Invidious Comparisons

While it's tolerably straightforward to compare the states on indicators of health care quality and access, as the Commonwealth Fund has done, trying to sort out the causes of disparities in actual health outcomes is far more vexing. (To be honest, people will bicker quite a bit about the health care quality measures, and they could be a lot more comprehensive and nuanced, but some of them are quite robust and they seem to correlate strongly with the more questionable ones.)

C. Corax asked about breast cancer rates in Utah. Actually they are on the low side. If you enjoy playing with numbers (and who doesn't?), the National Cancer Institute let's you generate your own tables on state cancer incidence and death rates, along with county-by-county comparisons, maps, historical trend charts -- it's a veritable McDonald's Playplace for the inquiring mind. Utah happens to have a high quality cancer registry, and so we know that its age-adjusted rate of breast cancer in 2004 was 113.7/100,000 women. Alabama had the lowest rate, and Washington state the highest -- a lot higher, at 136.6. Massachusetts, BTW, was pretty high too, at 130.1.

So why is this? We don't know all the reasons for variations in breast cancer incidence, but the most powerful factor we do know about is childbearing history. Having kids early and often is beneficial, and that's something women in Utah and Alabama are likely to do. People want to blame breast cancer on environmental factors like pesticides and radiation, and diet, and maybe that has a little bit to do with it, but as far as anybody has been able to tell so far, not very much. There's certainly good evidence for some important environmental factors, likely something about the diet, based on international comparisons, but we haven't figured out what they are yet. E.g., Japanese women have a low incidence, but when they immigrate to the U.S., in two generations their rate is similar to the U.S. average. Soy? Who knows.

But then I checked the kind of cancer that is most likely to be caused by exposure to radioactive fallout, thyroid cancer, and guess what? Utah is indeed number one -- 13/100,000, compared with the U.S. average of 8.6 and the lowest incidence state, Oklahoma, at 5.1. Is that because of bomb testing? Dunno. (Nevada isn't on the list because they don't have a tumor registry, sorry.) Pennsylvania, New Jersey, Connecticut, Massachusetts and other states you wouldn't necessarily predict are also on the high side, but that doesn't rule out that nuke testing is related to the high rate in Utah -- something else could be going on in the northeast. Remember, though, that thyroid cancer is pretty uncommon so we aren't talking a huge number of cases and the confidence intervals for the top four or five states overlap.

And finally, for all cancers combined, Utah has almost the lowest rate, in a statistical tie with New Mexico, at 405.9. We have a pretty good idea why -- a low rate of smoking and drinking in Utah. I don't know enough about New Mexico to say for sure, but I suspect they have a low rate of smoking there also. The state with the highest overall incidence of cancer is Maine, and Massachusetts is right up there as well in third place. But there are likely some paradoxical factors at work here. States with better health insurance coverage and better health care -- and Maine and Massachusetts are number one in that department -- have higher incidences in part because more cancers are diagnosed, because more people are screened for colon, prostate and breast cancer. In other states, some people have these cancers but die of other causes before they are discovered.

Life is easy, but epidemiology is hard.

It's a big country

And in many ways, it's more than one country. The Commonwealth Fund has come out with it's periodic state scorecard on health system performance, and let me put it this way: You don't want to live in Texas, Mississippi, or Oklahoma, and if you do live there, you aren't likely to be living for a long time. The Fund ranks the states on the dimensions of access (percent uninsured); quality (based on indicators such as percentage of people receiving appropriate preventive care, and hospital quality indicators, percentage of people who have a regular primary care provider, and certain more esoteric indicators such as the percentage of nursing home residents who are restrained);avoidable hospital use (admissions for pediatric asthma, nursing home admissions, etc.); and mortality susceptible to health care.

What is interesting about all this -- apart from a marked tendency to see those blue states at the top and red states at the bottom -- is that all of these dimensions are highly correlated. If everybody's insured, you also have higher quality, and healthier, longer-lived people. Of course, that makes you a Marxist, or at least that's what Mitt Romney says about Hillary Clinton. (Utah, by the way, is right in the middle at 24 overall, but that's because they're near the bottom in access, quality, and equity, but they make up for it in avoidable hospital use and longevity because the Mormons don't smoke or drink. Utah is always an outlier in these kinds of analyses for that reason. If we could just end tobacco addiction forever . . . )

I'm proud to be able to say that all six of the New England states are in the top ten, but Hawaii is the overall winner. The bottom ten? Alabama, Georgia, Florida, West Virginia, Kentucky, Louisiana, Nevada, Arkansas, Texas, Mississippi, Oklahoma. Think about it.

An interesting resource

Might even add it to the sidebar. Pharmalot is a blog, essentially, about the pharmaceutical industry, maintained by journalist Ed Silverman. Here's a current post about the Avandia story, with all the links that are fit to post. As you may not know if you depend on newspapers and TV for your news, there's an FDA panel meeting scheduled for Monday to decide the drug's fate, but it turns out the panel won't be considering Steve Nissen's meta-analysis that found Avandia increases the risk of heart attacks, which is what set off the whole controversy in the first place. (It figures.)

To review, Avandia is a drug for Type 2 diabetes that was approved on the basis of laboratory tests that showed it lowered blood sugar. But it was never shown in clinical trials to actually improve people's health or longevity. That's what's called a "surrogate" endpoint and a lot of drugs are approved on the basis of such measures. The drug companies like it because it's cheaper and quicker than waiting around a few years to see if the people who take the drug die. But too often, we find out after the drug has been approved, and we've had those few years, that yup, they croak after all.

Great Moments in Juxtaposition

On CNN.com, the following story: (Warning: This page may change, link is good as of 6:00 pm ET July 26):

BAGHDAD, Iraq (CNN) -- The U.S. military on Thursday reported eight recent troop deaths in Iraq.

A U.S. soldier from Multi-National Division-Baghdad was killed Wednesday "during a small-arms fire engagement" in southern Baghdad, the military said.

Three Marines and one sailor assigned to Multi National Force-West died Tuesday during combat in Diyala province.

Also, a soldier in the Diyala capital of Baquba died Tuesday of wounds from a roadside bomb. Diyala province is the sprawling territory northeast of Baghdad on the border with Iran.

A soldier was killed Tuesday in Baghdad when a roadside bomb detonated during clearing operations, the military said.

And a Marine assigned to Multi National Force-West died Sunday "in a noncombat related incident" in Anbar province, it said.

The U.S. military death toll since the war began in 2003 stands at 3638; seven civilian employees of the Defense Department have also been killed.

In other violence, at least 26 people were killed and at least 75 were wounded Thursday when a car bomb detonated in the main street of central Baghdad's Karrada district, Iraq's Interior Ministry said. At least one building and several cars were burning after the blast in the predominantly Shiite district, Reuters news agency reported. A Reuters cameraman said people were carrying bodies from the scene of the explosion and putting wounded people in vans headed to hospitals. Short bursts of gunfire could be heard soon after the blast, Reuters reported.

A suicide bomber in northern Iraq killed six people, including five police officers. The bomber detonated an explosives belt at a checkpoint in Tal Abta, about 55 miles west of Mosul, police said. Thirteen people, including 10 police officers, were were wounded.

