And one more thing about George Carlin

This was never mentioned in all those obituaries in the corporate media. (I'll bet Jean Valjean will really like this one.) Not safe for work, as they say.

Let's not forget what Carlin was really all about -- and why there's a broad cultural conspiracy to remake and redefine him now that he can no longer speak for himself.

Oh yeah, and this one too.

How do you know the toothbrush was invented in New Hampshire?

Otherwise it would be known as the teethbrush. (Before you start composing the hate mail, you should know that we have a tradition in Massachusetts and New Hampshire of insulting each other. It's okay, they're still Sox fans and we still go skiing.)

I'm planning to have big fun this afternoon getting endodontic therapy, popularly known as a root canal. This will be my third, which leads me to reflect that one of the particularly unintelligent aspects of our design is that the teeth just aren't built to last a lifetime. Here's some info from the CDC which might get your attention. Only one third of adults age 35-44 have all of their teeth. If you visit one of the poor countries, you will find teeth to be a scarce commodity. I have a friend who went on a medical mission to El Salvador and it turns out that the main thing the campesinos wanted was to have their teeth pulled. They were all rotten and painful, they knew they were never going to get reconstructive dentistry, so away with them, please. Francisco got on-the-job training as a dental assistant while his pediatrician wife wielded the pliers.

Now, I'm not sure why evolution has failed us in this regard. Maybe it's just that the choppers aren't built to last past reproductive age because by then, if we can't feed ourselves very well, the genome doesn't care. But a lot of people lose teeth earlier than that, and poor dental health is associated, not only with poor nutrition, but with chronic inflammation which increases the risk of heart disease, as well as overall debility. Remember this little kid who died from a tooth abscess because he couldn't get dental care?

So dental care really matters. Why is it, then, that as bad a job as we do extending other health care specialties to the population, we do much worse with dental care? According to the CDC report linked above, more than 44% of Americans who responded to the Behavioral Risk Factor Surveillance Survey didn't have dental insurance at the time of the interview. That's almost three times the percentage who lack health insurance. Employers just don't provide it, and in most states, Medicaid reimbursement is so low that few dentists can be found who will take it. Somehow we just don't think of it as having the same importance as "health" insurance, which seems entirely arbitrary.

So, when we get our universal, comprehensive, single payer national health care, let's not forget to include the dental plan.

Hello! Is anybody awake in there?

I mentioned this yesterday but at the time I assumed that it would get some attention. Now it appears to have gone down the memory hole. The government of Afghanistan, through an official spokesman, says it has incontrovertible proof that Pakistani intelligence tried to murder Afghan President Hamid Kharzai.

Now listen up folks. This refers to an actual, real attempt on Kharzai's life, in which a member of Parliament, a tribal leader, and a ten year old boy were killed, although Kharzai escaped unscathed. The United States, as you know, has invested very heavily in Pakistan as an ostensible ally in the War on Terror™, including handing them $6 billion on a handshake. How they actually used the $6 billion, we have no idea. It was supposed to be for hunting down all those bad guys along the Afghan border, but whatever they may have done with it, it wasn't that.

You might think that American journalists and politicians would have some slight interest in the suggestion that the intelligence service the U.S. is financing is actually on the side of the enemy. But no, nothing to see here, move along. I have seen not one single word about this published anywhere today, or uttered by anyone in the administration or the Congress. It was one of those international news briefs in yesterday's paper, and that's it. I googled it and that's what I found: reported on June 26, not a peep about it from anyone.

Now, I don't expect war between Afghanistan and Pakistan, if only because Pakistan's overwhelming military superiority rules out Kharzai actually doing anything about the situation. He's a U.S. puppet anyway and the U.S. is not going to let him throw too much shit at the fan, not with all our other troubles in that area. But this is one more indication that the quagmire for the United States in that area is just getting deeper. So far 40 U.S. and other NATO troops have been killed in Afghanistan in June, the highest monthly total since the U.S. invaded almost seven years ago. Afghanistan had a record opium harvest last year and is on track for a bigger one this year. Afghanistan supplies 90% of the world's illicit opioids, and 80% of Afghan opium is grown under Taliban protection and finances the Taliban movement.

Now, I'm not entirely sure what we ought to do about this. In fact I do not support Barack Obama's call to move troops from Iraq to Afghanistan. I don't think that deepening our military involvement is going to produce any sort of a solution. The Taliban are not my kind of folks, but they do not now nor did they ever constitute any sort of a direct threat to the United States. In fact, when they were in power, they suppressed the opium trade; their current relationship with opium is a matter of opportunism, is contrary to their moral code, and would probably end if they could securely seize power and didn't have to depend on it.

The reason the U.S. got involved in Afghanistan is because the Taliban were harboring a small, violent cult that had indeed organized an attack on the United States, precisely because the United States had military forces based in the Arab/Islamic heartland. Contrary to John McCain's nonsensical proclamations, these people are not a "transcendental"* or "existential" threat to the U.S. or the West -- they're just a gang of stateless fanatics whose greatest power derives from our habit of overreacting to them. And we could make them disappear entirely by removing those troops from Iraq, as they would no longer have a causus belli. (No, they don't hate us for our freedom. They hate us for our imperialism.)

However, we all know what's going to happen. The U.S. is going to be drawn deeper and deeper into Afghanistan, it's going to cost more and more lives and treasure, tensions with Pakistan will deepen and no doubt people will start blaming Iran as well. The course of events threatens to become less predictable and more dangerous, particularly in the context of the lame duck administration and a Republican presidential candidate who is premising his entire candidacy on bellicosity. Attention must be paid.

