Doing my Duty

I'm getting e-mails from all directions saying I have to do a post on the prospects for health care reform following the landslide presidential victory next year for Sen. Clinbamdwards and a filibuster proof Democratic Senate. At least I assume that's the timing people have in mind because it sure ain't gonna happen before that.

Proximal stimuli for this barrage include the new census data on the number of uninsured Americans, discussed here by Karen Davis; and from the capitalist side of the aisle by the Kiplinger letter (Tip o' the hat to the tipsters -- and keep those cards and letters coming folks); and the decision of the American Cancer Society to pull its PR resources from telling you to get a colonoscopy, to demanding health care reform. (Of course everybody thinks Sicko is going to have a big impact, but I do need to remind you that Farenheit 911 hasn't exactly gotten us out of Iraq.)

It does seem as though something has to give, but unfortunately, good public policy doesn't translate directly, or even necessarily indirectly, into political outcomes. Politics is the system, however it may be constructed in a particular society, for resolving conflicts among interest groups, not for serving some abstract national or public interest. Actually, of course, there is no such thing, the "public interest" is just a rhetorical trick. My interests are similar to yours in some respect, but not in others.

To figure out politics, people's individual interests (which are a function of both subjective and objective factors) have to be multiplied by two factors: the resources they possess to influence the policy making process, and the intensity of their interest in the particular issue. Uninsured people have a strong issue in change, but generally speaking have very limited political resources, in most cases actually quite close to zero.

People who have private insurance might want things to be different, for various reasons: every year the percentage of the premium they have to pay goes up, along with their co-pays; the've had problems with denial of specific services, or they've been forced to change doctors when their employer changes insurers; they have relatives or friends who are uninsured or who have been wiped out by long-term illnesses; they feel insecure about keeping their insurance; etc. But this is usually not the biggest problem in their life and they might feel as insecure about change as they do about the status quo.

The political resources of people in this category vary, but the ones with the most resources are also likely to have the best insurance, the easiest time affording it, the least insecurity, and even quite possibly something to lose if the new system is progressively financed. Some might welcome that in the interest of equity, but others are more selfish. So in general, the people with the strongest interest in change have the least ability to influence the policy making process.

Then you have the people with an interest in the status quo. The most important of these are drug companies and insurance companies. For insurance companies, reform is an existential threat, and they'll fight it with everything they've got, which is plenty. Drug companies stand to lose a huge chunk of their profits under a system that doesn't allow them to continue ripping off the public to the tune of tens of billions of dollars every year, and they've got plenty to fight that with as well. Doctors are a mixed group. Some of them -- notably those high priced specialists -- do stand to lose income under serious reform -- but many doctors are for change anyway because they actually give a shit about their patients. That's far from universal however, and it makes the AMA very cautious about this. (Historically, it's been the most powerful opponent of reform, but that has changed recently.)

So Mitt Romney's idiotic rhetoric about Marxism and socialism might have an effect on a few people, but the real problem is that we live in a moneyocracy, and while the overall economy, average standard of living, public health and social justice would all benefit from single payer national health care, that interest is too diffuse and too politically weak to prevail over the powerful, concentrated interests that stand to lose.

There are only two possible solutions to this problem. One is a massive social movement that succeeds in crystallizing that diffuse interest into an effective force. This has happened from time to time in our history, as recently as the 1960s. It's hard for historians and sociologists to nail down the historical circumstances and cultural context in which such things happen, but they do happen. This is called revolutionary change.

The second solution is to try to create incremental change that will restructure the underlying conditions so that the next step is easier to take, and the next step after that, until the vested interests are gradually whittled down and the broader interest has more effective means for expression. This is the Edwards approach: let people under 65 start buying into Medicare, make sure it's a good deal so that more and more people will take it; expand S-CHIP from the other side; and hope that the two of them will end up being the blob that ate the insurance system. Of course, the problem with this is that the insurance companies and the drug companies have this figured out, so they'll fight it just as hard as they will a flat out single payer proposal. That's why Chimpy is so determined to stop S-CHIP expansion, for exactly the reasons he states publicly: it will nibble at private insurance, i.e. donors to Republicans.

So which do you think is more likely to happen? Revolution, or evolution?

Am I missing something here?

Clifford J. Rosen, chair of the FDA advisory committee that approved continued marketing of the drug rosiglitazone (brand name Avandia) gets a chance to tell his side of the story in the new NEJM, and as the have been doing lately, the editors are kind enough to give you peons access to this item of great public interest.

Rosen writes, "The joint committee, which I chaired, consisted of 24 experts in cardiovascular disease, epidemiology, biostatistics, and endocrinology. After lengthy discussions, we concluded that the use of rosiglitazone for the treatment of type 2 diabetes was associated with a greater risk of myocardial ischemic events than placebo, metformin, or sulfonylureas." Now, as we have discussed here previously, rosiglitazone was approved because it lowers the level of glycolated hemoglobin, considered an indicator of the patient's level of blood sugar over time. This is called a "surrogate endpoint," i.e. it's not a clinical outcome in itself, but an indicator that is assumed to be associated with clinical outcomes because it corresponds to a link in the presumed etiology of disease.

But people don't take rosiglitazone to lower their glycolated hemoglobin, they take it to prevent the complications of diabetes. Which, according to the finding of Dr. Rosen's committee, it does not do. At least it doesn't prevent the most important complication, which is dying. As Dr. Rosen writes, "These data suggest that we urgently need to change the regulatory pathway for drugs for the treatment of type 2 diabetes to make clinical outcomes, not surrogates, the primary end points."

So here's my question, Dr. Rosen, one to which you do not even hint at an answer, or even acknowledge that an answer might be required: Why in the name of the Honorable Wilfred P. Bazinet did you and your committee vote to approve this drug? Since there are other drugs available which accomplish exactly the same thing, but which do not kill the people who take them by giving them heart attacks, why would any sane physician prescribe rosiglitazone and why would any non-suicidal patient take it? Therefore, why would the FDA approve it?

Now, this couldn't possibly have anything to do with it:

"Dr. Rosen reports receiving a lecture fee from GlaxoSmithKline and grant support from Eli Lilly, Merck, and Novartis."

Senator Larry Craig

Between innings of the Red Sox game (bunch of sorry-assed losers), I determined that the only news of the day as far as CNN was concerned was Sen. Craig. I caught James Carville saying that he has sympathy for Sen. Craig's family and professional associates, but has no sympathy for the Senator.

I don't entirely agree. I have about two percent sympathy for him. Many years ago I probably would have had more. Back in high school, we had to do senior projects, and a friend of mine, a hard core heterosexual, decided to make his an anthropological study of a "tea room," a public restroom in Pittsfield Massachusetts where men sought furtive and anonymous sex with each other. I was a bit surprised to hear that such a phenomenon existed, but on the other hand, it made perfect sense that men who had sex with men would do it furtively and probably under degrading conditions. You just couldn't be gay, there was no such thing. I have figured out that some of my schoolmates were gay, but it was definitely a secret at the time. It had to be.

The Stonewall uprising happened in 1969, before I got to college, and I remember being vaguely aware of it. While I was in college, I saw the very beginning of the coming out movement. One of my classmates pioneered it at Swarthmore with a letter to the student newspaper. I remember some of my friends being outraged and disgusted. Once again, I figured out later that some of my friends and acquaintances were gay, but they kept it buried deep. After Stonewall, things changed very slowly.

After graduating, I lived in Washington D.C. for a year or so on two occasions, a year apart. In both years, I was in charge of stage security for Washington's Gay Pride celebration. It is rather astonishing that a straight man with no particular engagement with the gay community would end up in that position, but it was because of my friendship with Bob Belanger, a pioneering gay activist. Bob was one of the early members of the Washington D.C. Mattachine Society, which was founded in 1961. It was a secret society, whose members were required -- not urged, but required -- to use aliases. It was named after a secret society of the Rennaisance, whose members wore masks.