Also Thursday, police found 20 bodies dumped across the capital, the Interior Ministry said. The slain bodies are thought to be the result of Sunni-Shiite sectarian violence. The number of such deaths this month stands at 524.

On the same page, the following headline:

General: Death toll down as U.S., Iraq forces take control.

War is Peace. Slavery is Freedom. Ignorance is Strength.

Update: Juan Cole commented on this (after I did):

We had just learned from Reuters last week that the number of guerrilla attacks in Iraq in June reached an all-time high, suggesting that the surge isn't actually going very well. CNN appears to have been one of the few news organizations, then, to pay much attention to Gen. Odierno's allegation that the surge is obviously working because US combat deaths have fallen so far in July. I know it is the general's job to spin things this way, but it is my job to call a spade a spade. In fact the secular trend of US combat deaths for April, May and June was significantly up:


' The previous three months were the deadliest three-month stretch in the war, with 104 deaths in April, 126 in May and 101 in June. '


This is up from 81 in February and March. So the quarterly average is still higher than in winter. Three weeks tells you nothing. (It is 130 degrees in Baghdad; what guerrilla in his right mind rolls out a big offensive in July or August?) Second, what kind of improvement is that, where over-all attacks rise but fewer US combat troops are affected by them? That sounds like US troops are having less contact with the enemy, which is hitting out more frequently than ever before at Iraqi security and civilian targets. That outcome does not point to "success" for the "surge"!

Aimless chatter

1) You've probably heard about the study in the new NEJM, to the effect that if your siblings and friends get fat, you're likely to do the same. I've had a chance to read the whole thing, and it's certainly sound research. They had the benefit of data from the Framingham Heart Study, a long-term, large-scale prospective cohort study that's been following thousands of people, and now their descendants, for decades. It's unique, which means, alas, that this study is probably not reproducible.

The limitation, of course, is that this study cannot tell us why this happens. The authors speculate that it more or less comes down to the idea of setting a bad example (although they don't like to put it in such invidious terms). In other words, if you see your buddies get fat, you start to feel like it's okay. Could be. But we know that it's very hard to control weight through conscious effort, so this has the perhaps counterintuitive implication that unconscious influences are more powerful than intentional effort. Or does it? Maybe it points to the importance of motivation.

2) In the same issue, George Annas discusses efforts by advocacy groups to give people with advanced cancer access to experimental treatments outside of clinical trials. Most people's instincts about this are both libertarian and compassionate -- the people are dying, for heaven's sake, if they want to try something let them, the worst that can happen is they'll die which they are doing anyway.

Annas goes through various complex arguments about how such a policy would metastasize throughout the legal regime -- in a nutshell, how do you limit it to the dying and to drugs that at least have been through Phase I trials -- causing all kinds of mischief. But the bottom line objection that's going to make sense to most people, I hope, is that such a policy would make it difficult if not impossible to develop effective treatments for broad use. The reason is that the only way we can establish whether a treatment is truly effective is through controlled trials -- half the people have to get the placebo. If everybody with terminal cancer is allowed to take investigational drugs, nobody will accept the placebo. But the fact is, most investigational drugs don't work, or they do more harm than good, so you really aren't doing anybody any favors by letting them have them. (Theoretically, in order to do a controlled trial, you need to have a condition called clinical equipoise: you really don't know whether one condition is better than the other.) So there is a huge cost to society in such a policy, and it doesn't actually benefit the individual whose liberty interest we think we are honoring.

3) The zombie autism/MMR thing is back. In the new BMJ, Ben Goldacre tells the appalling story of an article in the UK's Observer newspaper that claimed new research had found the prevalence of autism to be much higher than previously believed -- 1 in 58 -- and that "leading researchers" thought this might be due to the MMR vaccine. None of the above was true. Period. The article can only be described as hoax. The study found no such thing, one of the "leading researchers" had no such opinion, and the other, who is not even part of the study team, works for Andrew Wakefield, the doctor who started the whole thing with a fraudulent paper in The Lancet many years ago, which has been withdrawn. Wakefield is now in the U.S., continuing to rob desperate parents with his crackpot theories. Goldacre concludes:

Whatever one might think about Andrew Wakefield, he was just one man: The MMR autism scare has been driven for a decade now by a media that over-emphasises marginal views, misrepresenting and cherry picking research data to suit its cause. As the Observer scandal makes clear, there is no sign this will stop.

4) Still slogging through the Bible. Check it out if you find that sort of thing interesting. (If you can't blogwhore on your own blog, where can you blogwhore?)

Know when to fold 'em

My state's legislators, weary of having to actually tax the population in order to pay for essential government services, have been enviously eyeing the river of fools flowing south to Connecticut to deposit the silt of Massachusetts money in the casinos of New London County. So now some sorta kinda Indians, whose own land is in the wrong place, want the state to pretend their tribal nation is in the small town of Middleborough so they can build their own casino and dam up the southerly flow within Massachusetts borders.

Naturally, this proposal has divided the town, half of whose residents have visions of property value sugarplums dancing through their heads and half of whom live in Middleborough because they actually love the cows and horses and community. But the money has a way of winning out in these situations.

I've never been to Middleborough, but as a citizen and taxpayer I think this is a really, really lousy idea. Casinos, obviously, create nothing of value, they just siphon the money out of the pockets of addicts, enriching their utterly undeserving owners in return for letting the state skim off a few percent. And in case you think they stimulate economic development, au contraire, they suck the lifeblood out of the surrounding area. If you don't believe me, pay a visit to Atlantic City, which when I was a kid was a really fun place to go.

I remember in my salad days, when state lotteries were just coming in. I thought they were a good idea because the mafia already ran the numbers game, so why shouldn't the money go to the state instead? Wrong. The mob didn't advertise on TV and they didn't take bets at every neighborhood store and tavern. The state lotteries became a tax on the poor. Casinos are even worse. About 2% of American adults are pathological gamblers, but the rate doubles within 50 miles of a casino. (National Gambling Impact Study Commission. Final report. Washington, DC: US Government Printing Office, 1999) And what are the consequences of gambling addiction?

An overall decline in financial, social, and legal well-being is often linked to pathologic gambling disorder. Significant complications include depression, debt, divorce (the "3 Ds"), job loss, and incarceration. Rates of past-year job loss are twice as high in patients with pathologic gambling disorder (13.8%) as in nongamblers (5.5%). Rates of having filed for bankruptcy are four times as high in those with the disorder (19.2%) as in nongamblers (4.2%). Similarly, rates of divorce (53.5%) and incarceration (21.4%) are much higher in patients with pathologic gambling disorder than in nongamblers, who have a divorce rate of 18.2% and an incarceration rate of 0.4%. One third of the annual cost of pathologic gambling disorder represents criminal justice expenses.*

And who's going to pay for all this? The same taxpayers who think they're getting a free ride.