*Whatever the heck that's supposed to mean. I thought transcendentalism was a vaguely defined 19th Century New England literary movement.

The Front Page

Among the innumerable puzzles that only grow more baffling with age is the process by which news items rise to the top of the newscast and the front of the fishwrapper. For example, as you probably know because the story has achieved considerable national prominence, the most important thing to happen in the Boston Metropolitan area in the past 2 1/2 years is that a guy murdered his wife and baby in a suburban town in January 2006. Yesterday he was finally convicted and if you're interested, you can see the front page of the Boston Globe here. No, World War III hasn't started, it's just a trial. By the way, the other front page stories of the day are that the Archdiocese is moving its headquarters to Braintree (they had to sell their answer to the Palace of Versaille in Brighton to pay off the sex abuse victims), the state is charging some companies with securities fraud, and two birds at the local zoo are declining to do the nasty.

I looked it up, and according to FBI data, 1,107 American women were murdered by their husbands or boyfriends or exes in 2005. (That's the latest year they have data for. BTW, this number has been generally declining over the past two decades.) So why does one here and one there get the OJ treatment? Obviously, the people are white, this happened in an affluent suburb, and there was a little extra drama for the reporters to seize on since the perpetrator initially fled to his native England, but in fact the large majority of these murders involve white people so who really knows?

Anyway, this was a big national splash on all the main news web sites, and again when the guy was sentenced today. And no, as far as I can tell nobody used it as an occasion for some background reporting on the prevalence and nature of intimate partner violence or otherwise made constructive use of the story. It's just a tawdry little drama plucked more or less at random from the pile.

So what else happened yesterday? Well, for one thing, the government of Afghanistan accused Pakistani intelligence of trying to murder Hamid Kharzai. That would seem to be a cause for war, no? Probably not though, since Pakistan has nuclear weapons. Uh oh. Not an important story, though.

Iraqi officials accused U.S. troops of murdering 8 Iraqi civilians in 2 separate incidents, while there were bombings and assassinations all over the place in that country, plus a U.S. soldier killed. But they don't bother to report any of that any more, it's inconsistent with the narrative we're supposed to believe, which is that violence is down in Iraq, and The Surge is a big success. (Completely false.)

There are quite a few other stories they might have considered for the front page, quite a few of which they did not cover at all, others of which got buried. I can't figure it out. Can you?

And one more thing

I hid an easter egg in my post on George Carlin, but I guess nobody found it so here it is. Rogers, Oklahoma is the town destroyed by a tornado that Al Sleet, your hippie dippie weatherman, failed to predict. The trick to the hippie dippie weatherman routines was that amidst the ridiculous goofiness Carlin would slip incredibly dark material -- you know, stuff like nuclear war, irredeemable existential despair -- and make people laugh at it. I expect most people never even noticed what he had done to them, but those who did were forced to think.

But nowadays, it's not a matter of saying the unsayable. Stephen Colbert and John Stewart can say it all, but it just doesn't matter. Outrage long ago burned out vaporized.

The U.S. embassy in Albania conspired to cover up a scheme to sell $300 million in deteriorated Chinese ammunition to the troops in Afghanistan? Yeah yeah, so there's corruption and war profiteering, tell me something I don't know. The Justice Department systematically barred from internships and entry level employment anybody who had been associated with a liberal cause, a public interest group, or a public defender's office, who had clerked for a judge appointed by a Democrat, or who uttered words like "social justice"? The DoJ was politicized, old news, yawn. The former White House press secretary testifies before Congress that the Vice President and the President's Chief of Staff conspired to blow the cover of a CIA operative as an act of political revenge and then ordered him to lie about it? No fellatio involved, yawn. The Senate Intelligence Committee reports that the whole Weapons of Mass Destruction™ thing was a scam? Yesterday's news, not worth repeating. The Supreme Court issues an order to the EPA to make a ruling, and the White House responds by simply not reading the ruling? Pretty clever on their part, no?

I could, obviously, go on in this vein for several hours but I have work to do, as do you I'm sure. But we have a really, really, serious problem here: satire has become impossible. Transgression and subversion aren't even fun any more. There's nothing anybody could possibly say that would be outrageous. There's noplace left to go. We've crossed over the edge of the universe, sailing off into the fifth dimension.

What Marcia Says

This is a month old but I just came across it. Former NEJM editor Marcia Angell explains why the Massachusetts health care reform legislation, on which Barack Obama's national proposal is largely modeled, doesn't work. As I've said here many times, it does nothing to contain costs, forces low and moderate income people to buy insurance they can't afford, and will bankrupt the state before it achieves universal coverage.

A couple of quotes, but read it, okay? On the Massachusetts experience:

While those beneath the poverty level signed up for free insurance in even greater numbers than anticipated, very few people who were required to pay for their own insurance signed up. Even those eligible for partial subsidies were slow to enroll. The deadline to purchase insurance had to be extended, and 60,000 uninsured people were exempted from the mandate because -- yes, that's right -- they couldn't afford it (so much for universality). The state modified its requirement that all insurance meet a minimum standard. Jon Kingsdale, the executive director of the Commonwealth Health Insurance Connector, told me that was because the federal Employee Retirement Income Security Act prohibits states from setting standards when employers act as their own insurers (didn't the Massachusetts legislators know that when they crafted the law?), but he said that next year workers will be responsible for somehow upgrading their own policies, or (you guessed it) be fined.

