Primum no nocere

We've all heard of "First, do no harm," and we assume this is a fundamental principle of medical ethics. It is not. A physician who truly tried to live by that creed would be out of business. Medical intervention in general almost always carries some risk of harm.

For example, David Brenner and Eric Hall in the new NEJM remind us that those quick and easy CT scans, even though they make terrific pictures of our insides that doctors really get hot over, expose us to quite a bit of radiation. In fact, they estimate, up to 2% of cancers in the U.S. may be attributable to CT scans. That probably sounds worse than it really is for various reasons that I won't go into here because I'll do it another time, but still, it obviously isn't a good thing.

That certainly doesn't mean we should junk all the scanners, however, or that you should necessarily refuse one if your doctor thinks it's a good idea. Under many circumstances, a scan might be worth the risk. The issue is to understand the risk/benefit situation (I won't call it an equation or a ratio because it isn't that simple) and to make an informed decision that makes sense in your case. Since people like news you can use I will tell you that the single biggest parameter is age. CT scans create far more lifetime risk for children than they do for people over age 40 or so.

But rather than trying to make decisions based on a blog post, what you need to do is make your doctor look up the relevant information and discuss it with you. Mostly, they don't do that. Indeed, Brenner and Hall write that "In a recent survey of radiologists and emergency-room physicians, about 75% of the entire group significantly underestimated the radiation dose from a CT scan, and 53% of radiologists and 91% of emergency-room physicians did not believe that CT scans increased the lifetime risk of cancer."

I've had two abdomen scans in my life, both of them probably fully indicated, but still, I don't like to hear that. One of the most intractable problems in medicine, it seems, is just getting doctors to pay attention to what they are supposed to know.

Drive by observation

I'm at a meeting of grantees of a federal initiative called the National Child Traumatic Stress Network. This program, administered by the Center for Mental Health Services, aims at strengthening capacity within the U.S. to provide treatment to children who have suffered psychological trauma -- and no, it's not principally about drugs, but about evidence based counseling.

So far so good -- there's a lot of child abuse and neglect, child witnesses to violence, natural disasters, you name it, and kids get hurt. Oh yeah, there's also war. In the latest reauthorization, Congress directed some of the resources of the initiative to military families, but apart from that, I was really struck in my first day here by how many of the agencies just happen to have encountered a lot of children in military families that need their help. Obviously, it's tough on a child when Daddy disappears for a year and then comes home with half his face blown off, or dead, or just sullen and withdrawn and prone to explosive outbursts or drunk all the time. But short of such dramatic problems, the long separations, constant relocations, and anxiety, are very tough on families.

Military families have a lot of divorce, suicide, domestic violence. Let me tell you something, in case you didn't know. There is absolutely nothing, nothing at all, that is ennobling, or glamourous, or glorious, about war. War is ugly, and depraved, and destructive, for everybody it touches, victor or vanquished, liberator or occupier, aggressor or defender, right wrong or undecidable. War is evil. Warmakers are evildoers. Have no part of war.

The ninth circle

In case anybody noticed that I didn't post yesterday, it's because I was travelling to Richmond for a conference, and I expected to post after I got here. Foolish naivete.

What I mean to say is, I spent the day travelling, which is to say I spent the day in hell. My flight was only 2 hours late out of Providence, which means that according to the schedule I would miss my connecting flight but I wasn't worried, indeed my biggest problem was killing time in Philly. Philadelphia airport was a river of human misery, with the soundtrack provided by screaming, inconsolable babies. The people were sullen, exhausted, hungry, unhygenic, but their anger was buried in helplessness and apathy. Some stared vacantly like concentration camp survivors.

They always lie, of course, about when the planes are leaving. If they post a flight as half an hour late, you know that means at least 90 minutes. Then they pack the steel cocoons like slave ships, and then they just leave you there. In this case, the machine that loads bags into the cargo hold got stuck, and it took them an hour to figure out how to get it out of the way so they could close the cargo door. Once we finally did get to Richmond, we circled the city for 45 minutes, and when we finally landed, we had to sit there for half an hour until they got another plane away from the gate. Of course there were six open gates, but they couldn't use them, because we were assigned to one that was occupied.

The airline industry is the only industry, as far as I know, whose employees' attitude toward customers ranges from callous indifference through hostility to gleeful sadism. They actually hate us. We're a problem for them, and nothing more.

I could easily have driven from Boston to Richmond in the time it took me to fly. Next time, I will.

Back to Civilization

How the hell does such unmitigated garbage get published in the New York Times? Here we have yet another idiotic apologia for religion, this time from the director of an entity called "Beyond, a research center at Arizona State University." Check this out:

SCIENCE, we are repeatedly told, is the most reliable form of knowledge about the world because it is based on testable hypotheses. Religion, by contrast, is based on faith. The term “doubting Thomas” well illustrates the difference. In science, a healthy skepticism is a professional necessity, whereas in religion, having belief without evidence is regarded as a virtue.

The problem with this neat separation into “non-overlapping magisteria,” as Stephen Jay Gould described science and religion, is that science has its own faith-based belief system. All science proceeds on the assumption that nature is ordered in a rational and intelligible way. You couldn’t be a scientist if you thought the universe was a meaningless jumble of odds and ends haphazardly juxtaposed. When physicists probe to a deeper level of subatomic structure, or astronomers extend the reach of their instruments, they expect to encounter additional elegant mathematical order. And so far this faith has been justified. . . .