*(Leena M. Sumitra, MD and Shannon C. Miller, MD, citing Potenza MN, Fiellin DA, Heninger GR, et al. Gambling: an addictive behavior with health and primary care implications. J Gen Intern Med 2002;17(9):721-32)

Maybe I'd rather be a drug addict

This seemed like a good day to talk about gambling, what with all the excitement here in the People's Republic about maybe building a fantastic new casino in a small town in southeast Mass on land that will be fictitiously resanctified as Indian territory, and the NBA official who is headed down the crapper of sports history, but I'm going to defer that one because I have to say something about a couple of TV ads that are now playing relentlessly between innings. (Yup, my TV experience is largely confined to Red Sox games and the interstices therein.)

One is for a sandwich consisting of two big blobs of fried fatty ground beef, two slices of pasteurized process cheez food, and six strips of fried fat from a pig's belly (better known as bacon), on white bread, of course. The advertisement itself is almost as grotesque as the product. The second ad is for a calzone, "stuffed with cheese and toppings," weighing one full pound. I think they mean "fillings" rather than "toppings," but you know they're talking about various kinds of sausage, ham, and ground beef.

Now, I know that in the United States, corporations are legally human beings who have First Amendment rights, and that's a moral value handed down to us by Jesus, but there has got to be a way to stop this. I mean, where is the Culture of Life when you really need it? And how are we going to pay for all those Coronary Artery Bypass Grafts when we have much higher priorities, like spreading democracy throughout the Greater Middle East by the beneficent action of bullets and bombs?

Yeah yeah, it's a slippery slope and what about personal responsibility and where do you draw the line and so on and so forth, but I think it's possible to develop sensible regulations about what you can and cannot advertise on television. And a full day's worth of calories and a week's worth of saturated fat in one five dollar menu item is beyond the outer limits.

Donning the ALCOA sombrero

Come to think of it, you don't need to be even a little bit paranoid to think that this is really, profoundly disturbing.

Back to the Knitting

Okay, enough for a while of vile, degrading politics. I've been working with colleagues to analyze audiotapes of medical visits, adults seeing, for the most part, doctors with whom they have a long standing relationship.

These conversations are astonishingly asymetrical. You'd be surprised how little of the typical visit consists of discussion of the patient's health, symptoms, treatments, etc., in many cases. A lot of time is taken up discussing logistics (referrals, obtaining records, getting prescriptions refilled, etc.) and often a lot is spent on idle chit chat. But when discussing the patients' health -- symptoms, diagnostic test results, diagnosis and treatment -- doctors ask 86% of the questions. They also control the agenda, making nearly 80% of the utterances that open or close topics.

It might surprise you that in discussion of psychosocial issues -- things like patients' housing situation, substance abuse, criminal justice involvement, employment, family situation -- the asymmetry is even more extreme. Here, doctors ask 90% of the questions and give only 14% of the information. (In some other areas, such as prescribing antiretroviral medications -- these patients all have HIV -- the patterns are somewhat different.)

So let's think about this. Of course doctors have to ask questions and get information from us in order to figure out what's wrong with us and offer appropriate treatment. But shouldn't we be asking almost as many questions, and getting almost as much information from them? Shouldn't we be benefitting from the physician's expertise, not just so they can do things to us or tell us what to do, but so that we can understand what they believe is happening to us, what will likely happen in the future, and the factors underlying medical decision making such as risks and benefits of treatment, alternatives, and even doing nothing? That way, we can participate in decision making and choose the course that's best for us, given our risk aversion, pain tolerance, preferences, and the lives we need to lead.

If they're working for us, we ought to be telling them what to do some of the time, but physicians give almost 90% of the directives (recommendations, requests and orders). One of our readers, in fact, recently e-mailed me because she wasn't happy with a treatment her doctor wanted to prescribe. She had, it seemed to me, perfectly legitimate reasons for wanting to do something else, but most of us just can't have that conversation with our doctors. Sometimes they really don't like it -- they're the expert, and they don't want to put up with questions and doubts. Sometimes, we're just afraid that's how they'll react, because we're accustomed to doctors behaving that way.

But research has shown that patients who ask more questions and tell the doctor what to do some of the time actually have better outcomes -- specifically, in one well-known study, better control of their blood sugar if they have diabetes. In other words, forming a partnership with your doctor in which you are able to talk with each other as equals can actually make you healthier. I don't know if many doctors are ready for this, but I hope you'll try it. Let me know how it goes.

Political Science

Now that Mr. Bush has survived his colonoscopy without serious brain damage, as many had feared, attention returns to the question of the succession. Between innings of the Red Sox game I flipped to CNN to find coverage of the presidential campaign in South Carolina.

Rudolph Giuliani, I learned, is leading in the Republic Party primary polls in spite of his "moderate" positions on social issues* because conservative Republicans "admire his record on terrorism." Rudolph Giuliani has a "record on terrorism"? I don't even know what that's supposed to mean. But evidently conservative Republicans have collectively hallucinated that he has one, and whatever they imagine it to be, they admire it. The reporter, of course, did not trouble to explain what Giuliani's "record on terrorism" is, or is imagined to be.

I believe in democracy, and I believe that ordinary people should be able to decide who governs them. But it just isn't working in the present cultural and technological context. It hasn't often worked very well in the U.S., actually, so I'm not nostalgic for some golden age. But I do think the television has further falsified people's consciousness, and that it is ever harder for the mass culture to distinguish symbolism -- and often not even anything that rises to the level of symbol, but just attitude and vague associations -- from reality. Those images flicker by faster and faster, one after another, and they don't tell a story or make an argument, they just are, each of them a universe in itself, evoking synaptic networks of association without having to actually mean anything.

Hence Rudolph Giuliani has a "record on terrorism" because he happened to be the Mayor of New York when those guys flew airplanes in the World Trade Center, and even though he completely screwed up everything to do with preparedness before the fact and the response afterwards, he sounded like a tough guy on TV. That may be all it takes to be president.

*He doesn't want gay people to be allowed to marry, or to have protections against discrimination, but he does want to sponge off them when his wife throws him out of the house; and he promises to appoint judges who will make abortion illegal, even though he doesn't agree with them. That makes him a moderate.

Great moments in the annals of utter stupidity

And what else could I be talking about but our corporate media?

Having been cured of Irrational Bush Hatred Disorder through the magic of modern chemistry, I stopped reading all those vicious far-left hate sites like Daily Kos and the BBC and tuned in to the ABC nightly news. That's the patriotic network, unlike communistic CBS that slandered Dear Leader by calling him a draft dodger, when we all know that he volunteered to serve in Vietnam and received repeated awards for valor, unlike that draft-dodging John Kerry.

Anyway, ABC knows what news is important. The lead story -- and it was truly exciting -- the Dow Jones Industrial Average set an all time record high! They had a whole bunch of interviews with people -- I don't know who, just some people -- who told us how this proves the awesome power of the U.S. economy, and everybody in town was gonna join their investment club now, and we're all getting rich. There was some boring economist guy who said it's because the Dow stocks are mostly multinational corporations and business is booming in Europe and Asia, but we know the first guy was right.