On the financial impact on individuals:

Although insurers are prohibited from charging more for people with medical conditions, older people have to pay more. The premiums for a 57-year-old are twice as much as for a 27-year-old. According to the Connector's Web site in March of this year, the least expensive plan for a 57-year-old had a premium of $4,700 per year, a $2,000 deductible, and substantial co-pays and co-insurance up to $4,000 per year. (That cap did not include prescription drugs.) So a hypothetical 57-year-old with a $32,000 annual income (just over three times the poverty level) could pay as much as $8,700 out of pocket -- or over a quarter of his income. Family plans are, of course, different, but the effect is the same. Next year, those who haven't purchased insurance will be fined half the premium of the lowest-priced plan. Truly this is the Squeeze Blood from a Turnip Plan.

So it's probably just as well that Obama doesn't want an individual mandate, but then what is to be gained?

We need universal, comprehensive, single payer national health care. Period. Say it, Democrats. Don't be wimps.

Dirty Words

In case you haven't heard it before, Crooks and Liars has posted a performance of The Seven Words You Can't Say on TV. It's no offense to George Carlin to point out that this is somewhat derivative. Lenny Bruce told essentially the same story, with the same moral. But every creative person stands on the shoulders of giants, and Carlin had a lot to say that was different. Bruce was coming from a place of deep pain, he was angry and sarcastic, and much of the time, he wasn't even funny. But Carlin had a sunnier disposition and a gentler voice.

Lenny and George both wanted us to notice that certain words are off limits because they represent truths people want to hide. We might be afraid of the truth, we might be bigoted or hateful, we might just have silly ideas about what is proper, or there might be real ugliness we don't want parading around the living room in front of the children. Some of those sentiments may be defensible, others reprehensible, but the comedians' project was to demolish the mystic power of those words, to make them just like any other words, so we can be free to talk about the truths behind the taboos. Sometimes those truths are just silly, sometimes they're kind of important, sometimes they're urgent, sometimes they're profound. Doesn't matter, if you make it funny enough, you can say it.

The license to break taboos, to say the unsayable, goes back to Aristophanes, and no doubt to the dawn of language although, as far as I know, Aristophanes is the oldest written example we have. (Correct me if I'm wrong.) The license was held by Shakespeare's fools, by Moliere and Jonathan Swift and Mark Twain. But it has to be earned. Not just anybody can do it. There's a wormhole through the universe of bullshit that you somehow have to find.

So goodbye George, we'll miss you a lot. As will the residents of Rogers, Oklahoma.

The Old Ways

So, sitting on the tractor with the tiller ripping stumps and rocks out of the ground, I got to thinking. The European settlers who first came to Windham County had to cut down the trees with axes and crosscut saws and break the ground with draft animals. For a horse to pull a plow through recently cleared woodland, with its dense network of thick tree roots, must be impossible, and digging the stumps of old growth forest out of the ground with picks and shovels -- I don't see how it can be done. They might have been able to plant some small gardens between the stumps at first and then they just would have had to wait for the roots to rot out.

Maybe they had techniques I don't know about, but anyway, after 10 years or so they would have been able to clear most of the stumps and plow the land. It was full of rocks, which they piled up in stone walls -- more back breaking labor. People often think that these New England stone walls marked property lines or the edges of fields or pastures, but in fact they were mostly just a place to dump the rocks.

Now here's the curious thing. Most of Windham County today, outside of the towns, is woodland -- deep oak and hemlock forest, for the most part, full of huge trees. If you didn't know better, you would swear it had been woodland for thousands of years, but for one thing: those deep woods, even far from any roads, are criss-crossed by stone walls. In the 18th and 19th Centuries the settlers cut down the woods, almost completely, and Windham County was a land of farm fields and pastures, from Thompson to Woodstock to Windham. Then, in the 20th Century, the woods grew back and the only evidence of the past, at least to inexpert eyes, is those stone walls.

So what happened? In order to live like a 19th Century Yankee farmer, I would need horses, first of all. That means I wouldn't need enough cleared land just to feed my family, I'd need to feed my horses as well. So I'd need to clear at least all of my 20 acres and probably more just to make 5 acres yield enough for my own needs. Then I'd need to heat my house, fire my forge, and cook my food. That means I'd need firewood and charcoal. In fact the most powerful force driving the destruction of the Connecticut woods was charcoal making. Itinerant charcoal burners would come through, pay a fee to a local farmer, clear a patch of land, and build and burn charcoal ricks. The farmer got a few bucks and some new pasture out of the deal, but he probably wouldn't have had the motivation, or at least the time, to clear that pasture had the charcoal burner not come along.

I'm pretty sure, in fact, that my own land was never cultivated, that it was only pasture. The rocks were removed haphazardly, there was even a pile in the middle of a space defined by very sloppy walls, and some big ones were just left in place -- although it's hard to be certain about that because they rise up from below over the decades due to frost heaving.

Then, of course, charcoal and firewood were replaced by coal and oil, and draft animals by cars and tractors. Farming did eventually decline in Windham County, but the regrowth of the forest began before that. A lot of farms remain but the fields and pastures are now surrounded by woods, where once they just ran on continuously across the landscape.

Wildlife is coming back as well, in great profusion. I have read that the population of white tailed deer is far larger than it was before the Europeans came, but perhaps that will change now that the cougars are coming back. (Don't tell anyone.) When I was growing up in rural Connecticut, I never saw a turkey, but now they're as thick as black flies on the Athabasca. Okay, that's an exaggeration, but not by much. Fishers, black bears -- all sorts of critters that hadn't been seen for 100 years are back.