I met Bob working on organizing various national demonstrations against U.S. intervention in Central America, nuclear power, etc. Sometimes we'd drink together in one of Dupont Circle's integrated gay/straight bars. Yup, they had 'em then. Dupont Circle was a separate universe. Bob always spoke reverently of D.C. Mattachine founder Frank Kameny, but in doing a little quick fact checking for this post, I discovered that Bob actually displaced Kameny as Mattachine president in 1964. I don't know what the issues were, but I suspect that Bob wanted to be less covert and more assertive.

Bob told me that they had mailed a copy of their newsletter to J. Edgard Hoover, and that Hoover responded with a personal letter simply asking them not to send him the newsletter and never to contact him again. Hoover and Roy Cohn were two well-known people of that era whose personal lives were unambiguously gay -- Hoover in a life-long committed relationship, Cohn an extravagantly promiscuous sybarite -- and whose public activities consisted largely of persecuting pinkos, homos, and in Hoover's case uppity negroes. Hoover was in a unique position to get away with it because of his immense power, and Cohn had powerful friends. But both men's lives were tissues of lies.

They are archetypes for the homosexual gay bashers who are heavily represented in the ranks of the Republican Party and the Christian right. Along with self-hatred, manifested in insistent, conspicuous public activism, comes hard-core ideological conservatism in every domain, and self-righteous sanctimony.

Since then, it has steadily become more and more possible for gay people to live honestly. Here in Massachusetts we have a gay member of Congress, gay legislators, and a gay man in a high position in state government, all out and even in some cases married.

The news obviously hasn't made it to Idaho yet, but Craig has spent the past two decades in Washington D.C. He has plenty of examples of gay men who can be themselves both privately and publicly and still succeed in the world and be accepted. That is not, however, consistent with being a Senator from Idaho, or at least Craig doesn't think it is and he is probably right. But he betrays himself, people like himself, and humanity by not only denying himself, but working aggressively and publicly to promote bigotry and discrimination, and force others into the closet with him. Fear, shame, self-loathing -- I'm sure he feels all of those. But there's only one way out, and that is the path of truth.

This recent epidemic of outing of this particular class of suffering hypocrites is obviously healthy. It may just set some of their followers to thinking about the matter anew, and help speed the day when gay bashing as a political strategy is a spent force. As for Sen. Craig, I doubt there is any hope for him, but he should consider that if he believes homosexuality is sinful, he knows that lying is as well. Two wrongs don't make a right, and maybe, just maybe, if he starts to live honestly, he'll realize that it isn't wrong after all.

I've been wondering why this hasn't happened sooner

Juan Cole reports from Arabic and Kurdish media that there is a cholera outbreak in Kirkuk and Sulaymaniyah. I'm surprised it's happening up there where conditions are relatively good -- actually I'm not sure what the water supply status is in Kirkuk -- but with much of central Iraq, including the capital, lacking access to safe drinking water, cholera has seemed inevitable. With many people taking water directly from the Tigris, the probability of cholera moving south seems very high.

The Iraqi health care system is already overwhelmed, and there is simply no possibility of restoring potable water service to any significant part of the population any time soon. This could be a huge disaster. In the context of the disaster that Iraq is already, I don't know how much difference it will really make. But we have got to expect infectious disease to be a growing problem given the total collapse of infrastructure in the country.

Too much to worry about

I grew up during the height of Cold War tensions, including atmospheric nuclear testing, the Cuban missile crisis, the Arab oil embargo, Ronald Reagan going on TV to warn us that the commies were going to come up from Nicaragua and invade Harlingen, Texas. (Really! He really did that!) I mean, nuclear World War III would have been the end, my friend. But somehow we all believed that it just couldn't possibly ever happen. Miraculously enough, it didn't, and the problems of the 1990s seemed minor by comparison.

But right now the zeitgeist seems more tormented than it did when people were building fallout shelters in their back yards and school kids were doing duck and cover drills under their desks. The world around us has grown more dangerous in only one important respect: the incompetent and deluded occupant of the office of President of the United States. The problems we have now we already had in the 1990s. Al Qaeda was out there, a major nuisance but no more of an existential threat to anyone than the IRA was to Britain. We had grave and gathering environmental crises, the same ones we had now. We had ever-rising health care costs and lots of uninsured people, which combined with demographic trends to present a long-term problem of fiscal sustainability. Saddam Hussein's Iraq was a failing state -- not much of a threat to anyone, but a long-term political problem that created concerns for regional stability. U.S. workers were facing serious challenges from abroad as capitalists chased low wages and environmental standards wherever they would lead. The explosion of international travel created threats of global infectious disease outbreaks. And so forth. (I apologize to any inhabitants of your closet of nightmares who I've left out.)

But we figured we'd muddle through and do what we had to do to solve or at least ameliorate these problems. The idea that humanity could apply reason and foresight to understand dangers, develop effective responses, and make tomorrow better than today or at least equally tolerable, was once again ascendant. In other words, we believed in progress.

What a difference a corrupt Supreme Court makes. Now these problems are looking intractable, and the vise of danger seems to tighten every day. The situation represents a massive failure of all of our political institutions, from the political parties and leadership, to the mass media, to the self-absorbed, insular American electorate. Every day I wake up expecting a disaster. So far, the disasters have been largely in slow motion, and maybe they'll continue that way, or maybe there will be some sort of a big bang.

But either way, the country has got to mobilize and disable the Bush administration. If Nancy Pelosi considers him unimpeachable, then there are other ways for the congress to box them in and reclaim state power on behalf of the public, and on behalf of sanity. But we have got to recognize the depth of the crisis and the urgency of our situation.

Making my head hurt

As long-time readers know, I'm building a house. Actually it's built, and I'm finishing the inside now. Taping and plastering a ceiling yesterday I observed a strange phenomenon. A mysterious force causes the glop to fly off the ceiling and hit the floor.

I did a little research and I found that according to the theory of the late A. Einstein, this happens because the geometry of space-time is deformed by the presence of nearby massive body, in this case a huge ball of rock with a molten iron core. This seemed preposterous so I looked into the matter more deeply. According to Mr. Einstein's theory, the universe would collapse into itself, so he made up a number called the cosmological constant to fudge the data and stop that from happening. Yeah, right. But then a guy named Edwin Hubble looked through his telescope and decided that the universe consists of billions of separate agglomerations of billions of stars (or actually billions and billions, according to one of the leading proponents of this nonsense) most of which are rushing away from us at speeds of thousands of miles per second, which he deduces from the fact that the light they give off is redder than it ought to be. Therefore, the universe is expanding and the momentum of this expansion stops it from collapsing.

Yeah right. It follows from this fantastic premise that a long time ago, the whole thing must have been smooshed together, and after they do the math that turns out to have been about thirteen and a half billion years ago. So all of a sudden, for no apparent reason, this infinitely hot, infinitely dense ball of who knows what started furiously expanding. They figure that a few hundred thousand years later it must have cooled off enough to become transparent to light, and they claim that some radio waves that appear to come from all directions prove that happened.

But wait, it keeps going. Out of the pure energy of the early universe, they deduce by some magical incantations that only the elements of hydrogen and a little bit of helium would have condensed. Then the gases collapsed into stars, underwent nuclear fusion to form heavier elements, then the stars exploded and spewed these elements into space, where later they condensed into new solar systems and some of them condensed into planets and it wasn't until that happened that earth was possible, which was many billions of years after the whole thing started or, specifically, four and a half billion years ago. . .

Well it goes on and on. Evolution. Quantum mechanics. (No that's even more ridiculous than Scientology.) This is plainly nonsense. First of all, this universe is purposeless. Why would it go on for 13 1/2 billion years before we showed up? We're the real point of the whole thing, after all. Second, it just leaves too many questions unanswered. Why did it happen this way? Whose idea was it? How did the whole thing start, and how will it end? If you can't answer those questions, what good is your theory? And this business about the deformation of space time -- I can see for myself that it isn't deformed, stuff just falls, that's all. I mean, duh.

Now, compare this to the Bible. The Bible answers all those questions, and you scientist guys can't. The Bible makes sense, and your ideas are just crazy. QED.