It's a good thing they don't listen to far left haters like me, even ones in recovery, because this is what I would have said if I'd been one of those man in the street types. The Dow is supposed to set a new record every day. That's why people buy stocks -- because they expect them to be worth more in the future than they are now. I mean, I set a new all time record today: I'm older than I've ever been. Ditto for the universe, and Charles Gibson (who was off last night, I didn't catch the name of his replacement elocutionist). But in fact, the Dow did not set an all time record because it isn't adjusted for inflation. The Dow stocks are not worth the most today they have ever been, not by a whole lot. They are worth 20% less than they were at their peak back in 2000, adjusting for inflation.

Not only that, but the other, broader indices are down even in nominal dollars. In other words, since George W. Bush has been president, stocks have been a lousy investment. You would have been much better off keeping your money in a savings account. Actually, you would have been better off keeping it under a mattress, unless you happened to get lucky and pick the right stocks. But hey, it's a record!

So what's the next big story of the day? Treason! Espionage! A grave threat to our national security! A contract employee of the Department of Energy tried to sell uranium enrichment technology to a foreign power! A sober think tank expert came on to someberly intone that this is precisely the kind of technology that America's enemies want to obtain. Yes, we are besieged on all sides by terrorists and traitors. Only resolute leadership and suspension of civil liberties can save us from nucular armageddon.

So what happened exactly? It seems a construction laborer or maybe a janitor working to clean up an abandoned nuclear plant tried to sell some scrap machinery to -- drumroll please -- the French embassy. The French embassy. He also offered to sell them the secrets to making wine, soft cheese, sourdough bread, and onion soup. They were considering taking the deal if he'd throw in one of those flat floppy hats and some moustache wax, but then they realized that they already had sufficient uranium enrichment capacity to support their extensive nuclear power program and the nuclear warheads on their land- and submarine-based intercontinental ballistic missiles and long-range bomber fleet, so they passed.

But, they definitely are enemies of America, I learned that from Fox News.

By now, there wasn't much time left for the other important stories of the day. Well, there really weren't any. So I switched to the poker tournament.

Self-diagnosis

Sorry, the last couple of days my Irrational Bush Hatred, combined with Intermittent Explosive Disorder, have gotten the better of me and interfered with high quality posting. Having taken my Selective Serotonin Reuptake Inhibitor, Atypical Antipsychotic, Antianxiolytic, and Mood Stabilizer, I am now once again the very picture of glowing mental health.

And so, turning to the news of the day, George W. Bush, who I no longer irrationally hate, has vowed to veto reauthorization of the Supplemental Children's Health Insurance Program (S-CHIP) on "philosophical grounds," specifically, "when you expand eligibility . . . you're really beginning to open up an avenue for people to switch from private insurance to the government." Now, I'm not sure which philosophy that is. It doesn't really sound like transcendentalism, or logical positivism, or empiricism . . . hmm.

I know! It's the philosphy that insurance companies give money to Republicans.

If you're going to say that it is bad for people to have government-run insurance instead of private insurance, you probably ought to tell us why you think that is bad. As you know if you've been reading, we spend about 25% of our health insurance dollar on the administrative costs of private insurance -- marketing, profits, and paying rooms full of drudges to figure out ways to deny people coverage. Our largest publicly funded program, Medicare, has administrative costs under 3%, and has simple rules about what is and is not covered that are largely based on whether drugs and procedures are approved as safe and effective. (Long term care is not covered, which is a separate issue, along with the doughnut hole in drug coverage. But few people see these omissions as virtuous on philosophical grounds.)

Veterans in this country have not just public insurance, but actual socialized medicine. It's inadequately funded right now because Mr. Bush pretended their wouldn't be any casualties from his splendid little war, but the public is demanding that it be fixed, not privatized. Does a public insurance system mean "rationing" and cost controls? Yes it does. Mr. Bush invokes those terms to scare us, but why are they supposed to be scary?

We have rationing right now -- 45 million people who have no insurance and who don't get preventive care and basic services, and people with private insurance whose insurers ration their care in order to pump up profits. What we need is rational rationing, where we allocate services based on their expected benefits vs. their costs. That's what they do in all the civilized countries of the world.

And the civilized countries have cost controls, which we don't. That means they save money -- lots and lots of money. They spend, typically, half as much on medical services as we do, and they get more for it. Mr. Bush is opposed to that, it seems, on philosophical grounds.

So I would really like to learn more about this philosophy. Is it the philosophy his Economics 101 professor taught him? Maybe he'll explain it to us some day.

I'll retire to bedlam department

Boston Globe, July 18, 2007, p. A-13:

By Megan Greenwell, Washington Post | July 18, 2007

snip

Major General Benjamin Mixon, the top US military commander in northern Iraq, said during a news conference last week that the situation in Diyala had improved. "Now that the surge has reached its full strength, we are seeing definitive progress" in Diyala, he said, referring to President Bush's decision to send an additional 30,000 troops to Iraq this year.

snip

US troops stormed into an insurgent-controlled area of the province in search of the gunmen [who massacred villagers]. Backed by tanks, helicopters, and at least one F-16 jet, soldiers rolled into the eastern part of Baqubah , the capital of Diyala Province. Gunfire could be heard in the main market district, and Sunni imams in four mosques used loudspeakers to call on their followers to fight the Americans, residents told the Associated Press by telephone.

Pace, chairman of the Joint Chiefs, said he was particularly pleased with the security situation in Baghdad and al-Anbar Province, the vast region to the west of the capital. . . .Pace said his largely favorable impression of security in the region would influence what he tells President Bush about the results of the troop increase.

Boston Globe, July 18, 2007, p. A-13:

State Dept. says US ready for new talks with Iran on Iraq
Deteriorating security at issue

By Matthew Lee, Associated Press | July 18, 2007

WASHINGTON -- The United States is ready to hold new direct talks with Iran on the deteriorating security situation in Iraq, the State Department said yesterday.

Just Go

It seems that more and more politicians of both parties are embracing the Iraq Study Group concept that the U.S. should set a timetable to withdraw its combat forces and concentrate on training Iraqi forces to take over security. One obvious problem with that is that the new Plan B was Plan A back in 2004 and we've supposedly been training and equipping Iraqi forces ever since, but they never seem to be ready. But there is a more basic reason why Plan A and Plan B are both really bad plans. Here's Richard A. Oppel and John Elsen in the NYT today:

[M]en wearing Iraqi military uniforms stormed into a village in Diyala Province and killed 29 men, women and children. An Iraqi security official, Col. Ragheb Radhi al-Umiri, said the gunmen surrounded the victims and fired into the crowd. The attack occurred in a remote village north of Baquba, he said, and the bodies of some victims were “desecrated” before the attackers fled.

In an e-mailed response to questions, an American military spokesman in Baghdad wrote that American forces had received a report from the Diyala Provincial Joint Coordination Center about the attack, saying that men “wearing Iraqi army uniforms attacked Adwala village, killing 29 civilians and wounding four civilians,” and that the attackers rode in new Iraqi police trucks.

Now, I'm here to tell you that those guys weren't just "wearing" Iraqi military uniforms, and they didn't paint those truck to look like Iraqi police trucks in their garages. The reason they were wearing Iraqi military uniforms and driving Iraqi police trucks is because the United States gave them those uniforms, and those trucks, and the guns they used to shoot the villagers, and trained them how to shoot the guns (as if they needed it).