And for this we have to thank the industrial age fueled by petroleum and coal. With the much larger human population of today, we could cut down the woods from Maine to Georgia and we still couldn't survive in the old way, of course. So what are we going to do? It's what you might call an interesting question.

A note on agricultural methods: Roger recommends considering no-till agriculture. This is a new idea -- people have tilled the soil, in one way or another, for 10,000 years if not longer. It has merit in some situations but considerable limitations. The advantages are said to be, first, that it stops loss of top soil to erosion by wind and rain that occurs when tilled soil is left exposed, because crop residues are left on the surface; and that it reduces the number of tractor passes over the land, both saving fuel and preserving deep soil structure.

A major limitation, however, is that it is incompatible with organic farming. One of the most important functions of tilling is weed killing. If you don't till, you have to use herbicides, and generally you have to plant genetically modified crops that resist those herbicides. Small scale gardening is possible if you can go through constantly and pull weeds by hand, but not commercial farming. You also need very expensive, specialized seed drills in order to plant through the surface debris.

So I've looked into it but it isn't feasible or appropriate for me. Due to topography and climate, I don't have a problem with soil loss anyway. However, I'm definitely always looking for better methods and I'm interested in discussion of farming and gardening techniques. I've thought of starting a new blog along those lines, if there's interest.

Wherat has I bean?

Ize bean in the country, plowin up some ground. Last week I asked Festus* if it was too late to get in some corn and he said no it wasn't, I could put corn in right up to July 1. I'd been wanting to do it but I just hadn't had a chance what with working on the house and not getting time off from my city job and so forth.

So I went down there on Friday and I hitched up the tiller and I made about a 1,200 square foot corn patch. This got me to thinking about a few things.

Number one, if you didn't already know it, the way it is now, going back to nature and living the country life means consuming a whole lot of fossil fuels. Like just about every ear of corn grown in the U.S., mine depends on a diesel tractor. It may be less diesel intensive that average because I won't be using fossil fuel to reap it or process it and I won't be shipping it 5,000 miles, but I still need diesel to make the project work.

And alas, it turns out I was short a linchpin to hitch up the tiller. I had to make a 12 mile round trip to buy a 50 cent piece of hardware before I could do the job. Now sure, once I get settled in and I'm doing this every year I'll have a drawer full of hardware and I won't have to make a whole trip for something that stupid, except when I'm stupid enough to screw up and make it happen, which will be more often than I expect. But the point is, when you live out in the country, you have to drive some miles to buy groceries, visit your pals, get to the feed store, you name it. There's no bus and there's definitely no subway. In the city, I use my vehicle twice a month, if that. But in the country, I have to use it every day, and go some distance at that. I'm lucky enough to have a big woodlot, so I can heat with biomass. I need a gasoline powered chainsaw and log splitter and the diesel tractor to do that, but there's still a big net energy gain. I can get by on deadfall and trees with serious bole rot, and wood that's being cut anyway for other reasons, so I'm not clearing forest. (Full disclosure, I did clear three or four acres when I first bought the land.) Still, how many people are in a position to do that?

So all this started me thinking about the old days. What did the first Europeans who came to Windham County do, 300 years ago? What would happen if we tried to go back and do things their way, without using any fossil fuels? The answer might surprise you. I'll give you my conclusion tomorrow.

*For those who haven't been reading all that long, Festus is my friend who operates an organic farm with his wife in Windham County. I'm lucky he has time to talk to me in between working.

Thursday journal reading

A bit of this and a bit of that from the weekly medical journals.

Magic bullet? You have no doubt seen the typically breathless coverage of a report in NEJM this week about a man with metastatic melanoma whose tumors disappeared after an innovative immunotherapy procedure. In a pistachio cell, the researchers first took some CD4+ T cells from the patient. These are so-called "Helper T cells" which don't directly kill pathogenic cells, but call other elements of the immune system to do so. Think of them as artillery spotters. Anyway, the researchers then selected cells that responded to a protein displayed on the surface of the man's cancer cells, cultivated about 5 billion descendants of the selected T cells in the lab, and injected them into the patient. His tumors disappeared and he seems to be fine two years later.

What the teevee didn't tell you is that while this was a very informative experiment, this particular procedure will work for only a small minority of people with melanoma; specifically, those whose tumors display the antigen in question, and who have some other, as yet unknown lucky characteristics. In fact, not all of this patient's cancer cells displayed the protein in question. The researchers hypothesize that when those cells that did display the antigen died, they released other antigens which stimulated a broader immune system attack on the cancer. In any event, the bottom line is, every cancer is different, and while there might be a magic bullet for a particular cancer, it won't work for others. Progress in treating cancer remains slow, incremental, and oh yeah, expensive.

The power of wishful thinking: Jay Olshansky and Thomas Perls, in JAMA, report on widespread use of Human Growth Hormone (HGH), not only by body builders but also by clinics that purport to combat aging. In fact, the medical evidence is quite clear, HGH given to normally aging individuals does nothing to slow the effects of aging. On the contrary, the most likely effect would be to shorten the life span. Nevertheless, there are companies that give seminars to doctors in how to set up "anti-aging" practices and prescribe these drugs to people. This is called quackery. I commend to your attention Quackwatch, your comprehensive Internet resource for health frauds, scams, flimflam, bamboozlement, and bullshit. Before you believe anybody trying to sell you the miracle cure that "they" don't want you to know about, check it out at Quackwatch first.