Over the years I have often asked my physicist colleagues why the laws of physics are what they are. The answers vary from “that’s not a scientific question” to “nobody knows.” The favorite reply is, “There is no reason they are what they are — they just are.” The idea that the laws exist reasonlessly is deeply anti-rational. After all, the very essence of a scientific explanation of some phenomenon is that the world is ordered logically and that there are reasons things are as they are. If one traces these reasons all the way down to the bedrock of reality — the laws of physics — only to find that reason then deserts us, it makes a mockery of science. . . .

It seems to me there is no hope of ever explaining why the physical universe is as it is so long as we are fixated on immutable laws or meta-laws that exist reasonlessly or are imposed by divine providence. The alternative is to regard the laws of physics and the universe they govern as part and parcel of a unitary system, and to be incorporated together within a common explanatory scheme.

In other words, the laws should have an explanation from within the universe and not involve appealing to an external agency. The specifics of that explanation are a matter for future research. But until science comes up with a testable theory of the laws of the universe, its claim to be free of faith is manifestly bogus.

This is too easy for a hint, but in case anybody out there needs this spelled out: What the scientists are saying is that they do not know, ultimately, why the reality they discover is the way it is. How is this the same as "faith"? It is the opposite. Yes, there is much we cannot explain. Scientists leave it at that, and keep looking.

To state that because there is a gap in our understanding, the explanation must be God, is an act of faith. Elegant mathematical order is not an article of faith, it is a finding; the expectation that it will continue to be found as we probe deeper is not an article off faith, it is a hypothesis.

This is drivel.

Gosh, how'd they do that?

I will be disconnected from Your Intertubes for a few days, probably until Sunday unless I happen to stumble across a portal to the placeless space.

Meanwhile, all I got is that while Your Intertubes really are pretty magical, after a long day of thinking too hard about stuff you really don't care about, while trying to expend an hour or so of unneeded consciousness I got caught watching a TV show which purported to be finding the greatest magician. I watched out of the fascination associated with a train wreck. The competitors consisted of uncharismatic performers doing the stupidest, crappiest tricks I have ever seen in my life. I wouldn't put up with that degree of idiocy at a third grade birthday party.

Here's one of the amaaaaaazzzzing illusions. The magician asks his assistant what kind of a sweet she would like. She says a chocolate chip cookie. He has her reach into the bag which has been sitting open in front of her on a table for the past five minutes and -- TA DA! -- it's a chocolate chip cookie. Are people really stupid enough that they're sitting there baffled?

But then I remembered how we got into Iraq. Dick Cheney would tell the New York Times that Saddam Hussein had Weapons of Mass Destruction™; the New York Times would print on its front page that according to anonymous senior administration officials, Saddam Hussein had Weapons of Mass Destruction™; Dick Cheney would go on TV and say, "See, you don't have to believe me if you don't want to, it's in the New York Times!" Then all of the members of Congress, the talking heads, and your Uncle Fred started screaming and yelling, "Saddam Hussein has Weapons of Mass Destruction™! You don't have to believe the Bush administration if you don't want to -- it's in the New York Times!"

So the magic trick is we're supposed to believe that the magician's assistant isn't working for the magician. Why would anybody believe that? Maybe because they want to be bamboozled.

A blast from the blastocyst

I haven't written much about the whole embryonic stem cell thing, partly because I never saw it as the most pressing issue. The media and the public are obssessed with the possibilities for dramatic, high technology biomedical breakthroughs, but what we're really talking about are procedures that in a decade or two might benefit a small number of people in wealthy countries who have uncommon injuries or degenerative diseases associated with advanced age. The vast majority of the earth's people will never be able to afford these treatments, and they already are lacking in far more basic needs. Even in the wealthy countries, as a matter of fact, we can accomplish far more public health benefit for far less money with simple measures that we don't bother with. So while I have thought that restricting stem cell research on putative moral grounds is absurd, and the opposite of moral, I have had more important things to worry about.

However, I feel I should say something about the news that investigators believe they have created embryonic stem cells by reprogramming somatic cells, rather than by the somatic cell nuclear transfer cloning technique that the Catholic bishops and conservative Christian preachers swindlers consider to be the destruction of human life. I don't know why nobody is willing to say this publicly, but it is obvious that there is no basis for this claim whatsoever in the Bible or in Christian theology as it developed over the first 1,980 years or so. Apparently they all have a personal hotline to God, who called them up one afternoon and said "Zygotes are human beings. You know what you have to do." In other words, they're pulling it out of their asses.

Like most sensible people, I feel that the qualities that make an entity human in a morally meaningful way depend on a functional cerebral cortex, which embryos obviously lack. The preacher's swindler's claim is that zygotes and the embryos that develop from them have the potential to become a recognizable human being, and that potential alone endows them with the moral status of human beings. This can be reduced to the absurd with ridiculous ease, but for now let's pretend to accept it.

The swindler's are ecstatic this morning because the news gets them out of an awkward position. Opposition to stem cell research is politically unpopular and it was hurting their candidates at the polls. Now they claim the whole thing is resolved, not a problem, and they don't have to carry that piano.

I have potentially bad news for them. If these truly are embryonic stem cells, then it should not be very hard to induce them to form embryos. After all, once the zygote divides, you have nothing else but two embryonic stem cells, and they go on to form an embryo. The researchers have no interest in making embryos, so they haven't even tried to figure out how to get it to happen, but somebody probably will, because that will be a method for cloning humans. Actually it will produce a true clone, which somatic cell nuclear transfer does not, since in the latter case the clone does not have the same mitochondrial DNA as the individual who supplied the nucleus.