The reason the Iraqi forces aren't ready to take over security is not because they don't know how. It's because there isn't any such thing as Iraq any more. The government with which the U.S. is allied represents a minority faction of the Shiite sectarian majority, and does not govern anything, anywhere. When people sign up to join the Iraqi security forces and get those pretty uniforms, and trucks, and guns, it doesn't change their loyalties, which are to one or another faction, which might happen to be that of the Prime Minister or just as well might happen not to be. Note that most Iraqis (outside of Kurdistan) still say they believe in Iraq and want the nation to reconcile. But that's beside the point. I believe in reason and science and I want James Dobson to see the light. That doesn't mean it will ever happen.

Note that the new military strategy for which the generals are claiming success is to ally, not with Iraqi security forces, but with tribal and sectarian militias. The government doesn't like this, obviously, but on the other hand, when U.S. forces do patrol with Iraqi troops, their biggest fear is that the same guys they patrol with during the day are going to try to kill them by night.

So, the more Iraqi forces we train and equip, the more resources they will have to fight each other, and the occupation army, which they all hate. That is not a path to victory.

Here's the way out. Drive south. Get on ships. Leave.

And if you're worried about our own kids . . .

try not to think about kids in Iraq. A senior UNICEF official recently talked to reporters. I'm sure you can guess what's coming:

'Children today are much worse off than they were a year ago, and they certainly are worse off than they were three years ago,'' said Dan Toole, director of emergency programs for the United Nations Children's Fund. He said Iraqis no longer have safe access to a government-funded food basket, established under Saddam Hussein to deal with international sanctions.

Toole said conditions for women and children in Iraq had worsened significantly since the February 2006 bombing of a Shiite shrine in Samarra, north of Baghdad, which triggered a wave of sectarian violence and displacement that continues today.

He added that gains made shortly after the U.S. toppled Saddam's government in 2003, when people were able to move around the country freely and had access to food markets and health centers, had been lost.

''Nutritional indicators, health access indicators are all changing for the worse,'' Toole said. He said recently published data showing improvement refers to the situation a couple of years ago and is outdated. . . . .

He said the agency has so far received no government donations toward a $41.5 million appeal for its Iraq work through the second half of 2007.

Now, I want you to think about orders of magnitude. UNICEF wants $41.5 million for the rest of this year, of which it has received $0.0. The United States is spending $2 billion a week to kill people in Iraq. That is more than $41.5 million on the day shift, on the swing shift, and on the night shift, every day.

I would ask Joe Lieberman, who is a deeply pious and moral man, to explain why that makes sense.

PM Carpenter lays it down

Here.

The illusion of free will

I can't give you a link on account of you're not one of the elect, but Dr. Philip Mellen decided to find out whether people diagnosed with hypertension follow the standard dietary recommendations (called DASH, for Dietary Approaches to Stop Hypertension), and as he told the American Society of Hypertension, for the most part they aren't. Only 22% said they were -- and who knows, half of them might be lying.

This also happens to be the right diet for everybody. You already know the drill -- whole grains, fruits and vegetables, low fat dairy if any, lean meat and fish, nuts and legumes, no saturated or trans fats, steer clear of added sugar, low salt, around 2000 calories a day depending on your height and physical activity level . . .

The reason this diet prevents hypertension, diabetes, heart disease, and even some forms of cancer is because it's the diet our ancestors ate back on the African savannah* a million years ago. It's the right way for Homo sapiens to eat. And, everybody knows this. Our doctors tell us. It's on posters in the subway, it's on the TV, it's common knowledge. But we don't do it.

The cornerstone of clinical management of Type 2 diabetes is said to be diet and activity, but just about everybody with diabetes takes pills because they just can't do Plan A. Ditto with hypertension. Obesity is just about intractable and it's getting more and more prevalent and more and more extreme all the time. On the subway, it's now standard for two people to take up three seats. And there's the answer to all of it, two paragraphs above. Is eating that way horribly unpleasant, boring, depressing, disgusting? Of course not. You can make an endless menu of meals worthy of the very finest restaurants out of those criteria.

The problem is that we only imagine that our behavior is controlled by a "self," that our consciousness is co-extensive with an executive who is in charge, and that we decide everything we are going to do. On the contrary, there are wetware modules running inside our skulls of which we are largely or entirely unaware that generate much of our behavior. Back on the grassland, with our stone spear points and wooden digging sticks, 20,000 times Great Grandma could generally come up with the calories she needed but it took a lot of work and that put her in a bind sometimes -- the harder you work, the more calories you need. The sugar in extra sweet fruit or honey was worth grabbing. The game was very lean so a little fat was nice to have, and so was the simple starch in some tubers. Mega-Great Grandma was toiling all the time so when she got a chance to take it easy for a while and save a few of those scarce calories, it felt good. Evolution hard-wired her to like those things and to get them when she could.

Put her descendants into a world where they swim in sugar, fat and potatoes, and they can get essentially unlimited quantities while barely lifting a finger, and that's the wrong wiring. This problem is not about willpower, or individual choice, because those are largely illusory when it comes to basic drives like eating. It's an environmental problem. Those of us with more resources of time and money can modify our personal environments to some extent, and one dimension of the problem is that a better diet costs more. Also, those of us with more education, who grew up in higher income, more empowered households, develop more ability to delay gratification and make choices based on long-range criteria. (This is a sociological fact.) So obesity and it's attendant ills are more prevalent among lower income people. But it's a problem in all social classes.

It's a win that here in Massachusetts, it appears we're going to have the country's first state-wide ban on trans fats. The movement to get sugary drinks and other junk food out of schools has made some progress, but we have a lot further to go with that. Just think of everything else we could do through public policy to change our national food environment for the better, from the Department of Agriculture to the Department of Commerce to the Department of Education to the FDA.

Here's a powerful example of why the ideology of the "free market" and consumer sovereignty is so profoundly false. We can modify the food environment in such a way as to shape people's choices, and as a result, we can have a healthier population, that is more productive, suffers less, lives longer, and costs a hell of a lot less for health care. We can be happier, and healthier, and wealthier, if we make the food industry accountable to the public good.

* I'm among those who are convinced that the traces of a period of semi-marine existence are written into our bodies and psyches. At some point in human evolution, our ancestors lived by the ocean and spent a lot of time in the water.

Doctor Chatterbox

You've likely heard about the study by Susan McDaniel and colleagues (abstract only for the underprivileged) which finds that doctors often talk about themselves when, in the authors' view, they should be worrying about their patients instead. I have reservations about this paper -- they present a few examples that look anywhere from mildly to highly inappropriate -- but they don't have any actual evidence that these behaviors are necessarily harmful, or that they represent a big problem. I would call that a hypothesis raised by these observations, not a finding as they would like to have it.

I must say as well that, although I haven't been systematically looking for this particular category of behavior, I'm pretty sure I don't see as much of it in the hundreds of medical visits I have studied as they do. Most of the shootin' the shit kinds of interactions, talk that's unrelated to the business of the medical visit, seems to be entirely consensual and is often initiated by the patients. An important difference, however, is that McDaniel et al's data consists entirely of first meetings between M.D. and patient, whereas mine is generally of ongoing relationships. Physician self-disclosure seems less jarring and more appropriate when the parties know each other and have formed a bond.