Yes, there is a great deal wrong with medicine as actually practiced by people with M.D.s using FDA-approved drugs and devices. But it's not that they are hiding the truth from you in order to doom you to death from cancer or your child to autism. In fact, the main problem is that they're doing too much and might do better just to leave you alone. They don't necessarily know everything there is to know about relieving symptoms and helping you cope with your illnesses, so do go ahead and try the meditation and the yoga and massage and so forth if it appeals to you and you find that it helps. But don't expect magic.

Stayin' Alive: The World Health Organization has come out with its annual compilation of statistics, (warning: pretty big PDF) and it's chock full of fascinating info. Progress on UN goals generally, but slower than expected and with continuing immense inequalities. By 2030, they expect that 3/4 of all deaths will be from non-communicable diseases, a huge difference from the human condition as we have known it since we were chasing antelopes with sharpened sticks. They're expecting the 3rd leading cause of death that year to be COPD - i.e., tobacco. They're expecting the first and second leading causes to be heart disease and stroke, with tobacco obviously contributing to those as well although they don't say how much.

The merchants of death are still raking in the trillions. They are eeeeeeeevill.

Economics is Bullshit -- cont.

It's true - I just can't leave this subject alone. But it's important -- really important. The bogus worldview of economists is embedded so deeply in our political culture that most people don't even perceive it. Journalists, politicians, and most thoughtful, well-educated people think it's reality, not ideology. Economics professors fill the heads of college freshmen with pure garbage and nobody tries to stop them. Most offensive of all, to me, are the economists I keep hearing on NPR and reading in the NYT claiming that there's is the only really scientific social science, a claim based as far as I can tell on their extensive use of mathematics, whereas the precise opposite is true. Garbage in, garbage out. (And by the way, sociologists use math almost as much. Just sayin'.)

Anyway, I've taken on some of the absurd propositions of market theory previously. Today I want to talk about what is generally put forth as the basic measure of prosperity, the Gross Domestic Product. When the GDP is growing rapidly, the economy is said to be "healthy," and we're all supposed to be happy. If it's stagnant or shrinking, we're all supposed to be suffering. I first heard the GDP deconstructed by Hazel Henderson in 1979. She was right then, and she's still right today. Jonathan Rowe is notably carrying the torch today, but his insights are not at all new.

GDP is an attempt to measure the amount of money that changes hands for goods and services, legally. When it goes up, that's supposed to be good. One key reason why that presumption is false goes back to one of the critical - and utterly false -- assumptions of economic theory, which is that transactions have no externalities, that all of the costs and benefits to humanity are captured in the transaction between the seller and the buyer. Another reason why it is false is the related false assumption of economic theory, which is that the economy is a closed system, when in fact it exists in both a social and a natural context.

GDP grows when more people gamble away their life's savings and their homes in Atlantic City and Las Vegas, or drink themselves to death. Every dollar they put in the slot machine or lay on the bar is a plus. GDP grows when the pollution from power plants and automobile exhaust and factory smokestacks cause cancer and heart disease and the people have to get surgery and chemotherapy, the cost of which is counted as a positive value in GDP. Every barrel of oil that's pumped out of the ground and sold for $135 is that much more GDP. That the oil is gone forever results in no subtraction. When the hurricane destroyed New Orleans, every penny spent on demolishing houses and stashing people in trailers was added to GDP. The destruction was not subtracted.

In short, the GDP classifies costs and harms as benefits. And it classifies every expenditure as equal in social value, whether it's for a billionaire's private jet or a basic diet for 10,000 children. If 90% of the people are impoverished, it can go up just as easily as if everyone's needs are met. If we are destroying our heritage, be it of topsoil or drinking water or timber or the very atmosphere of the planet, everything we destroy is counted as profit. If we are destroying our social order, and people are suffering from addiction, and mental illness, everything we spend to try to fix them, or more likely to arrest and incarcerate them, is counted as a benefit. So are the bombs and missiles and bullets we use to kill people in Iraq and Afghanistan, and the secret dungeons we maintain around the world. It's all good. It's all part of economic growth.

Just ask an economist.

Health vs. Medicine

Yes, there is something not quite right about requiring people to purchase health insurance, or at least there might be or there probably is under the probable forms in which such a mandate might be enacted. This is one of those mildly complicated questions about which we have an extremely idiotic public discussion.

If you will note the URL of this blog -- which is the title of today's post -- you will find there a hint that I have a contrarian attitude about so-called "health care," which is a propaganda term intended to mislead. The medical enterprise does not "care" for our "health," for the most part. Rather it makes money by responding in some way to our ill health. And the sicker we are, the more money it takes in. "Caring" may or may not happen along the way, but it's entirely optional.

And here's another of its secrets: it really doesn't contribute all that much to our health and longevity, at least compared to other factors on which we spend much less money and for which there seems to be much less political support or market demand. We're talking seriously about some form of universal "health care," by which we mean pre-paid access to medical services, while we have malnourished kids, we're breathing polluted air, people can't afford to heat their homes, and there's still lead paint in old houses. How is it progressive to force people who are barely getting by to purchase "health" insurance if that's coming out of lunch?

First of all, it isn't. Any universal insurance scheme is completely immoral if it does not include progressive financing that assures it doesn't undermine people's basic material security and quality of life. But there would still seem to be a libertarian objection. Why should I have to pay for "health" insurance under any circumstances, even if I can afford it? Why can't I make that choice for myself?

And here's where we have to put together all the moving parts and make this dynamic picture understandable. There are two main reasons why the libertarian argument fails. Then there is the somewhat subtler argument about why universal prepaid medical services ("health insurance") is an appropriate social investment in spite of our current overspending on the product.