Update: But seriously,

Bill Nye, the harmless children's edu-tainer known as "The Science Guy," managed to offend a select group of adults in Waco, Texas at a presentation, when he suggested that the moon does not emit light, but instead reflects the light of the sun. . . . [N]othing got people as riled as when he brought up Genesis 1:16, which reads: "God made two great lights -- the greater light to govern the day and the lesser light to govern the night. He also made the stars."

The lesser light, he pointed out, is not a light at all, but only a reflector.

At this point, several people in the audience stormed out in fury. One woman yelled "We believe in God!" and left with three children.

Seriously.

Liberal Bias

It turns out that college professors are now a substantial source of political donations. Why not? They make decent salaries -- well, halfway decent anyway -- and they're traditionally civically engaged.

But I can almost hear the howls from the starboard precincts from here, because it turns out that about 75% of their dough is going to Democrats. Barack Obama seems to be the individual favorite at the moment. There you go, we told you the academy is a nest of hippie commie irrational Bush hating freaks. There's your proof, they discriminate against conservatives when they hire professors.

How about explanation B? People who are trained in critical thinking, and who are highly knowledgable, generally end up being liberal. It's not the university that has a liberal bias, it's reality. Most college professors don't even work in fields that have anything obviously to do with politics. They are mathematicians, physicists, chemists, biologists, engineers. Sure there are sociologists, historians, literature and art professors, and political scientists in there as well but it turns out that the preponderance of liberalism among academics is just as great outside of social studies and the humanities as it is within them.

Now, I say some of those fields don't have much to do with politics but unfortunately, that isn't true these days. Biology and physics are political after all, because Republicans and conservatives reject biological and cosmological science. Hell, Karl Rove even has his own personal mathematics. Let me be clear about this. People can differ in their values, in their goals for society, and in their tolerance for risk and need for certainty. These are the sources of legitimate differences of opinion. However, the major political divisions in our society right now are over questions of reality -- questions that have right and wrong answers.

And the Republicans are wrong. Completely wrong. About everything.

Update: After I posted the above, I came across this:

By ALAN FRAM, Associated Press Writer Wed Aug 22, 3:01 PM ET

WASHINGTON - Liberals read more books than conservatives. The head of the book publishing industry's trade group says she knows why — and there's little flattering about conservative readers in her explanation.

"The Karl Roves of the world have built a generation that just wants a couple slogans: 'No, don't raise my taxes, no new taxes,'" Pat Schroeder, president of the American Association of Publishers, said in a recent interview. "It's pretty hard to write a book saying, 'No new taxes, no new taxes, no new taxes' on every page."

Pragmatism

Lots of stuff in the new NEJM. I'm sure you've heard about that study about all the old folks having sex, so I won't discuss it. (How can I get in on some of that?) But I will draw your attention to Jacob Hacker's riff on Sicko, which the multi-millionaires at NEJM have graciously made available to you free of charge. Hacker endorses Moore's critique of the morally repugnant health care regime under which we currently perdure, but he thinks it's feckless to be talking about single payer national health care, essentially because the current Gordian Knot of a non-system has too many vested and hidden interests to unravel, and there's no-one who wields the mighty sword that can cut it.

Hacker recommends the approach of letting people under 65 buy into Medicare, and requiring or strongly incentivizing employers to either buy into Medicare for their employees or give them private insurance. He figures Medicare will be the better deal and it will eventually become the Blob that Ate Health Insurance, and there we'll be.

Maybe, but there's a lot that can go wrong with that, including the current limitations on Medicare. It theoretically pays only for treatment of disease, and has limited benefits for screening and preventive services. If it's extended to people under 65, the benefits will have to be enhanced in order for it to be appropriate. It also has a limited pharmacy benefit, as we know, and does pay for long term care, which means that young people with disabilities will still be on Medicaid. And, of course, we'll still have an affordability problem for people with moderate incomes, so there would need to be a sliding scale subsidy to make this really work, which means raising the payroll tax . . . In other words, we're still going to have to untie that Gordian Knot, even if we do this.

In the same issue, two studies find that bariatric surgery for severely obese people yields a substantial survival benefit over 10 years. One of them focuses specifically on gastric bypass, the other includes gastric banding. Both studies find that people who don't get the surgery rarely achieve substantial weight loss.

It certainly goes against the grain with me to concede that there are probably millions of people whose best bet is to have their stomachs reduced to the size of walnuts. There are complications of the surgery, people do regain some of the weight over the years, and they are likely to be somewhat nutritionally compromised. And of course surgery is expensive. It would be so much better if we could prevent this problem in the first place. I fear that if stomach reduction surgery becomes as common as haircuts, the pressure will be off to change the food environment and encourage physical activity. Society will be far, far better off if we stop getting kids hooked on sugar water and fried starch; stapling their stomachs after they get fat is the wrong answer.

But it seems to be the right answer for a lot of individuals. And there you have the fundamental conflict between medicine and public health, and that's why the URL of this blog is healthvsmedicine. Health versus medicine, get it?

Two additions to the sidebar, check 'em all out.

The Vietnam Syndrome

The Emperor of Mespotamia today compared his splendid little war in Iraq with the U.S. police action (as it was officially known) in Vietnam. He invoked the "price of withdrawal" in Vietnam as evidence that terrible things will happen if the U.S. withdraws from Iraq.

Well gather 'round kiddies, I lived through the police action. I didn't end up being part of it because the year I turned 18 was the last year of the draft, and I had a high lottery number, but I knew people who were drafted, and who fought, and who wound up with purple hearts. I even met guys who were destroyed by it, horribly scarred physically and psychologically. Here's what I remember about Vietnam.

The U.S. entered Vietnam because we knew that elections, scheduled to reunify the country, would result in a win for the Communist government of the north. The purpose of the intervention was to prevent a democratic process from happening. We spent 10 years defending a puppet government in the south from the Vietnamese people. Nearly 60,000 Americans died in the process, and something like a million and a half Vietnamese (though estimates vary widely on the latter). A popular South Vietnamese government never emerged, and there was never any pretense of democracy in South Vietnam during that entire time. The South Vietnamese army never became an effective fighting force, largely because they really weren't fighting for anything they cared about. In the end, the U.S. withdrew.

The Emperor today invoked "boat people, reeducation camps, and killing fields" as the consequence. The killing fields, in Cambodia, had nothing whatever to do with the U.S. withdrawing from Vietnam. They were a consequence of the U.S. intervening in Cambodia. The boat people were U.S. collaborators who were forced to leave the country after their protectors withdrew. That's unfortunate, but hardly the stuff of nightmares. Reeducation camps were six month experiences after which the participants were fully accepted as citizens.

That's it. That's the catastrophe. Vietnam then actually went into Cambodia, deposed the Khmer Rouge, installed a halfway decent government, and left. No more killing fields, thanks to those commie bastards. No dominoes fell. Nothing bad happened. Today Vietnam sells us coffee and shrimp, and Americans go there as tourists. Even if we did "lose" Vietnam because we were stabbed in the back by liberals and hippies, it turns out to have been a good thing. Maybe it's time for another backstabbing.

Standing at the bottom of the cliff

The news of the day is, of course, the Compassionless Radical vowing to veto the S-CHIP authorization, but everybody else in the world is talking about it so I'll let them do it.

I'd like to take a step back and point out something else that is fundamental. Last year in Health Affairs (sorry, subscription only, and the abstract is uninformative) Leslie M. Beitsch and colleagues analyzed data from surveys conducted by the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO). These represent state departments of public health, and municipal boards of health. They concluded that in the United States, public spending on public health in 2004-2005, from federal, state and local sources, was $149 per person. This is likely an overestimate because some of the spending that was counted is probably for health care or other purposes which are not strictly public health. In 2005, the U.S. spent $6,423 per person on health care, so public health spending was 2.32% of that.