All that said, it's still somewhat ironic and does highlight the converse problem in physician-patient interaction, which is that physicians are not generally very amenable to patient disclosures which stray too far from the strictly biomedical. Where it's known to be an issue, physicians will often ask about specific contextual problems such as criminal justice involvement, illicit drug use, housing, etc. But they generally have little understanding about patients' life worlds and neither know nor seem to care about how the problems of daily living may affect their ability to follow medical advice, take their pills, eat the proper diet, exercise, etc. When people complain of depressive symptoms, they'll get a prescription, rather than any effort to understand why they might feel sad. Now, an internist is not a psychotherapist, but doctors can certainly do a much better job of listening, and encouraging patients to confide in them. I'm not so much worried about doctors talking about themselves, as I am about them not letting patients do the same.

Profiles in Courage - a day late and a dollar short

I was not enthused about the nomination of Richard Carmona as Surgeon General, and I got a whole lot less enthusiastic when, having obtained Senate confirmation, he disappeared from the planet. I thought he must have been a victim of spontaneous human combustion, but then I actually saw a person who purported to be him giving a speech at the International Conference on Urban Health. It was really hard hitting stuff, all about how he was encouraging his staff to engage in physical activity for at least 1/2 hour each day.

So now he tells us that the reason he spent four years not doing his job is because the White House political commisars wouldn't let him. My outrage module was burned out long ago, but some of this stuff is worth noting just for the ludicrosity value.

Dr. Carmona said he was ordered to mention President Bush three times on every page of his speeches. He also said he was asked to make speeches to support Republican political candidates and to attend political briefings.

And administration officials even discouraged him from attending the Special Olympics because, he said, of that charitable organization’s longtime ties to a “prominent family” that he refused to name. “I was specifically told by a senior person, ‘Why would you want to help those people?’ ” Dr. Carmona said.

The Special Olympics is one of the nation’s premier charitable organizations to benefit disabled people, and the Kennedys have long been deeply involved in it. . .

On issue after issue, Dr. Carmona said, the administration made decisions about important public health issues based solely on political considerations, not scientific ones.

“I was told to stay away from those because we’ve already decided which way we want to go,” Dr. Carmona said.

He described attending a meeting of top officials in which the subject of global warming was discussed. The officials concluded that global warming was a liberal cause and dismissed it, he said. . . .

When stem cells became a focus of debate, Dr. Carmona said he proposed that his office offer guidance “so that we can have, if you will, informed consent.”

“I was told to stand down and not speak about it,” he said. “It was removed from my speeches.” . . .

Similarly, Dr. Carmona wanted to address the controversial topic of sexual education, he said. Scientific studies suggest that the most effective approach includes a discussion of contraceptives.

“However there was already a policy in place that did not want to hear the science but wanted to preach abstinence only, but I felt that was scientifically incorrect,” he said.

Dr. Carmona said drafts of surgeon general reports on global health and prison health were still being debated by the administration. The global health report was never approved, Dr. Carmona said, because he refused to sprinkle the report with glowing references to the efforts of the Bush administration.

“The correctional health care report is pointing out the inadequacies of health care within our correctional health care system,” he said. “It would force the government on a course of action to improve that.”

Because the administration does not want to spend more money on prisoners’ health care, the report has been delayed, Dr. Carmona said.

Hey doc, thanks for telling us all about it -- after spending four years not doing your fucking job, and not letting out one itsy bitsy, teeny weeny little peep about it to anyone, until after you've already been fired anyway, after the 2004 and 2006 elections, after God knows how many teenagers have contracted HIV or gotten pregnant because of abstinence-only sex education, after we've wasted your entire tenure not taking action on climate change, or prisoners' health care, or stem cell research, and people have, you know, like died because of it. Aren't medical doctors supposed to have responsibilities to human life and health? Not if their cushy job is more important to them, I guess.

I believe there is a special circle of hell reserved for such people. He can spend eternity with Colin Powell.

Update: The new nominee for Surgeon General, James Holsinger, tells the Senate Health Committee in his confirmation hearing that he would resign rather than submit to political censorship of scientific truth. (Holsinger has other problems, though he now claims the sodomites are okay by him after all.) It seems pretty obvious to me that would be a fundamental responsibility for anyone who accepts the job of Surgeon General, but evidently Carmona had a different view.

Advice to Uncle Karl

If you got nuthin' to hide, stop hidin' stuff. If you didn't do anything wrong, then swear to tell the truth, sit down, and tell it.

Magically, all those nasty, suspicious, accusatory, tongue wagging finger pointing enemies of the state will have to slink away with their tales between their legs, and you'll once again be king of the hill, top of the heap. So what's stopping you?

Oh yeah. Read the "if" clauses at the top of the post.

(Much too busy today for a decent post -- in fact I don't know how I do this most days. I'll try to get back later this afternoon.)

And the rubber meets the road . . .

the leather smacks the chin, push comes to shove, and the fan hits the shit. The battle over the Supplemental Children's Health Insurance Program (S-CHIP) is about to be joined. John Iglehart lays it out for you in NEJM, and as has been their habit of late (attempting to buy me off with half-measures), the editors have made this article on a matter of supreme public importance available to, yup, the public, even those who lack a medical degree or a faculty appointment. (So very bountiful of them.)

Anyway, as Iglehart explains, the Dems (and not a few members of the Republic Party) want to put an additional $5 billion a year into the program, in order to get all children of the working poor into the program. Some want to go further, expanding coverage to middle class families as well. Why do they want to do this? Because S-CHIP works: it gets kids covered who wouldn't otherwise be covered, and that means a healthier future for them and a better future for Americans, which we are proud to be.

I'm sure you can guess what's next: the Resident wants to shrink the program, not expand it. Robert Pear in the NYT explains why:

Administration officials have denounced the Democratic proposal as a step toward government-run health care for all. . . . White House objections to the Democratic plan are “philosophical and ideological,” said Allan B. Hubbard, assistant to the president for economic policy. In an interview, he said the Democrats’ proposal would move the nation toward “a single-payer health care system with rationing and price controls.”

You're in the groove, Allan. You have nailed it down, knocked it on the noggin, and told it like it is. Yup. Uhuh. Sí, oui, da, yes indeedy, you betcha, you got that right bro. Word. So let's get ready to rumble.

Oh yeah -- Just to put this in perspective, the occupation of Iraq costs $3 billion a week. So Hubbard is definitely right - it's not about the money.

Back to nature?

I'm sure readers would find my personal life as least as boring as I do, but I refer to it from time to time for purposes of illustration. Those of you who go back a ways already know that in addition to my home in Boston (where gainful employment is to be found) I own some land in rural Connecticut, where I am building a house. (Currently hanging drywall -- the end is in sight.) Yesterday, while Al Gore and his friends Sting and Madonna were raising global consciousness, I was working on the sustainable agriculture project, for real, in the broiling sun.