Why the libertarian argument fails: First, the individual decision about whether to purchase health insurance happens in the context of a society that has a pre-existing moral consensus about what should happen when people have severe but treatable illnesses and can't afford to pay for the treatment. That is, we treat them anyway, we don't allow them to expire on the sidewalk in front of the hospital. What generally happens when people become ill or suffer an injury is that they can no longer work, they spend everything they have, and then they become eligible for publicly funded insurance. So we pay for it anyway.

You could adopt a radical libertarian position that we should not, but once you start defending that position, you're going to find that you have difficulty defending libertarianism as a whole. In the interest of keeping this post to a manageable length, I will leave it at that. If anybody wants to have that discussion, I'll do it later. For now, I invite you to think about it.

The second major objection is that there are important public goods that are produced by "health care." These range from the blindingly obvious -- infectious disease control -- to the only slightly more subtle, such as overall work force productivity. Society as a whole suffers when there are a whole lot of sick people around who don't have to be sick, or whose symptoms can be controlled. There's also a cultural cost: it will just make us all feel bad to know that so many of our family members, friends and neighbors are suffering needlessly, and it would no doubt cause immense social unrest. To the extent it happens now, those consequences ensue in a modest way. Imagine if they were multiplied.

There is a justice issue here as well, if you care about it. Albeit there is much we can do to improve our chances for good health, personal choice is only a part of the story. There's the genetic lottery, followed by an evironmental lottery. If I'm hit by a car, I might have been careless crossing the street, or the driver might have run a red light. How does Ron Paul feel about leaving me to die because I can't afford trauma surgery? Finally, I might have dependents, who will become wards of the state, or I might be a dependent in the first place and have no control over my guardian's decision about whether to buy me health insurance. So for all these reasons, the liberty argument against some form of universal medical insurance fails.

And that's why all of the free, democratic countries of the world, other than the United States, have it. The citizens of the United Kingdom, France and Norway, do not feel oppressed by their various systems of universal health care. They do not feel that they have sacrificed their freedom for it. And you can ask them, if you don't believe me: polls consistently show that they are far more satisfied with their health care than we are.

Why the cost argument fails: We spend too much on medical services, no doubt about, anywhere from 50% more to twice as much and up compared with the other wealthy countries, and oh yeah, see above: they're happier with what they get. They are also healthier than we are, and they live longer.

So doesn't extending universal health care mean we'll spend even more than we do now? And how can that be good? (And doesn't that sort of contradict everything I've said above?)

Well, look at those countries with universal health care: they spend less than we do. How do we resolve this paradox? The answer is that they spend more rationally, in other words, they have rationing, which means allocating rationally. This happens in a lot of ways.

First of all, true single payer systems -- such as Canada's -- and true socialized medicine systems, such as in the totalitarian dungeon called Britain, can directly control spending to whatever extent the social consensus will allow. If they calculate that the amount a particular treatment costs for a person of a certain age and condition is not worth the likely benefits, they just won't pay for it. And yes, that means they have to decide that a quality adjusted life year is worth a finite amount of money. Americans seem to have an allergy to that idea. "You can't put a price on human life!" But in fact we do, all the time, when people work in hazardous occupations, when children in Africa die for lack of a $2 mosquito net or clean water, when we decide to defer maintenance on a bridge and take a chance it will collapse, or when we allow working people to go without medical care for that matter. And remember, we're already spending more, but we're getting less, so if they're putting too low a price on human life, they're still getting a better bargain.

Second, they drive a bargain with the drug and medical device companies. The drug companies claim that's going to kill the goose that laid the golden egg, by depriving them of profits to invest in research and development, but the technical term for that is that they're full of crap. They spend more on marketing than they do on R&D, and most of what they spend on R&D is directed toward drugs they can market effectively, not toward meeting the health needs of the population. Medical research is a public good and it should be publicly financed. Uh oh, more creeping socialism. Well of course it already is publicly financed to an extent. We should do it more. The money we save on buying drugs will pay for a lot of NIH-funded research.

Oh yeah, their physicians make less than ours do. But most of those countries have free or highly subsidized access to higher education. Doctors don't come out of medical school with a lot of debt, so they don't need such huge incomes for that reasons. The societies are more egalitarian in general, and offer more public goods and amenities -- such as subsidized higher education for your children, and paying for college is one of the main reasons American families feel pressure to have enormous incomes. Not to mention health insurance and long term care.

But even more telling, the really big bucks for U.S. docs are in high tech specialties. Primary care doctors here are comparatively underpaid, and their incomes are much more comparable to the incomes of physicians in Europe. And it's the primary care doctors who actually contribute the most to population health, and who keep people out of the clutches of those highly paid specialists in the first place. So it's actually the specialists' incomes we need to knock down, and we should pay primary care doctors more, because they work extremely hard, have huge responsibilities, and could do a better job if they carried smaller caseloads.

So here's the problem: the plans that are floating around, including the Obama plan, won't get a handle on costs because they won't fundamentally change the system. I'm willing to support them because they may be a step toward the needed changes, and might make the truly needed reforms more politically feasible. But if costs keep going up, these schemes will ultimately fail, because people just won't be able to afford to pay what they're being asked to pay. And that's asking for big trouble.

Okay, you want health policy wonking

you got it. The upcoming election may well be the most important election in U.S. history. Oh, the election of 1860 was important, but the outcome was never much in doubt and the terrain was very different. Lincoln was a regional candidate: he was not even on the ballot in most of the southern states. The election of 2008 will be contested, and it won't be about a single issue, obviously, but about a complex web of enormous challenges facing the nation and the planet.