So these embryonic stem cells, as surely as cells derived from a zygote, are potential human life. The only distinction is that they have not started to form an embryo -- but neither has a zygote, which the swindler's claim is a human life merely because it has the potential to yield an embryo. As do these cells. So the moral parsing they are doing just gets finer, and finer, and more and more absurd. Thwart the potential of an embryonic stem cell to become a human being, and you're fine and dandy, still going to heaven. Thwart the potential of a zygote to become a human being, and you're a murderer, going to hell. How do we know this? Well, it must be in the Bible somewhere, you just have to look harder.

The Age of Denial

John Kenneth Galbraith's popular economic history of the first part of the 20th Century is called The Age of Uncertainty. My history of the present era -- once I get done with the other three books I keep meaning to write -- will be called The Age of Denial.

The presidential campaign we are now enduring is utterly surreal. Barack Obama, rightly, has gotten a major wacking for talking about a Social Security crisis, when there actually isn't one. But helloooooooooo Barack, Hillary, John, Chris, all you characters -- there really are crises out there, major problems that we need to acknowledge and get to work on. I don't expect the Republican candidates to be connected in any way to reality, but somebody has to be.

Medicare and Medicaid: Yes, a for real, honest to gosh, big bad crisis, embedded in the broader crisis of a dysfunctional and increasingly unaffordable health care system in genera. Y'all are talking about various ways of increasing the number of people who have health insurance, but forcing people to buy insurance they can't afford is to ignore the real, fundamental problem. Actually it just makes it worse. Oh yeah, it isn't progressive either.

Debt: Both public and private. Social Security can pretty much pay for itself, with a little tweaking, but the rest of what government does is hugely underfunded. In fact, by any rational accounting, the United States is bankrupt. And so are a lot of it's people, who have been living on credit card and home equity debt. The dollar still has a long way to fall, and all that bad debt is just starting to peek out from the arcane and obscure books of financial institutions. It's gonna get uglier and uglier.

Decaying infrastructure: And while we're living beyond our means, we haven't bothered to maintain the house. All those highways and bridges and water treatment plants and schools and airports and water mains and what all built mostly in the 1950s, and some before that, are ready for the scrap heap. We must pay.

Nuclear weapons: Don't get me started. The problem is not that Iran might get them some day. We need to eliminate the ones that already exist.

Peak oil: Nothing to see here, move along. Oh, okay, let's make ethanol from corn . . .

Global climate change: Yeah, the Democratic candidates occasionally mention this. They want to make ethanol from corn. Aside from that, nada. In fact, the issue is no longer just carbon emissions -- the horse has left the barn, folks. We need to plan and prepare for the consequences. It is happening, now.

Sustainability of the human population: The price of food is already going up with the price of the fossil fuel used to grow, transport and process it, and now it's going up even more sharply as we start to cook food into fuel. Malthus was actually right, you know -- we just got a break for a century and half or so with the demographic transition in the wealthier countries and rapid technological advances in agriculture. There isn't another ace in that deck, believe me.

Drug resistant pathogens and emerging infectious diseases; grotesque economic inequality in the U.S.; declining real incomes of American workers; the needs of a growing population of elders, including more and more extremely old people; and more stuff I could think of.

We aren't talking about any of this! We're obsessed with a non-existent threat of the Islamofascist movement taking over the world, the moral status of zygotes, the invading brown Mexican hordes who are going to make us all eat tortillas and play giant guitars or something -- in the worst case scenario, they might even get driver's licenses -- and how we can cut taxes on investment income.

Oh well, you won't get elected by bringing people down.

A Readin' Fool

I was going to explain that I've been a little light on posting lately because I've been trying to catch up on my reading. Unlike your average highly paid pundit, I have this idea that I ought to know what I'm talking about before I spout off in public. Then I came upon this news from the National Endowment for the Arts, which reviewed recent academic studies to conclude that young people today aren't reading. Some highlights, as reported by the Boston Globule's David Mehegan:

Only 30 percent of 13-year-olds read almost every day.

The number of 17-year-olds who never read for pleasure increased from 9 percent in 1984 to 19 percent in 2004.

Almost half of Americans between ages 18 and 24 never read books for pleasure.

The average person between ages 15 and 24 spends 2 to 2 1/2 hours a day watching TV and 7 minutes reading. . . .

Apparently, things are not much better among college students. In 2005, almost 40 percent of college freshmen (and 35 percent of seniors) read nothing at all for pleasure, and 26 percent (28 percent of seniors) read less than one hour per week. Even among college graduates, prose-reading proficiency declined from 40 percent in 1992 to 31 percent in 2003.

Now this goes a long way toward explaining why we're in so much trouble. No wonder politics is all about who you want to have a beer with and the way Hillary laughs. Most voters don't know the difference between Medicare and Medicaid and think we stood shoulder to shoulder in World War II with our valiant German allies against the Stalinist threat to take over the world. They not only think Saddam Hussein had Weapons of Mass Destruction™, they think he used them against U.S. troops. They don't know Sunni from Shiite from Shinola. They believe the Bible is literally true but they haven't read it and they have no idea what's in it. (Which, by the way, is the only way a sane person could believe that.) They have vague impressions that there are problems out there but they have no basis for understanding or thinking critically about competing policy proposals -- which leaves us wide open for demagoguery and outright lying by politicians. And that's what we get.