What do we mean by public health? The functions Beitsch et al list include emergency preparedness, maintenance of vital statistics, tobacco prevention, public health laboratories, environmental health, food safety, drinking water safety, environmental regulation, substance abuse prevention -- activities that prevent disease and promote health before you see the doctor. These are interventions at the level of communities and populations, rather than individuals. Some of medicine is preventive, such as immunization, and that is considered a public health intervention, although the truly public health part of it would be more properly construed as efforts to make sure that as many people as possible receive recommended immunizations or other preventive services, rather than the services per se.

As I have discussed here many times, the gains in life expectancy in the past century are mostly attributable to public health measures, with medicine contributing only a small proportion at first. Most observers argue that medical intervention has become more important in the past couple of decades and may account for about 50% of the gain in life expectancy since then, but still, is 43:1 really the correct ratio for spending on individual biomedical intervention vs. public health?

Why this gross disproportion? The economists would concede that it is a market failure, although, as you know if you believe me, markets always fail and it is nonsensical to expect markets to produce sensible amounts of public welfare in the first place. Public health is a public good. Individual consumers can buy very little of it, and in fact tobacco companies and "food" manufacturers spend billions to make sure people buy public sickness instead. I can't go out and spend out of my pocket to make sure the food in the supermarket or the water that comes out of my tap isn't contaminated, to make the air I breathe clean, to assure that my doctor is competent or my father's nursing home run safely, to prevent young people from taking up tobacco or heroin -- only government can do these things.

But once I'm sick, I'm going to demand health care. Furthermore, culturally, when we see people who are ill, we don't feel right if they don't get treatment. Seeing uninsured people expiring at the doorstep of the hospital because they can't pay would simply be unacceptable to the public. But we are much more tolerant of distant threats to health that might or might not affect a given individual. That isn't "rational" from a utilitarian or cost-benefit perspective, but it's how people work.

There is an allegory in public health, whose origins as far as I can tell are lost in the mist of time. There is a road that runs right up to a steep cliff, but there are no warning signs and no barriers. People keep driving right off the cliff and landing at the bottom seriously injured. So what do we do? Do we put up a sign, or a fence, or better yet rebuild the road so it turns away from the cliff? No, we wait at the bottom, and when the people fall, we take them to the hospital and patch them up. It's a good deal for us, because we get paid a lot to do it. If we built that fence or rebuilt the road, we'd stop our gravy train.

We need . . .

universal, comprehensive, single payer national health care. The Democratic candidates for president, with the exception of two who have no chance to be nominated, aren't willing to say it. The -- sorry, this is an informal setting -- half-assed measures that Clinton and Obama propose focus entirely on covering people who are currently uninsured, and will do little or nothing to solve the crisis in health care costs. Edwards has what I will call a three-quarter assed proposal which may be intended to make it easier to move toward a single payer system, and there is something to be said for that, I suppose, but I'm going to tell it like it is.

In a classic article in Health Affairs, Uwe Reinhardt and colleagues explain why the U.S. spends 2 or 3 times as much per capita as other countries, and no, it has absolutely nothing to do with better health care quality or outcomes. On the contrary, the U.S., as I assume you all know by now, ranks close to the bottom among the wealthy countries, and even below some not so wealthy countries, in health status indicators and in the quality of its health care system.

The reason we spend so much, as Reinhardt explains, is "a highly complex and fragmented payment system that weakens the demand side of the health sector and entails high administrative costs." Switzerland, which has a more or less universal coverage system similar to the system Massachusetts is now trying to implement, came in second in per capita spending, at 68% of the U.S. level. The median country in the Organization for Economic Cooperation and Development spent 44% as much as the U.S. in recent years. As a percentage of GDP, the median in the other OECD countries was 8.3%, compared with 13.9% in the U.S. It is projected that we will be spending 18.4% of GDP on medical goods and services by 2013. As shown in a previous post, Medicare and Medicaid alone are projected to consume 20% by 2040, if there is no change in current policy.

Is this because we have more and better medical services? Just the opposite is true. The U.S. has lower physician to population and nurse to population ratios than most of the OECD members. We also have fewer hospital beds per capita than most. But, unlike all the rest, we don't provide affordable coverage for everybody and only a select portion of the population has access to those services. As Reinhardt et al state, "[S]some relatively low-cost medical interventions can yield additional QALY's [Quality Adjusted Life Years] at relatively low incremental costs . . . . At the other end of the spectrum, however, the health system can wrestle additional life years from nature's course only at increasingly higher incremental costs."

We don't do the former very well -- people without health care don't get those cheap, preventive services -- but we do the latter with total disregard for cost. Neither public nor private insurance providers in the U.S. use any overt considerations of cost-effectiveness in providing benefits. Drug companies develop new chemotherapies for cancer that provide an extra month or two of life at the cost of tens of thousands of dollars. They are FDA approved because they are "effective," and then we have to pay for them.

Medicare does not pay for catastrophic costs or long term care - there are lifetime limits on hospital benefits and nursing home care -- so people who need those benefits end up spending their savings and then, when they are destitute, Medicaid picks up the bill. There is no "invisible hand" that metes out justice in these situations. Some family fortunes are destroyed, some spouses are impoverished, because a person happens to have a long, expensive terminal illness. Other fortunes are preserved and people are well supported in their retirement because they happen to escape this fate. The money is spent, one way or another, but without consideration of benefit or justice.

We also pay far more for inputs, including drugs and medical devices, because the fragmented payers have little market power. The drug companies claim they need their huge profit margins to pay for research and development costs, but we know they allocate most of it to marketing, and focus their research on products with commercial potential -- which is usually based principally on how the products might be marketed -- which has little relationship to public benefit. Most of the basic research that leads to new medical technologies is carried out at public expense, by the National Institutes of Health, but drug companies, not the public, capture the resulting profits.

Finally, the administrative complexity and the perverse effects of competition among insurers add huge costs -- it is estimated that 24% of spending on "health care" in the U.S. is for administrative and marketing costs, nearly all of it for private health insurance. Much of this money is spent figuring out ways to deny people care -- not on the basis of cost-effectiveness, which would be beneficial, but on the basis of arbitrary rules intended only to save the insurers money, such as refusal to cover "pre-existing conditions" -- a phenomenon which can only exist in a fragmented system. Administrative costs for public insurance systems, including our own Medicare, are on the order of 3%.

In college economics courses, the professor first introduces a set of assumptions which are false. He (almost always he) then constructs an elaborate description of an alternate reality, one in which we do not live, based on these assumptions. Along the way, the professor and the students forget that the assumptions are false and the theory does not describe reality. This counterfactual theory is then treated as truth in economics departments, in think tanks, by politicians, by reporters and by fake reporters who just make shit up, such as John Stossel, and even by judges. The reason this phony theory is treated as the truth is because it provides a justification for inequality, privilege, and vested interest. It is a lie.

The only arguments against universal, comprehensive, single payer national health care are based on this fake theory. In a reality based world, we would do what is in all of our interest. Among other fundamental benefits, it will give us a way of solving the Medicare and Medicaid crises by:

Applying rational considerations of cost and benefit to decisions about what to pay for;
Improving the health of the population and delaying serious illness by providing appropriate preventive care and early intervention;
Spreading the cost of health care across the population in a manner which produces justice and equity;
Eliminating wasteful administrative costs.

The so-called "free market" does none of the above.

Back at you . . .

I'll be away from Your Intertubes until Sunday, so here's a drive-by post until then, based on your comments to the bit about the future of Medicare.

Mr. Gunn suggests applying the American Enterprise Institute Global Warming Correction Factor, thereby making the problem disappear and hallucinating the problem we want to worry about. While that is tempting, we here are in the Reality Based Community because it seems to be coming back into fashion, and we want to be in with the in crowd. C. Corax's suggestion, that by eliminating social security and letting the old folks starve, we can simultaneously contain Medicare costs, is indeed reality based but perhaps the AARP will have sufficient political clout to resist it.

Ana notes that predicting the future depends on assumptions that the world will go on more or less as it is now, except for obvious current trends. That is so. Most of the risk here would seem to be on the downside, however. The GAO's projection is based on economic growth continuing at the average rate since WWII; life span continuing to increase at about the rate it has been lately; and health care costs continuing to increase as they have been, which is actually a kind of optimistic assumption since the driving force is continuing advances in medical technology.