There will be so much for President Obama and the new, Democratically controlled Congress to address (I'm not even contemplating the alternative, because I would have to move to Tasmania) that it's probably feckless to try to predict where health care reform will fall on the agenda and how it will fare in 2009 with everything else that's going on, but people are peering hard into the crystal ball.

As you probably know, Obama himself has proposed an incremental reform that addresses availability, although it does not result in universal coverage and does little to contain costs. He would make the federal employees' plan available to everyone, and set up an authority similar to the Massachusetts Connector to facilitate access to private plans, which would have to be offered on the basis of community rating (i.e., they'd have to issue insurance even if you're sick and they couldn't charge you extra for it). There would be sliding scale subsidies for lower income people, but no mandate to have coverage, except for children. Employers who did not contribute to their own employees' health care coverage would have to make an (unspecified) contribution to subsidize the national plan.

If this were to be implemented as written, it would certainly make the system more fair, and would almost certainly reduce the number of uninsured people, by extending coverage to people who are now excluded due to pre-existing conditions or high risk such as age), and perhaps to some extent by providing subsidies to low income people who do not qualify for Medicaid. The latter proposition is questionable, however, because such a reform could actually make insurance more expensive than it is now for young and healthy people - as they would have to join the same risk pool as older and sicker folks.

Whether the subsidies would be adequate to pull such people into the market is not clear. That is one reason why Obama's decision not to include a mandate, as in the otherwise similar Massachusetts plan, has been questioned. Pushing them in with a mandate forces them to act against their own interest in actuarial terms (although if they are hit by a bus they'll be happy they are insured), but it provides a subsidy for the higher risk people in the pool. Without the mandate, the insurance is more expensive for everybody else. And when the generation Y or Zers or whatever they are do find themselves under the bus, the taxpayers are probably going to end up paying for their trauma surgery anyway.

As for cost containment, there are vague concepts of disease management programs and a U.S. equivalent of the British National Institute for Clinical Excellence, but no stated commitment to enforceable guidelines for cost-effective treatment. Much of the cost problem concerns Medicare in any event, which would still pick people up as they turn 65 and which is not really discussed. Obama would allow Medicare - and I suppose the new national plan as well - to exercise its buying power and negotiate with drug companies, which would result in a substantial one-time reduction in cost to the government but would not stop the long-term upward trend in spending.

Proposals that currently have the most support in Congress -- notably the Healthy America Act sponsored by Sens. Wyden and Bennett -- aren't much different. The HAA also offers access to community rated plans, with individual mandates and subsidies for moderate income people. It lacks the national plan in the Obama proposal, however -- rather, it would only create the regulated private insurance market. Given that there seems to be an emerging consensus around a reform of this basic outline among Democrats and the nearly extinct species of moderate Republicans, we may indeed get something like it in 2009. Large employers are happy with this style of reform, which will likely end up saving them money. Health insurers probably don't like it much, since the more heavily regulated market will probably squeeze their profits, and drug companies will like it even less. Physicians, for the most part, should be okay with it, but we'll have to see how hospitals feel about it since these proposals do aim at keeping people out of hospitals and reducing spending on the most expensive services, in various ways.

So, even with the overwhelming public demand for change, and a landslide victory for the party of reform in November, we'll have a long way to go. They'll be yelling about socialized medicine, government control, taking away your individual choice, restricting competition, rationing, and Obama is actually an alien from Aldeberan sent to infiltrate the government and prepare the way for the extraterrestrial invasion. And they'll be spending a lot of money to stop it. After November, la lucha continua, on this and every other contested ground.

Blogging in the Long Emergency

I believe I have expressed this sentiment before, but sometimes the stuff I usually write about just doesn't seem important enough to merit the bits and bytes. Reading the NYT I found this in the business section:

Commodity prices went wild on Wednesday, with the price of corn shooting through the $7 barrier for the first time, soybeans and wheat moving up sharply and oil jumping more than $5 a barrel. . . .“You know those complaints you’ve been hearing about high food prices? They’ve just begun,” said Jason Ward, an analyst with Northstar Commodity in Minneapolis. . . . Meanwhile, oil futures jumped $5.07 to close at $136.38 a barrel on the New York Mercantile Exchange. The immediate catalyst was an Energy Department report showing commercial oil stockpiles in the United States fell 4.56 million barrels. . . . Some traders say that the market is now gearing for a quick rise to $150 a barrel.

All that bad weather in the midwest is contributing to the spike in grain prices, as well as flooding cities and towns and killing boy scouts. Is that because of the more energetic atmosphere resulting from rising CO2 levels, or is it just happenstance? We don't know for sure, but either way, the worldwide shortage of grain makes prices jump on any hit to supplies.

Meanwhile there's this:

By ANDREW C. REVKIN -- Some shark populations in the Mediterranean Sea have completely collapsed, according to a new study, with numbers of five species declining by more than 96 percent over the past two centuries.

“This loss of top predators could hold serious implications for the entire marine ecosystem, greatly affecting food webs throughout this region,” said the lead author of the study, Francesco Ferretti, a doctoral student in marine biology at Dalhousie University in Nova Scotia.

Particularly troubling, the researchers said, were patterns indicating a lack of females of breeding age, which are essential if populations are to recover even with new conservation measures.