Death to television!

Are you thinking what I'm thinking?

Tom Engelhardt is, but even he seems to stop one step short of the abyss.

What happens if, three months from now, or even a year from now, the people in metropolitan Atlanta - almost 5 million of them - open their faucets and nothing comes out but air? Engelhardt seems unwilling to follow through on the thought experiment, apparently because he's afraid he might be missing something, but I'm willing to be educated if what seems obvious to me really is not.

With no water in the pipes, people cannot flush toilets, bathe, do laundry, wash dishes, clean kitchens, bathrooms, hospitals -- not that there would be much point because all of those facilities would be useless. Obviously every restaurant would have to close, but so would all of the factories and offices, regardless of whether they use water in their operations, because the workers would be unable to perform the bodily functions of excretion.

Are you with me here? You could, conceivably, truck in drinking water for 5 million people, but all that would accomplish is to keep them alive long enough for the miserable death that awaits them, from starvation, infectious disease, fire, or the violence attendant on the collapse of social order. There would be no functioning economy. No-one would have an income. It would be nearly impossible to prepare food. Human excrement would pile up in the parks and front yards and gutters. There would be little or no health care, no local tax revenues. It would be impossible to extinguish fires; immense conflagrations would sweep whole neighborhoods. Atlanta would be uninhabitable. All of those 5 million people would have to be evacuated. And then, even if the rains came, they would not be able to return. The city would be destroyed.

If Sonny Perdue's prayer rally doesn't work, that's his Plan B. Why isn't anyone saying so? For the same reason the Boston Globe featured an in-depth story last week about the high price of oil, with all their expert analysts blaming it on rising demand and predicting that world-wide demand for petroleum will be 120 million barrels a day by 2020. No, it won't, because that much oil will never be extracted, not in 2020, not in 2030, not in 3030. Yes, demand has increased, but the reason that has caused such a price spike is because supply cannot increase in response. But they won't say so because they don't want to have to think about the consequences.

As Englehardt discusses, climate change is bringing drought to many parts of the earth, not just the Southeast. This is probably not, in many if not most cases, a temporary crisis. It is a long term change. Ultimately, water stores in many areas will be gone. The vegetation will burn. The people will have to leave. That just might turn out to include parts of the U.S. Southeast -- including densely populated, urbanized places with many trillions of dollars of fixed capital, all of which would be lost. Nobody is lifting a finger to make even the slightest plan of preparation for such a contingency. We knew damn well what a major hurricane would do to New Orleans, and nobody did a damn thing to get ready. Are we going there again?

And yes, it might not happen; enough rain might come in time. But nobody knows that; it's not in the forecast. Hope is not a plan.

House veto override is scheduled for tomorrow

Tomorrow being Thursday. Please don't forget to contact your representative and insist on a vote to override the veto of the the FY 2008 Labor-HHS-Education Appropriations conference report.

Enter your zip code in the Capitol building icon right under Chimpy, click and off you go. Do it for the children.

UPDATE: Veto override failed in the House by 2 votes. No spending bill until after Thanksgiving. If your representative voted against the override, make sure to move heaven and earth to get the baby killer voted out of office in 2008.

Sprots

I hope no-one minds a little thumb sucking today -- anyhow that's all you're going to get.

The rest of the world may already have noticed that Boston of late has become a paradise for aficionados of large men performing useless feats of physical prowess. I, shamefully, number myself among them. We have the Red Sox, World Series champions for the second time in 4 years; the Patriots, who are going through the NFL like a McCormack Reaper and are widely predicted to end the season undefeated; the New England Revolution are playing in the MSL championship game on Sunday -- and they need to win it just to get on the front page of the sports section. The Celtics, long a laughing stock, went out and acquired two superstar players in the offseason and now they are off to a 6 and 0 start. The Bruins are still mediocre but hockey is well on its way to second tier status anyway.

So, like it or not, I'm forced to pay attention to the role of sports in culture and society. I really haven't quite figured this out. What's it all about, anyway? Why do tens of thousands of people blow a week's pay to cram themselves into a giant salad bowl and yell at steroid abusers in plastic armor beating the shit out of each other?* Why is half of the reporting staff at a major metropolitan newspaper dedicated exclusively to these pointless endeavours? Why do people's spirits soar and crash with the thud of a ball to the right or left of an arbitrary yellow line, or the visual hallucinations of a cranky old man with a whistle?

When the Red Sox rolled down Boylston Street a couple of weeks ago in a caravan of WWII era amphibious assault vehicles (yes), we are told that a million people lined the sidewalks to yell and scream and faint for joy. The City spent tens of thousands of our tax dollars for police overtime, and closed down a major traffic artery for much of the day, but nobody would even have remarked upon it if they had spent 2 million dollars and closed down the whole city.

So what were the economic and public health consequences of the Red Sox winning the World Series? Well, it undoubtedly increased sleep deprivation, consumption of alcohol and empty calorie salty snacks, workplace and school absenteeism, and quite possibly acute cardiac and cerebrovascular events. The NFL has been moving all the Patriots games to night time, so we're getting the same effects every week now through January.

On the plus side, however. . . uhm. Hmm.

But you know, cities that don't have a major league sports franchise are second class, and their citizens feel deprived. I dunno. Can anybody explain it?

*I more or less stole that from somebody but I can't remember who.