The life span question actually doesn't matter all that much. Even if the U.S. life expectancy stalls out or goes down a bit, the number of elderly people will continue to increase because there are so many people now in their 40s and 50s. And, even if they live to be 80 instead of 83, it won't affect Medicare costs very much because a big chunk of the money is spent on people in the last year of life, regardless of exactly when that happens. Ditto with Medicaid: it's mostly going for people in terminal stays in nursing homes, whatever age they may happen to be.

Failure of GDP to grow as expected would just make the problem worse, of course. But increasing medical costs we can actually do something about. In fact we have to; the question is whether it happens in a just and humane way, or results in a dramatic increase in social inequality. I'll get to that.

Roger wants to know why Social Security remains nearly constant as a percentage of GDP, even though a larger proportion of the population is retired. The reason is that when you retire, your social security benefits are fixed for life, based on the average earnings during your working years. After that, they are only indexed to inflation. But, the GAO assumes that GDP per capita will continue growing. So, as retirees live out their lives, each one of them consumes, year by year, a smaller percentage of GDP. Medicare and Medicaid, however, increase with health care costs, which exceed not only the rate of inflation, but the rate of GPD growth. Your benefits are not fixed at retirement, but represent an open-ended commitment.

Ferdzy and Kathy both note, one way or another, that part of the reason this is a problem is because there are competing demands, specifically military spending and interest on the national debt. Actually, those aren't entirely competing. A big reason we have a national debt, and will have a bigger one in the future, is because we choose to spend our treasure on fighting wars and building machines to blow up people and stuff.

As Roger points out, Medicare and Medicaid spending also represent consumption. They represent spending on something which is valuable to people, they are part of the GDP and unlike war spending, there is a payoff, the money isn't going down the rathole. That's an important point. It isn't necessarily bad for health care to take up an increasing share of the economy. After all, we can only eat three meals a day and there's little point in having houses bigger than we need or 198 pairs of shoes. As basic necessities become more affordable, of course we spend more of our income on other things. So the question is not, will Medicare and Medicaid cost more in the future than they do today, the questions are 1) will it be worth it and 2) will the political process result in equity and justice in the way our health care dollar is spent.

As Ferdzy notes, it looks like it won't, because those increasing Medicaid costs ipso facto mean more impoverishment. Furthermore, if Medicare and Medicaid really do get to be 20% of GDP, will taxpayers -- or rather the politicians who answer to the wealthiest and most powerful taxpayers -- be willing to fully fund them? Most people think not, especially since we will also have that huge interest bill and the 20 year war with Oceania to pay for. The result will be increasing gaps in coverage, or much more difficulty getting onto Medicaid. Remember that right now, most elders who wind up on Medicaid do so because they need long term care, and they have to completely wipe out their savings and become destitute before they are eligible.

So this is a real problem, but it doesn't have to be. We could afford it if we wanted to, although a good part of that spending is inefficient and we should not spend money that doesn't buy what it's worth. But we're unlikely to end up spending that much, which means some people will get screwed.

My final answer next time.

The Final Enemy

Yes, yes, I know, western civilization is collapsing, but I'll let others worry about that for now and focus on a specific issue.

Americans have a deep need for something to conquer, and so before the Global War on Terror we had the war on cancer and the war on poverty, and the "moral equivalent of war," by which Jimmy Carter meant energy conservation. (The moral equivalent of war? Would that be genocide?) But what you may not have noticed, because nobody labeled it that way, is the war on death. By God, we're going to vanquish it.

In the new BMJ, Dee Manging, Kieran Sweeney and Iona Heath offer a perspective from a slightly less bellicose country when it comes to the sickle-wielding evildoer. (Free full text access! Now how about re-opening the whole journal?) They aren't talking about heroic measures to extend the lives of the desperately ill, but rather mundane preventive interventions such as statins to reduce the risk of heart attacks. It turns out that when people over age 70 take statins, they do indeed have a slightly lower risk of cardiovascular disease morbidity and mortality. On this basis, statins are widely prescribed for elderly people. And why not? When I'm over 70, I'll probably be just as disinclined to have a heart attack as I am now. I don't plan on living forever, but I'm going for 100, because I still have a lot to do.

There's a problem, however -- although the treated group has lower cardiovascular risk, they don't live any longer. They just die of something else. Mangin and colleagues don't see this merely as a pragmatic failure, they see it as morally wrong.

When we vaccinate children in infancy, we are selecting out a cause of death for them, in this case justifiably, because deaths from infectious disease tend to occur prematurely. It is only when we select out causes of death for people who have already exceeded the average lifespan that the endeavour becomes morally questionable. . . . By providing treatments designed to prevent particular diseases, we may be selecting for another cause of death unknowingly, and certainly without the patient's informed consent. This is fundamentally unethical and undermines the principle of respect for autonomy. . . .

Prevention has side effects other than the hazards of the treatment—in particular, the shadow cast over a currently healthy life by the threat of disease, which might be magnified in elderly people for whom mortality looms closer. When we convey risk to any patient we should be cautious—it is like putting a drop of ink into the clear water of the patient's identity, which can never be quite clear again. . . . We should not carry on extrapolating data from younger populations and using linear models that use absolute risks of disease specific mortality and morbidity rather than all cause mortality and morbidity. If we do, the only ones to benefit will be drug companies, with increasing profits from an ageing population consumed by epidemics rather than enjoying their long life.

I am not offering this as a solution to the problem I identify in my previous post. The cost saving from not prescribing statins to people over 70 will be small. Applying this philosophy more broadly and accepting the inevitability of aging as we weigh preventive treatments might make a worthwhile contribution to reducing overall health care costs, but it will hardly solve the problem. (More on that anon.) But it will certainly relieve us of needless preoccupations and allow us to direct our physical, intellectual and spiritual energies in more rewarding directions.

There's the bad guy! Shoot the guy next to him!

David M. Walker, Comptroller General of the United States (who runs the GAO, a research service of the Congress), recently told an audience in Chicago that "Unless we reform Social Security, Medicare and Medicaid . . . by 2040 our government could be doing little more than sending out Social Security checks and paying interest on our massive national debt." As you may recall, a certain individual with a prominent job in Washington spent a good deal of time after the 2004 election saying the same thing, and insisting that Social Security be phased out because we can't afford it.

It's true that we do have a big bill coming due for federal entitlement programs. Here is Mr. Walker's own graph depicting the problem. (Click the thumbnail for the full sized image.)



Do you see what I see? Because it appears that nobody else sees the same thing. Does Social Security appear to be the problem here? Does it look like the work force of the future won't be able to generate enough income to pay social security benefits to their parents and grandparents? If my eyeballs are screwed in straight, it looks as though, in 2040, social security as a percentage GDP will be just slightly above where it is now, and declining. So why are we having all this panicked discussion of social security?

On the other hand, I can spot a teeny weeny little problem there. Do you see it too? I hope so, because nobody else does, apparently. So, what is to be done? I have some thoughts, obviously, but first let's start talking about the real problem for a change.

Nothing to be done?

Denise Grady in the NYT today wants us to go back to the summer of love and just go with the flow when it comes to our relatives with Alzheimer's disease. While I'm sure that's good advice as far as it goes, it's hardly a solution. People with dementia eventually become unable to manage activities of daily living, they become incontinent of urine and feces, they may engage in dangerous or offensive behavior, and ultimately it becomes, in most cases, impossible to care for them at home no matter how profound your spiritual enlightenment and they end up in nursing homes consuming family fortunes at the rate of $10,000 a month until everything is gone, whereupon they perform the same disappearing act on the taxpayers.

And yes, I'm talking about my own father (who actually, I believe, is properly diagnosed with frontotemporal dementia, but it doesn't matter) and it could be any of us some day. Half of all people over age 85 have Alzheimer's disease. Not all of them live long enough to end up in a state of total dependency, but everyone who does live for 8 years or so will.