I am planting fruit trees, and I intend to do some vegetable farming and maybe put in a vineyard as well. Yes, it's a hobby farm, essentially -- I've written before about my friends Festus and Angie, who are real farmers, and they work harder than human beings were designed for. But President Gore wants us to rely more on local produce, and I'm going to do what I can.

Here's the story of this land. Like essentially all of Connecticut, it was clear cut in the 18th and 19th centuries for firewood, charcoal, and pasture. It appears that my land was never plowed, because it's so rocky. There are a couple of desultory, half built stone walls, as though someone removed a few of the most egregious rocks from the surface to improve the pasturage, but there's no way anybody ever got a plow through the rubble that remained. Early in the last century, the owners planted pine trees in a strip of about 200' along the road, and left the upland to return to wilderness. It once again became dense forest, dominated by oak interspersed with hemlock groves.

I had a logger come in and selectively harvest, in exchange for building a road into the heart of the property and clearing about 3 acres out of the 20. (In case anyone wants to guilt trip me, my neighbor and I also bought up 35 acres of abutting property that was slated for development, and sold it to the state at a substantial loss for incorporation into the state forest.) I now have a barn and couple of acres of arable land behind the pine plantation, and further back, a house and another acre of land, separated by a wetland. Behind the house is a steep hillside and an upland forest, deep and dark, teeming with wildlife.

My mission, I have discovered, is to defend this little clearing from the voracious forest, equipped with a 15 horsepower diesel tractor and a three-gang mower deck. Any place I don't mow for a few weeks turns into an impenetrable mass of wild raspberries and seedling trees. The rough ground has already cost me four sheared mower blades. I'm steadily digging out rocks and stumps and spreading topsoil to fill in the ditches and hollows, to make the land cultivatable but also just to make it defensibly mowable. The rocks already make three huge piles, enough, I think, to build a stone barn. Unlike the settlers who first farmed here, I don't have the assistance of three sons, two brothers, and a team of horses, so I depend on the tractor for these tasks as well, assisted by a chain saw and a pickup truck. I'm also slowly pushing back the perimeter in places because I need to open up more sunlight and take advantage of the best, flat land. I turn the harvest into firewood with the help of a gasoline powered log splitter, and I turn the waste into mulch with a gasoline powered chipper.

If I were to keep at this for a while, then start to truck in manure and till and plant, I could have a farm like Festus's, and sell my produce at the local farmer's markets and the Willimantic Food Coop. I could heat my house with renewable biomass energy, and probably have a surplus to sell to the neighbors. I could spend the winter eating canned vegetables, cold frame greens, and tubers from the root cellar. Maybe I will do all that some day. I'll use less fossil fuel than trucking and flying in the goods from Mexico and Chile, and I'll do it all organically and sustainably, building up the topsoil instead of depleting it, eschewing pesticides, growing real tomatoes designed to be eaten instead of packed into box cars.

That's all good and fine and sweet, but there's nothing natural about it. Nature is my enemy - the encroaching forest, the marauding deer and woodchucks, the insatiable insects. I have to slash them down, fence them out, burn them and drown them. (Just last week I burned out four trees full of tent caterpillars with a propane torch.) Festus has a 22 to deal with his woodchuck problems, and he's surrounded his entire property with a 12 foot fence to keep the deer out. Most of the local farmers use electric fencing, powered, ultimately, by burning coal and fissioning uranium. There is absolutely no way that I will be able to cultivate the land without the tractor -- probably a bigger and better one than I have now, in fact -- and the chainsaw. Stihl has named my chainsaw the Farm Boss, because it's marketed to farmers. The land I cultivate will be nothing like the primeval land -- rock free, treeless, all the roots pulled out and cow manure tilled in, the deep forest loam stripped off to leave bare soil between the cultivated stalks in summer and a lawn of winter rye in the off season.

Ted Kaczynski, the anti-industrialist radical terrorist, hunted rabbits with a rifle and lived in a house made of plywood. This is how we live now, in a world we have remade. We just can't go back. We can try to live in this world a little better, a little more heedfully, more carefully. But it's still the human made world.

By the way -- anybody need some rocks? I have some . . .

A possible breach of medical ethics?

It's been fascinating hearing the chatter about the "Doctors' plot" terrorism case in the UK. Much punditry has focused on the cruel irony that people who have taken an oath to do no harm would be involved in such heinous acts.

Actually "do no harm" is not in the Hippocratic oath (and Cervantes busts another myth), but it would seem to be the case that attempting mass murder is inconsistent with our expectations of physicians. Alas, although I cannot say whether physicians are more likely to become mass murderers than, say, welders or medical sociologists, they are definitely likely to get away with it, and what is most notable about some of those who have been caught is the impressive totals they managed to run up before the murder did out. The Jihadi sawbones are probably most noteworthy for their incompetence, not their intentions.

The weirdest of my punditry experiences was listening to a discussion on the BBC about how appalling this all was and couldn't the National Health Service do something to screen out doctors who might be evil and so forth? This lengthy conversation managed to assiduously avoid the very recent, very notorious, and presumably highly relevant case of Harold Shipman, M.D., a veddy veddy British gentleman who murdered at least 150 of his patients and probably closer to 300. He never confessed and we don't know his motives but evidently he just enjoyed it for some reason.

Then there was Michael Swango, an American physician addicted to poisoning his patients. He also tried to poison some of his coworkers, and was caught at it -- yet he was permitted to continue practicing medicine.

Kenneth Iserson, M.D., has compiled stories of several physician mass murderers. Again, what they tend to have in common is an extraordinary ability to get away with it, because of relevant skill and guile, assisted by physicians' high social status and cultural reluctance to question their judgment and actions. A couple of these cases are of doctors who were carrying out the policies of depraved political leadership, in Iserson's book the grotesque human experiments conducted in imperial Japan, and of course the comparable Nazi experiments are somewhat better known in the U.S. (I'm not sure why.) But that's a somewhat different case.

Please do not become paranoid. Such anti-doctors are, of course, one in a million. Most of the docs I know really, deeply, sincerely care about their patients and want to honor their profession. The worst of them really, deeply, sincerely care about money and want to be rich and adored, but murdering people is generally not conducive to those goals.

What is particularly noteworthy about the UK terrorist docs is that, in spite of their evident hatred for Britons in the collective and abstract, and their indifference to human life, there is no indication, at least so far, that they did not practice medicine in an exemplary manner. If killing people was what it was all about, they could have emulated Dr. Shipman and done it quietly for years. But that, obviously, it is not the point of so-called terrorism, which is a public action intended to draw maximum attention. Murder is just a means to that end, and it wouldn't surprise me if, in their professional lives, they would have found the idea of harming patients appalling and impossible. Humans are weird, that's for sure.

Proud to be an American

I see those bumper stickers everywhere, and I wonder. Why I should take any pride in the accident of birth that makes me a U.S. citizen?

Certainly my birth was fortunate. I was among those many Americans who had privileges and opportunities, which I didn't entirely squander. And, as a citizen of the United States, I have obligations to contribute to the society and the polity. Some might take pride in the extent to which they have done so. I also have obligations to the people around me, and I might take pride in the achievements of people who are close to me, and anyone whose achievements I may have encouraged, or assisted or supported. But just being an American? Why should I be proud of that?