No shortage of fools, anyway

We may be running short of oil, water, top soil and seafood, but the supply of dupes and dolts is infinite. It seems the Creation Museum needs to expand because the current facilities can't handle the crowds.

Meanwhile, back when Sonny Perdue scheduled his prayer meeting for today, the long range forecast called for rain in Atlanta tomorrow -- the only day in the forecast with rain penciled in. Just a coincidence of course. Alas, the forecast has been changed, the rain is missing them to the north, so it appears the prayers had the opposite of the intended effect.

What the Governor should have done, of course, is hire a guy to dress up in feathers and dance with a rattle. That actually works. As for the Creation Museum, if Noah could build a ship bigger than a modern supertanker all by himself out of gopher wood, I don't know why they need half a million dollars to enlarge the parking lot. Mike Zovath just needs to get out there with a shovel.

Compassionate conservatism update

As I warned a few days ago, the Emperor of Mesopotamia has gone ahead and vetoed the HHS funding bill, claiming it's fiscally irresponsible. Jennifer Loven of AP is actually reality based, as opposed to fair and balanced, in her discussion of budgetary issues:

Since winning re-election, Bush has sought to cut the labor, health and education measure below the prior year level. But lawmakers have rejected the cuts. The budget that Bush presented in February sought almost $4 billion in cuts to this year's bill.

Democrats responded by adding $10 billion to Bush's request for the 2008 bill. Democrats say spending increases for domestic programs are small compared with Bush's pending war request totaling almost $200 billion.

The $471 billion defense budget gives the Pentagon a 9 percent, $40 billion budget increase. The measure only funds core department operations, omitting Bush's $196 billion request for operations in Iraq and Afghanistan, except for an almost $12 billion infusion for new troop vehicles that are resistant to roadside bombs.

Much of the increase in the defense bill is devoted to procuring new and expensive weapons systems, including $6.3 billion for the next-generation F-35 Joint Strike Fighter, $2.8 billion for the Navy's DD(X) destroyer and $3.1 billion for the new Virginia-class attack submarine.

Huge procurement costs are driving the Pentagon budget ever upward. Once war costs are added in, the total defense budget will be significantly higher than during the typical Cold War year, even after adjusting for inflation.

I don't know why Ms. Loven has joined me in hating America, but if you're an America-hater too, enter your zip code and click on the capitol dome, and let your representative and Senators know that you demand a veto override. The vote in the House was three votes short of 2/3, so we only have to swing three more reps into the America hating column to get this done.

Time for Plan B

As I'm sure you know, the Intergovernment Panel on Climate Change has opened a conference to produce what amounts to an executive summary of its work. Most people don't know that the term "executive summary" refers to a summary of a study intended to guide action - hence "executive" as in "execute," to carry out. That's what this report is intended to accomplish -- to provide policymakers with a basis for action.

Alexander Cockburn, the increasingly bizarre Nation columnist, is convinced that global warming is a hoax engineered by the nuclear power industry. How Bechtel and General Dynamics managed to suborn 1,500 scientists in a wide range of disciplines from more than 100 countries, with nobody blowing the whistle, is not clear to me and Cockburn isn't saying. In any case, even if the scientists are making the whole thing up, whether to collect their secret payments from the nuke builders or to get themselves bigger and better grants, the report is going to be heavily diluted and toned down by political pressure from a few countries -- notably the United States, China, and Saudi Arabia -- that don't want any interference with our God-given right to burn fossil fuels.

I'm afraid I have some bad news: it doesn't much matter because it's too late, much too late, to avoid major effects of anthropogenic carbon release. You can screw compact fluourescents into every light socket on earth, get every commuter from LA to Shanghai into car pools, bring every last soldier, marine, sailor and airman home from Iraq and put the entire $100 billion a year into building wind farms, and it will barely make a difference. It's coming -- and probably bigger and faster than anybody was predicting five years ago. Sure, let's do what we can to cut down on using fossil fuels - it's equally important because we're going to run out some day, and because it doesn't make sense for the U.S. to be trying to conquer the world just to assure access to supplies.

But, as far as climate change is concerned, we need to be preparing to deal with it, not deluding ourselves into believing that we can stop it. The terms of debate need to shift, radically, and very soon.

Georgia Governor Sonny Perdue is holding a mass prayer meeting tomorrow to ask God to send rain. He says that rain is plan A, plan B, and plan C. In other words, there is no plan whatsoever for the day when Atlantans open their faucets and no water comes out. Maybe the Governor's prayers will be answered and that won't happen any time soon, or maybe it will happen in a couple of months. Think about it -- nobody in Atlanta will be able to bathe, flush a toilet, wash clothing, wash dishes, cook a meal. And nobody is doing one single damn thing to plan for that day, a day that very well might come before the Atlanta Falcons end their season. But Sonny is no crazier than the rest of us -- he is a perfect representative of the whole damn world.

Current events

Got a tip from reader Kathy about a little business as usual at a health insurer in Cal that ducked $35.5 million in expenses by dumping sick people. Yeah, that's what the God-given Free Market does folks. The scandal, as far as the LA times is concerned, is that their head hit-woman was given the assignment of wacking 15 sick people a month, and paid a bonus for exceeding the goal. That's not a scandal, that's how insurance companies work. The scandal is that she only got 20 grand for screwing over 301 people and saving the company $6 million bucks. Come on, Health Net, have a heart.