So why haven't I written about this more? Basically because there isn't a whole lot to say about it. There you are. It's a big problem, that's just going to keep getting worse. Not only is there no cure or preventive measure in sight, we still don't even understand the etiology. Drug companies are working feverishly on the problem, but mostly in order to steal our money. They're hoping to find more drugs like Aricept and Nimenda, that do little or nothing but because they might do just a little something for somebody, desperate people are willing to pay a lot for them. They don't have any ideas for anything that will actually work.

I wish I could say it's all Karl Rove's fault, but he's in the clear on this one. Single payer health care won't help even a little bit, if it's modeled on Medicare, because Medicare does not provide coverage for long-term care. People with dementia have to pay out of pocket until they are flat broke, and then Medicaid takes over. Medicare or universal single payer coverage for long-term care would spread the burden more equitably, but it wouldn't reduce the total burden on society.

Even physician assisted suicide doesn't help because you have to be competent for that. My friend suggested that I take out a contract on myself with the mafia, to be executed only if I become demented, but they're criminals -- they'd just pocket the money and not bother to shoot me. Why take the chance? What am I going to do about it?

So that's it. This train is coming and it's going to run us all over. By 2050, something like 15 million Americans with the disease. I wish I had something useful to say but I don't. I'm stumped. We're stuck with this.

Right Speech

The whole field of rigorous study of physician-patient communication is essentially 40 years old. It got started with the availability of affordable, portable recording equipment, which Barbara Korsch first put to work to study interactions between pediatricians and mothers. Her most important observation was that the doctors would throw around a lot of medical jargon that the mothers didn't understand, but they would not speak up and ask questions.

On the one hand, we've come a long way since then, on the other, we're pretty well stuck. We've come a long way in that people have developed all sorts of approaches to coding and analyzing these interactions, and we do have some consistent observations about them. We're stuck because we still don't have a cogent idea of what approaches to physician patient communication are likely to result in the best medical outcomes, and we have even less idea how to teach doctors and patients to be more effective in communicating with each other.

The dominant paradigm is called patient-centered communication. Doctors are supposed to understand patient's health-related preferences and goals; factors in their life worlds that effect their health, ability to follow medical advice, and priorities regarding the risks, benefits and costs of various approaches to health care; and patients' health literacy levels and knowledge about medical issues, so they can explain medical concepts effectively. The dialogue is supposed to include opportunities for patients to ask questions, state their preferences, and clarify their understanding. And treatment decision making is supposed to be shared, based on a process in which physician expertise and patient values and feelings are equally considered, resulting in informed choice on the part of the patient.

Unfortunately, the evidence relating this paradigm to medical outcomes is mixed. There are fundamental difficulties, obviously, in deciding whether you have correctly measured whether these criteria are met. Even so, what is right for one patient and one doctor isn't necessarily going to be right for the next pair, and what is right in one situation isn't going to be right in another. Some patients don't want to make informed choices, some don't care to understand the doctor's explanation for their condition, they just want to be told what to do. It's less work, they have other things to worry about, and what is the doctor being paid for anyway, but to make medical decisions?

Of course, these same people might accept the prescription but not take the pills, but they also might just do what the doctor thinks best. The empowered patient who asks questions and makes informed choices might make bad ones, that result in poor medical outcomes; or might also be just as likely to accept the prescription but then not actually take it.

We can find statistical relationships between certain patterns of physician behavior and endpoints like medication adherence or glycemic control in diabetes, but these aren't necessarily much help to doctors who are trying to maintain relationships with individual patients, each of whom is different from all the others.

On the other hand we can apply fundamental ethical frameworks to the issue. We might feel that it's just the right thing to do to at least give people the opportunity to be informed, active partners in their health care. But then we need to figure out how to make that happen. I'll tell you right now that it's the exception. However you try to characterize physician patient communication, it tends to be radically asymmetrical and physician-dominated. Prescribing seldom incorporates even the basic elements of informed choice, or even informed consent, which is a weaker standard. Patients seldom ask questions about their health or health care, and in my own research, physicians actually make more statements about their goals, preferences and feelings than do patients.

I know that a lot of people, including me (see two posts back) often have complaints about their relationships with physicians, although most people say they like their own physicians personally and are happy with them.

Why do you think it is that medical communication is so asymmetrical? Do you speak up with your own doctor when you don't understand something, or you are reluctant to do what she or he wants? If not, why not?

What I Worry About

I'm not losing much sleep over the current financial crisis. I don't mean that I'm not troubled by all those people losing their homes -- and presumably ending up destitute in the process -- but I'm referring to the fallout in the financial markets. It's costing some rich people money they can afford, it will hurt some pension funds and non-profit endowments and retirement accounts a bit but investment portfolios always have some losers and some ups and downs. Yes, it might tip the U.S. economy into recession but that's bound to happen sooner or later and it's just something we'll have to get through.

I know we have to deal with resource depletion and global warming, and we're going to have water wars and famines and rising oil prices and more storms and droughts and all that stuff, but Homo sapiens spent its first quarter of a million years at the mercy of the weather and the local ecosystem so we might as well get used to it again. There are a lot more of us to get decimated than there were in the past, and it could turn ugly here and there, but I'm sure the Ice Age wasn't any picnic either.

Bird flu? A mere bagatelle. (Whatever that means.)

I do, however, worry about President Cheney attacking Iran. It's obvious he wants to do it -- he's got Charlie McCarthy out there with Hamid Karzai and Nuri al Maliki, insisting that Iran is causing all the problems in their countries even though they both insist that they're down with Iran, it's cool. He's got his floorboy generals accusing Iran of killing our boys over there in Eye Rak, even though the evidence evaporates whenever anybody tries to look at it. And anyway, I thought it was al Qaeda. Make up your damn mind.

Yup, Uncle Dick is trying to whip up the war frenzy. He hasn't gotten the crowd going much, so far, but you know what? It doesn't matter. He'll just do it anyway. The Democrats in Congress not only won't try to stop him, the second the bombs start to fall, they'll fall in line, stand shoulder to shoulder, and Support our Troops, or rather our heroes who drop bombs from the sky on people who can't even see them. There's nothing braver than that.

Anybody out there care for a small wager?

God Damn the Pusher

Okay, it's a day late, but I promised one of those rare personal anecdotes. My father has dementia, now very advanced, but just a few months ago he could still communicate pretty well and enjoy some activities. He was in an assisted living facility due to a lot of need for help with activities of daily living.

One day my mother went to visit him and found him slouched in a chair, drooling, and unable to walk. She thought he'd had a stroke. Then they told her they had given him a new medication, called aripiprazole, so she called me up to ask if I thought that might have anything to do with his setback.

Ahh, yeah, maybe. It's an antipsychotic. The side effects include increased salivation and asthenia, i.e. weakness, lack of energy or strength. And oh yeah, there's this little, its bitsy, teeny weeny insignificant BLACK BOX WARNING:

WARNING

Increased Mortality in Elderly Patients with Dementia-Related Psychosis

Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. ABILIFY (aripiprazole) is not approved for the treatment of patients with dementia-related psychosis.

And oh yeah -- there are no trials that have shown that this stuff has any beneficial effect in people with dementia-related psychosis. Did my father even have dementia-related "psychosis"? He was back in his navy days, and he thought he was on a ship. I don't know whether that's "psychosis" or not, but who cares? I particularly like the brand name, don't you? "Abilify." It is to laugh. So they took him off the drugs and the problems immediately cleared up.

Anyway, he kept declining of course so my mother eventually moved him to a nursing home. After a couple of weeks, she went to visit him and found him, yup, slouched in a chair, unable to walk, and drooling. She went to the nurse and yup, sure enough, they'd given him Abilify. But they didn't do it to abilify him, they did it to disabilify him. He was going into the physical therapy room, they told her, and they didn't want him wandering around like that. And yes, a physician wrote the prescription in both cases.