So when I see the Cadillac Escalade with the "Proud to be an American" bumper sticker, I can only imagine what that means to the proprietor. Maybe he was once a poor campesino in Guatemala, whose ancestors had hoed the same mountainside for 10,000 years. But now the European settler government in Guatemala City was making war on his people to squash their demands for land, education and health care. After they killed his father and uncles, and destroyed his livelihood, desperate to feed his babies he hiked through the jungle and jumped on a freight train, riding it north for three days with nothing to eat. Then he ran through the desert and nearly died of thirst, until he found his second cousin. For the next five years he hid in the shadows, doing back breaking work for $20 a day, half of which he sent home to feed his family until, in 1986, Congress and President Ronald Reagan gave him a way to make himself fully a part of the community he had helped to build and feed. They even made it possible, eventually, for his wife and children to join him, and for his family to make a life here just as Mr. Reagan's impoverished and oppressed ancestors had once done. Maybe that's what they are proud of.

But that's highly unlikely. I think they despise such people, who they call criminals who were given amnesty for their despicable deeds. Or maybe they really despise them because of their dark brown skin, and strange food and music, and because they pray in the wrong language. The people in the Cadillac, of course, pray in English, the language of the Bible.

Judging by their other bumper sticker, maybe they're proud because they twice cast their presidential ballot for a talentless and narcissistic son of privilege, who failed at everything he tried but was always bailed out by his powerful Daddy and his Daddy's rich friends, until some of his Daddy's friends put him in the White House, because they needed a malleable fool to pretend to be president while they tried out their demented plans for world domination. I guess that makes them proud, even though the world domination thing hasn't worked out so well, at least not so far.

Or maybe they're proud because they get to sit in front of their television and cheer while they watch the bombs they paid for blow up houses and people. Hey, it is the home of the brave. Maybe they're proud because in the richest country in the world, only 32 million people can't afford an adequate diet. That's only 10 percent, after all. Or maybe they're proud that the United States imprisons the highest proportion of its population of any country in the world. Now that's quite an accomplishment -- especially for the land of the free. Maybe they're proud of spending the most on health care of any country in the world -- an even more impressive accomplishment when you consider that we have the worst health of any wealthy country, and are the only one that leaves a big chunk of its people with no health insurance at all. Maybe they're proud that 5 percent of the earth's population manages to consume 25 percent of the earth's resources. We're number one!

I don't know. I can think of a few more things they might be proud of, so I can't decide. But in any case, can they really take credit for it?

Aaargggh

Please forgive me, I'm finding it hard to come up with anything worthwhile to add to the discussion today. I mean, what more can anyone say? The country is taken over by a gang of murderous thugs, war criminals, thieves, liars and fascists. Elite opinion about the situation ranges from "Tut tut, isn't that a shame," to "Thank God we at last have strong and effective leadership in this country," with any real oprobrium directed at those of us who are alarmed about the situation.

While I try to think of something interesting to write about, you might want to check out John Tierney's piece about the retrial of Dr. Dan Hurwitz, which we discussed here recently. The miscarriage of justice in this case was ameliorated in the end, but only partially. The bottom line, as Tierney suggests, is that the judgment about whether a physician has acted appropriately in prescribing narcotics ought to be in the hands of knowledgeable people -- he suggest other physicians, although I might broaden the representation on the responsible body a bit -- not the DEA and prosecutors. If the Board or Commission or whatever it is wants to make a criminal referral, okay, but prosecutors and cops are out to notch their pistol handles, not make complex judgments about difficult medical decisions. Law enforcement in the area of physician prescribing is harming the public as well as innocent doctors, by depriving people of access to medications they desperately need.

And these prosecutors ought to be disbarred.

Flotsam from the hypnagogic state

Food rules: There's clam chowder and chicken noodle soup. Why can't there be clam noodle soup and chicken chowder? Is there a law against it?

The senses: I have no idea why we speak of five senses, there are at least 7 and arguably a few more. In addition to the classic sight, hearing, taste, touch and smell, there is obviously balance. We are always aware of the orientation of the head with respect to gravity, due to a discrete sensory system consisting of little stones dangling in fluid filled loops connected to the inner ear. When this sense goes awry, the effects are devastating. Then there is proprioception. We are always aware of the state of flexure of our joints and the positioning of our body parts, again due to a discrete sensory system consisting of separate receptors in the joints. So that's 7, without a doubt.

"Touch" is really four different senses: pressure, heat, cold and pain. These each have discrete receptors and independent channels to the brain. Obviously we can feel the warmth of the sun, for example, or the chill inside the freezer, or the pain of an old injury, without the perception that anything is touching us. Heat and cold receptors can also be activated chemically (as by capsicum and menthol), so we can even feel heat and cold simultaneously. So if touch is really four senses, that's 10.

Finally, even with our eyes closed, we can sense the presence of an object close to, but not touching, the area between our eyebrows. This is particularly pronounced with pointed metallic objects. Try it. That's 11.

Alter ego?The cartoon character Popeye has two foils, one a big hairy bully named Brutus, the other a big hairy bully named Bluto. Is there any significant difference between these characters? Why do they both exist? (They never appear in the same episode, as far as I know.)

Dress Code: Why do nerds fasten the top shirt button without a tie, and wear pants that are too short? What developmental pathway could possibly lead simultaneously to social ineptitude and a fascination with asocial intellectual challenges, and compulsive top shirt-buttoning and pants shortening? (It is possible to do up the top shirt button non-nerdily, but the shirt must be specifically designed for it.)

Jihadoofusses: Excuse me, jihadoofi. (I always have trouble with the Latin plurals.) It's disturbing, of course, that there are depraved people out there who want to kill large numbers of their fellow humans at random, but since the tragic Madrid and London train bombings, the ones who have tried it in the so-called western countries are all candidates for supported housing. The clowns at Fort Dix got caught because they went to the CVS to copy their jihadi propaganda video onto DVD. The wacko plot to blow up fuel tanks at Kennedy Airport, in spite of the breathless hype of the authorities, was completely nonsensical. The worst they could have done was start a fire that probably would have been put out by the safety systems in 20 seconds, but they lacked any means even to do that. I won't even go into the Seeds of David, or the guy who wanted to destroy the Brooklyn Bridge with a blowtorch, or the payasos who thought that puncturing the Lincoln Tunnel would somehow flood Manhattan.

Now we have these guys in the UK. Again, contrary to what the authorities have claimed, their car bombs bore no resemblance whatsoever to the devices used in Iraq, and would not have caused carnage of any sort. Gasoline does not explode, it burns. In so doing, it does not propel any nearby nails as shrapnel. The propane tanks in the cars might have exploded in a gasoline fire, but probably would not have, and even if they did, it would not have been a big deal. We saw the truth of all this when the same guys drove a similarly rigged vehicle into the airport terminal in Glasgow and managed only to set themselves on fire. If this is the general character of the existential threat to Christian civilization, I'm not losing any sleep.

Why does the hypnagogic state exist?