In other news, the American Public Health Association wants you to know that a House-Senate conference committee has reached agreement on the FY 2008 Labor-HHS-Education Appropriations bill. The bill includes increased funding for public health -- and remember, that's about 2% of what we spend on health care -- so the Occupant has promised a compassionately conservative veto. Enter your zip code and click on the capitol building right under Chimpy to let your Senators and Representative know that they need to make sure the bill gets a veto-proof majority.

And, in what may be the most important news in the history of the planet, or the least important news since Conan O'Brien was stalked by a priest, former Arizona Governor Fife Symington says the ETs have visited. You'll have to make up your own mind about that.

The consolation of philosophy

My thanks to the commenters on my post about my father -- and thank you particularly for sharing some of your own stories. I try to let my personal life intrude minimally here, but as a disciple of the late Irving Kenneth Zola I take very much to heart his insistence that sociology can only be called objective when we disclose ourselves. It may seem paradoxical but only if you haven't thought about it very hard. Obviously, I have a personal stake in the issues I write about here. You should only conisder me credible to the extent I reveal it.

I've often wondered whether some readers might consider me a bit morbid because I write about death a fair amount, but the fact is, in the field of public health, it is unavoidable. Death is, after all, one of the central facts of life. One of the chief metrics of population health is life expectancy, and that is synonymous with death expectancy. Furthermore, bereavement is the lot of all of us and so our response to it as an important contributor to our quality of life. Death is also an important problem in public health because, in our society anyway, it just costs so damn much. It's a big burden on our health care financing and delivery systems, and when we worry about the future sustainability of Medicare and Medicaid, in one way or another it's a central issue.

So, as we continue the Thinking Deep Thoughts project, it's time we turn to what, for many, is the deepest thought of all. What should we consider to be the goal of public health? That is essentially equivalent to asking what we value about human existence. It's as fundamental as it gets.

Obviously the answer is not the maximum possible life span for every human. I'm sure that if we devoted the NIH budget to achieving that it would not be long before we could keep the colonies of cells that originated as human organisms alive indefinitely. That blob on the bed with the tubes sticking out of it might be nothing but a mass of cancer cells or a circulatory system nourishing a body with no cerebral cortex, no heart pumping and no gas exchange happening in the lungs but by God, human life is sacred.

But short of such a reductio ad absurdum, it does become a puzzle, given the reality of scarcity and competing interests. The Ayn Rand objectivist/libertarian view which is popular in the high tech industry is that we should each try to get whatever we want and not give a shit what happens to anybody else unless we just happen to feel like helping somebody out. The Christian -- and Republican -- version of that philosophy these days is that it extends to everybody who has a functioning cerebral cortex, but we need to extend the protection of the law to entities with human DNA that lack human consciousness.

Us non-Christians, who feel empathy for our fellow human beings and some loyalty to the species have various approaches to the problem. One is to invoke a concept of basic needs -- some fundamental level of entitlement that each person is granted. If kids are dying before their 5th birthday, that is unacceptable -- except, of course, to Christians, because we're talking about children who have already been born. We should make sure that everybody has adequate nutrition, some minimal standard of housing, education, meaningful employment, and health care.

In contrast to such a rights based view, there are theories of distributive justice. These are more difficult to describe because it is not easy to formulate a theory of deserts -- maybe people who work harder or contribute more should get more back, but of course we can contribute in a lot of ways, including being nice, or nurturing, or amusing, as well as doing things that make money in the marketplace.

Then there are utilitarian theories, in which we try to define the good in some measurable way and maximize the quantity of it. "The good" usually includes some amount of justice, and basic rights, of course, so they get more than a bit mixed up, but they represent different starting places.

In public health people try to quantify the good through concepts such as Quality Adjusted Life Years and Disability Adjusted Life Years. Survey a bunch of people and ask how much life span they would give up to avoid going blind at age 55 or developing crippling osteoarthritis or whatever, and discount years of life in said condition by the appropriate amount. Alas, how people answer these questions depends on culture and circumstances. People who don't expect to live to be 55 anyway can't exactly answer it. We need some degree of justice before we can even undertake this exercise; the only way to break out of the inherent circularity is by starting with a basic rights formulation, and trying to figure out how we can toward justice or the good from there.

So what does all this mean when we are contemplating bereavement, or our own mortality? My view is that we should ask ourselves what is, to us, the good, and then ask what we can do to contribute to it in the time we have. When we can no longer do so, our time has been enough. We hope that it has been well spent.

Obsolescence

Tom Lehrer retired from performing because, he said, satire became obsolete when Henry Kissinger won the Nobel Peace Prize. If that killed satire, by now it has been consigned to eternal damnation, and forever forgotten.

But now I'm starting to think that words have become obsolete, along with rational thought. Pat Robertson endorses Rudy Giuliani for president? Now to me, that's equivalent to an endorsement from Charles Manson, but Rudy is happy to have it. I see a syllogism here:

Pat Robertson believes that the 9/11 attack happened because God withdrew his protection from the U.S. as punishment for our tolerance of homosexuality and abortion.

The abortion and homosexuality tolerating Rudolph Giuliani's main claim to the presidency is that he is the best candidate to protect the U.S. against another terrorist attack.

Ergo, Pat Robertson believes that Rudy Giuliani is more powerful than God.

QED

Of course, we don't expect the free press, guardian of our liberties, to point that out. Why should they? Diane Feinstein voted to confirm Michael Mukasey as Attorney General because she's afraid of the prospect of "diminished transparency" in the Justice Department. Dana Perino, referring to Pervez Musharraf, tells the assembled guardians that it is never reasonable to restrict civil liberties in the name of fighting terrorism.