Now here's a little primer in medical ethics:

1) Physicians are to act in the best interest of the patient. You don't write prescriptions to zonk people out in order to make life more convenient for nursing home staff.
2) Medical treatment requires informed consent. In this case, because my father is incompetent, my mother has a signed health care proxy and a power of attorney. They gave him this drug without even telling her, let alone asking.
3) Physicians are supposed to be diligent and keep themselves well informed about the conditions they treat and the treatments they use. In other words, Read the Fucking Label.

Atypical antipsychotics have never been shown to be efficacious, and have never been approved, for use in people with dementia. So why are they prescribed for that purpose? Because drug companies send good looking young people around to doctors' offices who tell them it's a good idea.

Finally, although I admittedly have a small sample, this happened twice to one man in the space of a few months, so do you think maybe it happens a lot, like routinely? Maybe. My mother wrote a letter to the nursing home staff telling them never to do it again, and they were taken aback and non-plussed. They were supposed to get informed consent for treatment? They were supposed to prescribe drugs for the benefit of patients? These were highly unusual demands.

Reader and Advisor?

I don't know how it's playing in the wide world, but the tabloids in the northeast, and for that matter the front page of the New York Times, have been much occupied by a horrific crime that happened in Cheshire, Connecticut last week. Two career criminals, on parole, invaded a home in an affluent bedroom community and went on a rampage of rape and murder that left two girls and their mother dead. The father, no doubt unfortunately from his point of view, escaped. The details of the crime, as described in the Times, are so depraved that I won't describe them for you.

The howls of outrage from the right have also been so predictable that you can probably write them for yourself. I happened to flip past Glenn Beck, on my way to the rebroadcast of the Daily Show, and he was yelling, literally, about the idiots on the parole board who let these guys out of jail.

Well, y'know what? It's not that simple. Neither of the psychopaths in question had any known history of violence whatever. One was a house burglar, and the other did smash and grab robberies from cars. Sorry to give you the news Glenn, but we can't lock up every burglar for life. It would cost more than, well, the war in Iraq, in other words we're talking Big Government, which I'm sure is not what you want. And the absolute worst thing we could do would be to eliminate parole, which means just dumping criminals onto the street without any period of supervision or reintegration. In fact, Connecticut was pretty diligent in this case. Both of them had a period of closely supervised release in a halfway house, including electronic monitoring. One of them had just had the monitoring bracelet removed two days before the savagery erupted.

Steven Hoge, MD, director of the division of forensic psychiatry at New York University School of Medicine, in New York City, tells JAMA's Lynne Lamberg in the August 1 issue that clinicians, at best, do little better than chance at predicting who will commit violence in the future. Violence is associated with severe mental disorders, but neither of the Cheshire suspects has been diagnosed with mental illness. One putatively predictive tool, the Historical, Clinical, and Risk Management 20-item checklist, includes items such as previous violence, young age of first violence, and non-compliance with treatment, and it apparently has some predictive value, but it appears that it would have rated these particular individuals as unlikely to commit violence.

Anyway, you can't incarcerate people because of what you believe they might do in the future. This was a disturbing, horrific event and of course everybody wishes there were some way to prevent it. But as far as I can tell, there just wasn't a whole lot that anybody could have done.

Doctors Orders!

Dr. Showalter has links and commentary about a new "Action Plan for Enhancement of Medication Adherence." I basically agree with his reservations -- adherence isn't just about educating patients, it's about doctors and patients figuring out what each other's goals are and getting on the same page. (Paternalism, anyone?) In other words, it's a two way street. I'm not going to adhere to medical advice if it just isn't worth it to me, and you could educate me up the wazoo and it isn't going to matter.

But I will add this -- it's a two way street in another way, because doctors don't always adhere to medical advice either. There are some prescriptions people just should not adhere to, because they shouldn't have been written in the first place. I'll tell you a case in point, one of those personal anecdotes I try to use sparingly, tomorrow.

But, if I am feelin' the city breakin' and everybody shakin' and what I want to be is stayin' alive, and my doctor does happen to have the right idea about how to do it, then whatever it takes to help me follow the advice is a good thing. Right now, half the people don't, and yes, this is a big problem.

Weird science

Sharon Begley in Newsweek reviews the history of the global warming denial industry.

I don't have much to add to this except to note that, while I'm not a climate scientist and I have only limited ability to evaluate the arguments on my own, I still have very good reasons for deciding who to believe about this. If a basic scientific question becomes a partisan political issue, something is wrong. Denial that tobacco causes cancer was financed by the tobacco industry, the scientists who supported that denial were funded by the tobacco industry, and they did no empirical research of their own but merely produced critiques of real research done by others -- the overwhelming majority of biomedical researchers who concluded that tobacco does indeed cause cancer and heart disease long before it became public policy to discourage tobacco use. And the tobacco industry also gave vast sums to Republican politicians to promote the appearance of scientific doubt and protect the industry from regulation.

With global warming, the parallels are perfect. The few scientist deniers are funded by the fossil fuel industry. They do no empirical research, they just raise doubts about the research done by others, the vast majority of climate scientists who conclude that human activity is indeed warming the planet. And they give money to Republicans to turn this non-debate into a political issue and stop any meaningful action to limit fossil fuel consumption.

It is particularly telling that the global warming denial movement has simply shifted its premises every time its position became untenable: first they claimed the planet was not warming. When that was conclusively proved false, they claimed human activity had nothing to do with it. When that was conclusively proved false, they claimed that human induced global warming would be of trivial importance, even beneficial. I don't know what the next step will be, but the point is, you should always smell a rat when a camp of doubters remains committed to a conclusion, even as their reasons for belief keep changing.

That's why you don't need a Ph.D. in atmospheric science to know who to believe. Cui bono.

By the way,

for what it's worth, the lyrics to Stayin' Alive, by Barry, Robin, & Maurice Gibb:

Well you can tell by the way I use my walk
I'm a woman's man
No time to talk
The music loud and the women warm
I've been kicked around
Since I was born

And now it's all right
It's okay
And you may look the other way
We can try to understand
The New York Times' effect on man

Whether you're a brother
Or whether you're a mother
You're stayin' alive
Stayin' alive
Feel the city breakin'
And everybody shakin'
And we're stayin' alive
Stayin' alive
Ah ah ah ah
Stayin' alive
Stayin' alive
Ah ah ah ah
Stayin' alive

Well now I get low and I get high
and if I can't get either, I really try
Got the wings of heaven on my shoes
I'm a dancin' man and I just can't lose

You know it's all right
It's okay
I'll live to see another day
We can try to understand
The New York Times' effect on man

Whether you're a brother
Or whether you're a mother
You're stayin' alive
Stayin' alive
Feel the city breakin'
And everybody shakin'
and we're stayin' alive
Stayin' alive
Ah ah ah ah
Stayin' alive
Stayin' alive
Ah ah ah ah
Stayin' alive

Life goin' nowhere
Somebody help me
Somebody help me
Yeah

Life goin' nowhere
Somebody help me
Yeah
Stayin' alive

Well you can tell by the way I use my walk
I'm a woman's man
No time to talk
The music loud and the women warm
I've been kicked around since I was born
And now it's all right
It's okay
And you can look the other way
We can try to understand
The New York Times' effect on man

Whether you're a brother
Or whether you're a mother
You're stayin' alive
Stayin' alive
Feel the city breakin'
And everybody shakin'
and we're stayin' alive
Stayin' alive
Ah ah ah ah
Stayin' alive
Stayin' alive
Ah ah ah ah
Stayin' alive

Does it seem apropos?

Fear and Trembling and the Sickness Unto Death

Fear is good, of course. If it weren't for fear I wouldn't be writing this and you wouldn't be reading it because our ancestors would have been killed by snakes, tigers, or the people next door. Humans would not have stayed around long enough to invent Your Intertubes, smart bombs, KY Sensual Evening Wash, or any of the other things that make America great.

However, evolution has put fear on an overly sensitive trigger. For a small band of hunter gatherers on the edge of the Savannah, it's better to be unnecessarily scared 100 times than not scared when you should have been even once. There's very little cost to steering clear of a place, ducking and covering, or running. You can always gather your roots and berries later or someplace else, scavenge the next carcass, or go after the next herd of wildebeest. Also, it's very unlikely that fellow members of the band would give you false warnings -- what motive would they have? There was little hierarchy and nothing to steal.

