cut off aid to the United Nations Family Planning Fund to America's surreally casual mobilization for an invasion of Baghdad -- a city that is, in the Left Behind books, Satan's headquarters.

Political attitudes and actions that make no practical or moral sense to secularists become comprehensible when viewed through Christian pop culture's eschatological looking glass. At a time when America is flagrantly flouting international law, spurning the U.N. and tacitly supporting the land grabs of Israeli maximalists, surely it's significant that the most popular fiction in the country creates a gripping narrative that pits American Christians against a conspiracy of Satan-worshipping, abortion-promoting, gun-controlling globalists -- all of it revolving around the sovereignty of Israel.

To those of us who exist in reality, these people appear essentially psychotic. The Book of Revelation, which provides the template for their delusions, is probably the record of mushroom trip. Even if you decide to believe that it somehow literally predicts the future, it's a long way from the weird visions on the page to any particular, comprehensible narrative of coming events. Furthermore, you just have to decide, on no particular grounds, that the apocalypse is going to happen sometime soon, and then map the book onto the world of today. When the book was written, of course, there was no such thing as a Muslim, or a Pope, just for starters.

But there you are. This nuttiness happens to be the core belief of tens of millions of Americans including the core constituency of the current president of the United States -- who just might believe it himself. In any event he is very careful not to publicly deny it, and to sprinkle his speeches with code words indicating that he does, in fact, believe. In my view, it is credible to argue that this is the most urgent problem we face -- the nation, and the world, have urgent problems that require concerted action, and here we have a substantial segment of the population that is running from all responsibility into the comforting arms of a delusion.

And they are not just huddling in their dreamworld by themselves. They are politically active, politically powerful, and imposing their visions on the governance of the world's most powerful nation. The result is that we do indeed risk, not their imagined Armageddon, but real disasters: widening war, climatic catastrophe, resource depletion, economic collapse. Nobody is going to get raptured up out these disasters, and Jesus isn't going to descend from the heavens to save anybody. We're all going to face hunger, and pain, and good old fashioned death. And that includes you, Mr. LaHaye.

There is no excuse for tolerating this nonsense, or treating it respectfully. This belief system must be clearly labeled for what it is, by every responsible politician, commentator, and anyone else with a public platform. It is nothing but the ravings of lunatics. It has no place in respectable society.

Happily Announcing . . .

Two new additions to the blogroll.

First of all, the former editors of Today in Iraq are starting over at Iraq Today. It's a little more free form, hopefully a little bit less wearing on the editors, but it will still be good, and provide, we hope, the same sort of active forum for discussion and news about Iraq and related events in the world.

Second, I have added Dr. Showalter's AlignMap blog to the blogroll. He has a lot to say about the physician-patient relationship, with a focus on what is usually called "compliance" but which he prefers to call real-world treatment implementation.

So please do check out these great resources. I'm pleased that the project begun as Today in Iraq lives on.

Some overall thoughts about health disparities

Sorry I missed posting yesterday, I was extremely busy -- I had two presentations at the Minority Health Conference, plus an evening meeting, and lots of business to catch up on with colleagues.

Among advocates for equal access and justice in many fields, such as higher education, there is often a tension between people who advocate for racial and ethnic equality, and people who focus on social class. For example, Walter Benn Michaels argues that the emphasis on "diversity" in higher education has covered up for the continuing, indeed growing elitism of selective colleges and universities. Admitting rich black and Latino kids as well as rich white kids is not really doing anything to promote equality of opportunity.

The language of racial and ethnic disparities has become pervasive in health policy in recent years. But in health and health care there really little conflict between concern with race/ethnicity and concern with class, or at least there isn't so far. For one thing, everyone recognizes that a major driver of disparities in health is social inequality, and people who want to reduce health disparities are committed to reducing economic inequality, and working to eliminate poverty and associated environmental causes of ill health such as sub-standard housing, differential exposure to pollution, inadequate opportunities for recreation, malnutrition, etc.

We know that socio-economic status in the U.S. is correlated with race and ethnicity, but that means that policies to reduce economic justice in general will also reduce ethnic disparities. That said, we also know that discrimination and historic disadvantage are part of the reason why inequalities exist in the first place, so that the solutions to inequality must include overcoming racism and correcting historic wrongs. There is no conflict there.

Second, everyone concerned with health care disparities stipulates that universal access is an essential first step. But we also have come to recognize that it is not enough. Once people get in the door of the clinic or hospital, they still face unequal treatment, inappropriate treatment, miscommunication, and unequal outcomes, associated with their culture, identity, skin color, and environmental disadvantages they bring with them from their lifeworlds. So race and ethnicity remain essential categories in the pursuit of justice. We'll have much more to say about this.

Live blogging from the New England Regional Minority Health Conference

Okay, not really live. I didn't get a chance to post until the end of the day, mostly because I've been presenting and otherwise had work to do. There was also the embarassing episode when I spent a half an hour after lunch looking for my vehicle in the parking garage. We are, to be excessively exact, located in the Mashuntucket Pequot Tribal Nation, more appropriately identified as a vast gambling casino complex stuck in the middle of woods and farmland in eastern Connecticut.