If they started pointing out that stuff politicians say doesn't make sense, why there would be no end to it, would there?

This time it's personal

Nobody close to my family reads this blog -- hell, my mother doesn't know your Intertubes from the Pony Express -- so I feel okay about posting this here. It's private, but it's nothing to be ashamed of anyway.

My father has advanced frontotemporal dementia. It happens to be of the variety called primary progressive aphasia, not that it matters. It isn't the same as Alzheimer's disease but it ends up in the same place, for all practical purposes. He is in a nursing home. He has long been incontinent of urine and feces, has been unable to carry on a meaningful conversation for a long time, and is now unable to speak, does not appear to recognize my mother, barely responds to stimuli, is essentially unable to walk, and recently he became unable to feed himself, so they have to spoon feed him. There is some concern that he has difficulty swallowing.

Unfortunately, there basically isn't anything else wrong with him. I say unfortunately because that means he could live forever, without a functional frontal cortex, if they just put in a feeding tube when he finally becomes unable to eat. By that time, he will also undoubtedly be permanently bedridden and unaware of his surroundings. Remind you of any prominent public issue of the past couple of years?

I had a conversation with my mother, who has his health care proxy and is legally entitled to make decisions about his care, about what the goals of care should be and what ought to be done in certain contingencies. She agrees with me that the goals of his care should be comfort and dignity. She does not want any procedures that would conflict with those goals solely for the purpose of extending his biological functioning, what "Christians" call his "life."

However, my mother does not believe it is up to her after all. Among the practical considerations is what to do if he acquires an infection, such as pneumonia or a urinary tract infection, and it can't be managed at the nursing home with oral or intramuscular antibiotics. The alternative would be to send him to a hospital for IV antibiotics. In the hospital, they aren't interested in spoon feeding him so they would put in a feeding tube, also a urinary catheter, no doubt. Once it goes in, it's a major deal to take it out. Jamming a tube up his nose and down his throat is not consistent with his comfort and his dignity. Since he is unable to consent to it, and undoubtedly would not want it, it is a violation of his rights.

But, the staff at the nursing home told my mother that he recently became agitated and started flailing his arms. They found this disturbing and had difficulty calming him down. The next time it happens, they said, they will call 911 and have him transported to a hospital. They did not ask my mother, they told her. The reason, although they did not say so, is that the ambulance crew will strap him to a board and at the hospital, they will have no qualms about tying his limbs to the bed. That's before they jam the tube down his throat. She doesn't think she can refuse this. I told her yes she can too, but she doesn't believe me. She has a meeting scheduled with the nursing home staff tomorrow, so we'll see what comes of it.

Oh, did I mention that the home has been purchased by a large, for-profit chain? Recently she got a Medicare statement showing the services they had billed. They included five sessions with a psych nurse from something-or-other behavioral health associates. A psych nurse? He can't talk, and he isn't taking any psych meds. They also billed for a podiatrist to drain a hematoma on his foot, even though he has never had a hematoma on his foot or anywhere else.

Now, let's get back to Bill Frist and the rest of the Republicans in congress, George W. Bush, Jeb Bush, the Catholic Bishops, the evangelical preacherscon artists and the rest of the raging mob who tried to turn Michael Schiavo into a criminal for doing what was right for his wife, in the process forcing the taxpayers of Florida to squander more than $100,000 a year to indulge their sanctimonious hypocrisy and their hatred of human life. They do not have "moral values." They only way they care about the weak and vulnerable among us is as a resource to exploit for their own enrichment and aggrandizement.

I love my father. When his disease finally kills him, it will do it by stopping him from eating, just as Terry Schiavo's disease killed her, and that will be right for him, as it was for her. It's too bad that we have to die, but we do. When the time comes, it comes. Anybody who truly respects human life respects that. James Dobson, George W. Bush, and the Cardinals in their silk robes and fat gold rings despise human life, they despise the dupes who enrich them, and they despise me and you. They are vile, foul, and profoundly evil.

Long slow slide -- then you hit the ground

Few Americans remember the Great Depression. For my grandparents, it was an essential formative experience, but for people of my parents' age, it's a childhood memory, with little impact on their understanding of the world. Since World War II, Americans grew accustomed to a steadily rising material standard of living and eventually came to take it for granted that the average person would always be wealthier than people of a decade before. However their own dreams had fallen short, people invested not merely optimism, but faith, in the greater well-being and achievements of their children.

But now workers' real incomes have been stagnant for the better part of 20 years. Greater labor force participation by women kept the boats rising for a while, but that spring ran dry a while ago. People turned to borrowing against their home equity, but now they're tapped out. Economic growth means greater and greater enrichment for the very few, but little or none of it flows to ordinary people, who are running and place and increasingly vulnerable to an illness, a job loss, an insurance company that won't pay off for a fire or a flood.

Right now we see people beginning to respond to political appeals for greater economic justice. The Democrats' push to expand S-CHIP is very popular, and the Occupant's rhetoric about socialized medicine is not resonating. Talk about raising taxes on the wealthy no longer scares people, because they no longer imagine that they will be wealthy one day.

But what will happen when stagnation turns to deterioration? I don't have the crystal ball that tells me whether the U.S. economy will enter a period of overall contraction soon, but the possibility of a real short-term catastrophe from the confluence of rising oil prices and financial collapse is certainly non-trivial. What I do know, however, is that there is no real possibility that the decline of the American middle class will suddenly be reversed under the Hillary Clinton administration. We have profound, long-term structural problems that nobody -- and that includes John Edwards and Christopher Dodd and Dennis Kucinich -- is talking about.