Notice that evolution has made it possible for us to be equally afraid of what we observe with our own senses -- something that looks like a snake, or a dark forest -- and of what our fellows tell us, which is true of every social and flocking animal from chimpanzees to field mice that have alarm cries. So, unfortunately, in the very hierarchical, complex societies in which we live today, with immense stores of capital and institutionalized social power, there is plenty of motivation and opportunity for people who are in a position to do so to use fear to manipulate others.

There is along tradition of this in the United States beginning, of course, with our puritan preachers, the first leaders of the seminal English settler culture who specialized in terrifying the townspeople with horrific visions of hell. In 1741, Jonathan Edwards of Enfield (now in Connecticut), preached one of the most famous of the early American sermons, in which he said:

O sinner! Consider the fearful danger you are in: it is a great furnace of wrath, a wide and bottomless pit, full of the fire of wrath, that you are held over in the hand of that God, whose wrath is provoked and incensed as much against you, as against many of the damned in hell. You hang by a slender thread, with the flames of divine wrath flashing about it, and ready every moment to singe it, and burn it asunder; and you have no interest in any Mediator, and nothing to lay hold of to save yourself, nothing to keep off the flames of wrath, nothing of your own, nothing that you ever have done, nothing that you can do, to induce God to spare you one moment.

Except, of course, for Rev. Edwards and his church.

God seems now to be hastily gathering in his elect in all parts of the land; and probably the greater part of adult persons that ever shall be saved, will be brought in now in a little time, and that it will be as it was on the great out-pouring of the Spirit upon the Jews in the apostles' days; the election will obtain, and the rest will be blinded.

Funny thing about that, it didn't happen. Anyway, here we are again. This time, God's wrath will be visited upon us if we don't give George W. Bush and Alberto Gonzales the power to listen to our telephone calls and read our e-mails; to send young people eternally to shoot and bomb Iraqis and meet their own deaths in the process; to use the institutions of the law to persecute their enemies and protect their friends; to relieve the wealthy of the burden of taxation and to leave the poor to their spiritually enobling fate. In Edward's sermon, Satan was explicitly named as the instrument of God's wrath. In George W. Bush's sermon, God's instrument is Muslim terrorists.

What is inexpressibly discouraging about all this is that the election of a Democratic majority in both houses of Congress changed nothing. Your Democratic legislators are terrified into submission by the mere threat that Mr. Bush will blame them for God's anger, if they don't give him everything he wants. There is no help for us.

The Spirituality of Reason

Why are Americans, uniquely among the wealthy and well-educated nations, so inclined to cower from the reality that shows itself to observation and reason, and hide in the superstition, fantasy and magical thinking of primitive forms of religion? For some reason, human culture has started to grow up in Europe, yet we have a pervasive developmental disorder.

I haven't come across any good analyses of this question, indeed I haven't found many efforts to grapple with it at all. It's just something we observe. A majority of Americans do not believe in biological evolution, and a substantial proportion reject the very existence of the physicist's universe. Questions such as whether adding carbon dioxide to the atmosphere causes it to become warmer, whether burning coal deposits organic mercury in bodies of water and contaminates fish, or whether instructing teenagers not have sex causes them to be celibate are treated not as empirical questions, but as propositions to be answered by faith and resolved through political power.

This situation is obviously extremely dangerous. In fact, unlike al Qaeda, which shares this basic philosophy, it poses an existential threat to our society, because we are already fighting it over here (and we aren't fighting it over there, either). But why are we like this? I don't have any very good ideas about why Americans are different from Europeans in this regard, but at least I have some idea of the appeal of unreason.

Scientific explanations for the world can be inconvenient, of course, as in the cases of global warming, pollution, and sex education, because they might mean we have to do something we would prefer not to do such as drive our cars less, use less electricity, or accept the fact that our kids might have sex whether we like it or not. But the big questions such as the origin and nature of the universe, and the evolution of life and human consciousness, pose graver threats to the ego. In the universe so unimaginably vast in space and time, into which we emerged by accident, we mean absolutely nothing. In Andrew Marvell's words,

. . . for the world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.

There is, after all, something deeply fearful in our nature. I believe this is the same impulse that makes us behave as cowardly bullies in international affairs. Every problem is an existential threat to be met by overwhelming military force. Only if we swagger and bomb and shoot our way around the world can we ever feel safe. But if we can't even confront a rag tag band of fanatics holed up in remote mountains 8,000 miles away with equanimity, proportionality, and a rational strategy, how can we confront the indifference of the universe?

I don't know why Americans are such cowards, but I do know how to be brave. The way to thrive in this ancient, immense, cold dark universe is to believe in ourselves, celebrate ourselves, and take comfort in the meaning we have to each other. Who cares that there isn't a God who loves us or looks after us? We have each other, and eternity is before us as a species. We can work together to survive, grow, learn, and reach out to the planets and the stars. The universe may seem pointless, but it is far more awesome than some old codger who lives in the sky. Discovering it, understanding it, and learning how to live in it are enough to give meaning to any life.

Marvell's verse began with some words I omitted: Ah, love, let us be true To one another! Well, we aren't always faithful to our romantic partners, but that isn't what he meant.

Smorgasbord

1) I've long been one of the party poopers at the Massachusetts universal health care celebration -- with apologies to my friends, but I've got to be honest. The reform does nothing to contain costs or move effectively toward a more rational allocation of resources. The result is that we aren't going to be able to afford it. My fellow party poopers Alan Sager and Deborah Socolar explain it all for you here.

2) I read the wrap-up articles on Iraq yesterday from several sources -- AP, WaPo, the NYT, and others. They all say the total of U.S. deaths in Iraq in July was the lowest this year. And they gave the figure as 78. First of all, the military usually delays reports of combat deaths by at least a day or two, so the total for July is now 80. That's still the lowest this year, but that's highly misleading. It was a bad month for the Brits, as it happens, so the total of MNF deaths in July was higher than in January, February, or March. Second, July has always been a slow month for combat deaths in Iraq -- there was a dip in 2006 and 2005 as well. This year was actually the deadliest July for U.S. forces, by a lot. (Might have something to do with the 130 degree afternoons. Killing Americans is just too much work under the circumstances.) Third, it was a particularly deadly month for Iraqis, so the Americans may have been keeping their own asses a little bit safer than they did in June, but they weren't doing shit for the Iraqis, and why are they there again? Reporters are unencumbered by the thought process.

Update: Specifically, according to the official Iraqi government count, which is a gross understatement, the death toll for Iraqi civilians rose in July to 1,653 from 1,227 in June. But hey, we're winning! We're definitely winning!

3) Here in the People's Republic, we've had legislation introduced which has a chance to be a model for the U.S. It would make eliminating racial and ethnic health disparities a goal of state government and back that up concretely, with an office in the secretariat of Health and Human Services that will evaluate all state policies with respect to their impact on disparities -- and that means environmental policy, housing, transportation, education, labor, economic development, you name it -- not just health care and public health. It would also put up some money for meaningful programs and policy evaluation. Eliminating social disparities in health saves the state money, gang, by reducing future health care costs and disability, and improving the productivity of the population. That's what liberalism is all about -- being all that we can be. Here's info about Massachusetts House Bill 2234. You'll be hearing more about this.

Get off your sorry butts

As you know if you've been reading, the House is considering re-authorization of the Supplemental Childrens' Health Insurance Program (S-CHIP) today. It's going to pass both houses, but the Emperor of Mespotamia has vowed to veto the bill on what he calls "philosophical" grounds, because it will successfully provide government sponsored health care to children, and he's against that because, uh, insurance companies give money to Republican candidates.

That means we need to override the veto. That means we need 2/3 in both houses. That can happen, and if it does, it will be one good shove toward the disposal chute for the Chimpoleon administration. The American Public Health Association has set up a web site to make it very easy for you to contact your Senators and Representative and let them know that this bill is important to you. Go here, and do it! Millions of children will thank you.