I will talk about the conference and the many important issues we've been discussing here, but first I want to say something about this bizarre place. The Mashuntucket Pequot had nearly disappeared -- there were no more than a couple of dozen people who even thought of themselves as Pequots, and even that was only on occasion, I think, although they will be quite annoyed if they read this. Butonce they gained federal recognition, and then the right to build this fantasy land, they had something of a revival of identity, if not culture. Whether people can truly reconnect with folkways, community, and history so thoroughly lost is questionable, anyway. Maybe it is not impossible.

But in any event, the "Indianness" of this place is transparently phony. Actually, to my outsider's eye it's offensive, bordering on the sarcastic. A giant quartz glass sculpture of a man with herculean proportions, dressed in a deerskin loincloth, aiming an arrow into the sky. That sort of nonsense. Even worse, "Wampum Rewards," free stuff you earn for losing 50 times as much money in the slot machines. Waitresses with a feather sticking up from the back of their head.

But, I gotta admit, these folks who used to live in a broken down trailer park are doing great now, raking it in from all these fools. This is the most absurd and inappropriate way of making reparations for the holocaust the English perpetrated on the indigenous people here. Most Native American groups get nothing -- including some of the most historically continuous, cohesive and needy groups, such as the Navajo -- while a random sample of groups, most with little cultural continuity or identity, get rich. And we do it at great social cost, with a lot of people coming out here and losing their retirement savings, kids college fund, and marriages. But the state depends on their cut now, so it won't go away.

This is no place for a curmudgeon.

The Soul Thief

That's Alzheimer's disease and other forms of serious dementia. We have many looming challenges, ever more grave and gathering during the past six years of misrule, but this is in fact one of the most serious. Global climate change is obviously up there near the top, along with the inevitable decline in global petroleum production. (These are complexly linked, in ways that could redound to benefit or harm.) The prospects for major war -- also closely associated with the question of petroleum -- are deeply worrying, but war can be avoided.

The fiscal disaster facing the United States has been greatly exacerbated by six years of irresponsible tax cutting and military profligacy, but the demographic problem facing the U.S. (and other developed countries) is real enough. Naturally, the current administration focused on the wrong problem. Social Security wil not be terribly difficult to sustain as the population ages, in fact it can be made very nearly solvent simply by eliminating the cap on income subject to the FISA tax. However, the solvency of Medicare, and also the Medicaid burden for long-term care for the indigent elderly, does present a very difficult challenge.

Actually Medicare spending is projected to rise from about 3% of GDP now to 8.8% by 2030, which is a lot but ought to be manageable in an increasingly wealthy society. (About half of that increase comes from the growing population of people over age 65, and half from increasing cost per beneficiary.) Nevertheless the transfers represented by Social Security and Medicare in 2030 are projected to be 50% of federal tax revenues.

But dementia doesn't have a whole lot to do with Medicare spending -- the burden ultimately falls on Medicaid. That's because there is little that can be done medically about dementia, but people with dementia ultimately require long-term, largely custodial care, and only Medicaid will pay for that once people exhaust their savings -- as most will. Medicaid spending is projected to grow faster than Medicare spending in coming years. Right now Medicare costs about $420 billion/year, while combined state and federal spending on Medicaid is $322 billion, or 76% as much. By 2015, Medicare spending is projected to be $792 billion, while Medicaid will cost $669 billion, or 85% as much. Presumably Medicaid spending will surpass Medicare spending by 2030.

While most of us want to live a long time, there is some really bad news connected with that: 3% of people age 65-74 are diagnosed with Alzheimer's disease, but after age 85, the prevalence goes up to nearly 50%. And, since there are other prevalent forms of dementia -- not counting mild cognitive impairment, which is almost ubiquitous in people over 85, we're talking prevalence at least half that of Alzheimer's -- a large majority of people over age 85 suffer from dementia. It's difficult to say how many of them will require institutional care before they die -- that's a race between the ability of medicine to extend life and the processes of dementia -- but obviously, if we keep living longer and longer, we're going to have more and more people living in dementia wards of nursing homes, and maintained there at public expense. Before they land there, they will spend months or years in custodial care, destroying their families' fortunes.

We are talking about a phenomenon that will require a massive shift in resources. It's already happening -- adult day programs, custodial care facilities, and nursing facilities for people with advanced dementia are springing up all over the country. It's difficult to keep them staffed.

I'm not going to sugarcoat it -- these assisted living facilities and nursing homes are very depressing places to visit. Even the nicest ones can't do anything to compensate for the destruction of the social capacities of their residents. The people cannot even make friends with each other, because they cannot form new memories and they have very limited ability to communicate. They mostly just sit in silence. Some may respond in a limited way to focused stimulation by staff, and to visitors, but the spark merely flickers and then dies out again. There is no dinner conversation, no deconstruction of the afternoon movie, no repartee over the desultory game of bingo that the most functional can still manage to play, or pretend to play. Five or six thousand dollars a month is keeping the people clean, dressed during the day, and fed. That's it. Nursing homes, costing twice as much, are even worse.

Unless we can achieve real breakthroughs in preventing, or at least greatly delaying, the common forms of dementia, we face what I believe can legitimately be called a disaster for society. This is in fact a philosophical and ethical challenge as well as fiscal challenge, and it is a deeply personal challenge for each of us. We need to talk about it a lot more.