We have done absolutely nothing to prepare for peak oil or global climate change or the catastrophic water shortages that will soon plague the fastest growing parts of the country; upward pressure on food prices; relentless increases in health care costs; the relentless decay of the 1950s era national infrastructure. We are still a very wealthy country and we can save our collective asses with a crash program of investment, but we aren't going to do that because we're spending half a trillion dollars a year desperately trying to maintain global military domination -- to what end, no-one can tell us.

I haven't heard a single Democratic candidate for president even hint at the true choices which face us. But what will happen to our political culture when frustration with stagnation turns into desperation as ordinary Americans can't afford to heat their houses, send their kids to college, or pay for health care? As more and more of them have trouble buying clothing and groceries and keeping their cars running? Are we finally going to confront reality and enter an era of honest political discourse, or are we going to have a demagogue rise up by promising to conquer our way out of our difficulties?

Stay tuned.

And if you want the grim view

Here it is.

If you actually believe this, your mind ought to be concentrated wonderfully, as by a hanging.

I think we're all Bozos on this bus

Here is the CEO of the French oil company Total:

In an unusually stark prediction for the head of one of the world’s biggest oil companies, Christophe de Margerie, CEO of the French group, said it would be difficult to reach even 100m barrels a day.

The International Energy Agency, the rich countries’ watchdog, in its “business as usual” projections, has said oil supply will reach 116m barrels a day by 2030, up from about 85m b/d today. The US government has a similar forecast of 118m b/d in 2030, including a relatively small contribution from biofuels.

Mr de Margerie, however, said while forecasts could always change, “100m barrels [per day] . . . is now in my view an optimistic case”.He added: “It is not my view: it is the industry view, or the view of those who like to speak clearly, honestly, and not . . . just try to please people.”

If 100m bpd is the optimistic case, then the most likely case is that peak oil is approximately now. Note who is saying this. Note also that discussion of this issue is marked by pervasive confusion. Many commentators counter that the problem is not a lack of adequate reserves from which additional petroleum can be extracted*, but rather a failure so far to make the immense investments necessary to exploit new reserves. But this is to entirely miss the point, which is not that we are running out of oil, but that what remains is more difficult and expensive to find and extract than what we have already consumed. Therefore, in the future current quantities of petroleum can only be provided at an ever higher price. Since people have only finite wealth and income, they will have to consume less of it. It is also the case that making the trillions of dollars of new investment needed to extract more petroleum will take time, and so before new reserves come on line, old ones will be further depleted. Hence Hubbard's peak. Therefore the argument that the reserves are there, we just need to spend more to get at them, is not a counterargument at all. It is precisely the problem.

This also dooms the argument that peak oil is not really a big problem because we can substitute petroleum equivalents from tar sands and oil shale. Extracting these resources is much more expensive than drilling for ordinary crude oil -- in environmental as well as monetary terms, by the way. So once again, consuming these resources can happen only at a higher, and ever rising price. You can even call them petroleum, if you want; we still have the same Hubbard's peak.

So what will happen? Will civilization collapse? Will Ted Kaczynski's dream come true? I doubt it. For one thing, as the polyannas never tire of telling us, petroleum represents a smaller percentage of economic output than it did during previous oil price shocks. We have become somewhat more energy efficient, and that trend will continue, perhaps strongly enough to enable us to keep our material well-being above water for quite a while. It's even likely that demand growth will moderate and the price may dip back down a bit, for a while. Who knows, maybe cold fusion will pan out after all and we'll all be saved.

But, more likely than not, it's gonna be a bummer. It already is. The price of home heating oil is up 25% from last year, which puts many families, already living from paycheck to paycheck, in deep trouble. If they're just hanging on making their mortgage payments, this will be the killing blow. U.S. workers, who haven't seen a significant increase in their real income for decades, are going to see an actual decline in their standard of living. It's going to make everything more expensive, especially basic needs -- food and clothing. That's really going to hurt the people in the poorest countries. What will be the political consequences, here and abroad?

And geopolitically, as petroleum stocks decline, what remains becomes a greater and greater prize. Hence, war and stuff like that. That particular bummer is already happening too. And, the massive investment in petroleum exploration and extraction is going to mean less investment in all the other stuff we desperately need to be doing.

But is declining petroleum extraction good news for the environment? Au contraire. It will drive more coal burning, and the environmental damage attendant on coal mining; conversion of coal to liquids, adding yet one more layer of environmental damage and even greater carbon emissions; more of the very nasty and destructive process of mining tar sand and oil shale; more and more drilling for oil in environmentally sensitive places; substitution of food crops for biomass crops. And meanwhile, we'll keep burning almost as much petroleum as we do now, with only a very slow decline, which will come far too late to have any meaningful impact on climate change even it isn't overwhelmed by those countervailing forces.

So I'm sorry Atrios. Kunstler may be over the top, but this is more than a mere annoyance. It's a big problem, with even more ramifications than I have taken the time and space to mention. It's really gonna hurt. Is my timing a little off? Is the big hurt coming in 8 years instead of next year? Maybe. So we should spend those years living in a fool's paradise?

* The conventional term is "produce," but of course that is wrong. Humans cannot produce petroleum; they can only use up what is already there.