The western North Atlantic fisheries on which Massachusetts was built have completely collapsed in the past decade. Fleets are going farther and farther afield to strip mine the oceans of one species after another. There isn't much left. The deepening drought in California has already permanently destroyed thousands of acres of farmland, and it's going to render cities uninhabitable soon enough. Such things are happening all over the world, in rich countries and poor, from Spain to Australia to Brazil and Zambia: climate change, resource depletion, and soon hunger and thirst.

Should we be worried about physician-patient communication, or health insurance, or flu vaccines? I'm nost sure.

UPDATE:The global water situation, from TAP.

Epidemiology and Reality

Funny thing that Steve should leave his comment on my previous post because I was just planning to say something along the lines of the question he raises. Steve proposes, "To my way of thinking, irrespective of the legitimacy of the analysis, any conclusion to restrict the right of a law abiding, sane person to obtain a concealed carry permit can and should be legitimately discarded. The individual right to be discreetly armed trumps the analysis."

This is a clear example of a very common ethical problem in public health. If I can show, to whatever degree of certainty you want to stipulate, that a regulation of some kind -- such as actual existing laws requiring that motorcycle riders wear helmets or drivers wear seat belts, banning smoking in public places, banning marijuana altogether, or as in the case at issue banning law abiding citizens from carrying concealed firearms -- will reduce injuries and deaths, is that sufficient justification for doing it? The "nanny state" is substituting its judgment for our individual choice, and the loss of liberty is a fundamental cost that overrides whatever statistical benefit to the population as a whole one might expect.

In fact, the question is never that simple and the proposition is constructed on a false dichotomy. Individuals, in exercising their own liberty, inevitably run up against the liberty of others. Just because you own a gun doesn't mean you can use it to rob, rape or kidnap people. The state deprives you of your liberty to take those actions in order to protect the liberty of the rest of us. When that guy in the Indianapolis Planet Hollywood dropped his gun on the floor and it shot two other patrons, he deprived them of their liberty to freely enjoy a public place and to enjoy the use of their own wrist and hip, respectively. So there are competing liberty interests here, it cuts two ways.

When a motorcycle rider suffers a brain injury, the state may wind up having to take care of his dependents, and may even end up spending tens of millions of dollars over his lifetime for his institutional care. That means collecting taxes from everybody else, which obviously impinges on our liberty. The state has a legitimate interest in preventing that, on behalf of all of us.

There are additional complexities. Tobacco is addictive, so are tobacco addicts really exercising their liberty by smoking? Many, if not most of them, will tell you that they do not want to smoke but cannot help themselves. Perhaps legal restrictions that encourage them to stop are actually enhancing their autonomy.

The point is not that letting people carry concealed handguns is wrong, or that making them wear motorcycle helmets is right. The point is, these decisions are always a matter of degree, there are no absolutes. Many libertarians make the mistake of assuming that only government can take away our freedom, but that is just obviously wrong. So can other individuals, and private organizations. None of us is ever really "free" anyway, all of our choices are constrained by circumstance. Even the most committed libertarian ought to be able to see that there is a legitimate role for government in arranging those circumstances to make people feel as free as possible. Without such government action, we will all be at the mercy of the most ruthless, or the most irresponsible, of our fellow citizens.

Update: One of the definitions of "liberal" (from Dictionary.com) is "favorable to or in accord with concepts of maximum individual freedom possible, esp. as guaranteed by law and secured by governmental protection of civil liberties." This neatly sums up the difference between liberalism and libertarianism: liberals recognize the need for government action to protect liberty, whereas libertarians think that liberty just happens.

No doubt you've come across this awful story of a little girl who took a handgun out of her grandmother's purse during a shopping trip and shot herself. Our friend Kathy thought I might want to take this occasion to discuss the proliferation of state laws allowing people to carry concealed handguns. When I decided to take her up on it, I didn't know what I was getting into.

This is certainly not the only anecdote about a legally carried concealed weapon that ended up doing something it shouldn't oughteradone. Kathy even sent in a few. Seattle's mayor wants to ban guns on city property after a shooting at a folklife festival, but under Washington law, he may not be able to. Here's a guy who shot his friend in the back. And so on. I believe I told you earlier about the guy whose gun fell out of his shirt pocket in the Planet Hollywood in Indianapolis and put a bullet through two American Public Health Association conference goers. The Chief of Police went on TV to say there would be no charges filed because "he had a puhmit fo the weapon." On the other hand, we don't seem to hear many stories about people fending off muggers and rapists with their concealed handguns. That's not to say it never happens but, the question is, what is the net effect on public safety of letting people go around with concealed hand guns?

The NRA aggressively pushes so-called "shall issue" laws, which require authorities to give a permit to carry a concealed firearm to anybody who applies, who isn't disqualified by a criminal record or mental illness. From 1979 to 1998, 23 states adopted such laws. But the effect these laws have had turns out to be a major point of controversy, which is difficult for me to untangle for you hear.

In 1997, JR Lott and DB Mustard published a study entitled "Crime, deterrence and right-to-carry concealed handguns." (Mr. Mustard, in the library, with a pistol?) They compared crime statistics before and after states passed such laws, and ran various regression models See my explanation here) to try to isolate the effect of the laws. Two of their 21 models found significant effects. They did find reductions in rape, aggravated assault, and homicide overall, but they found increases in larceny and auto theft, and they did not find significant effects on rates of robberies or the percentage of homicides that involved strangers.

Daniel Webster and colleagues published a detailed critique of these findings in American Journal of Public Health later in that year. Unfortunately, the arguments for the most part are technically complex and almost certain to be opaque to policy makers and to you, dear reader, so we have been left with a scientific controversy, rather like those which long surrounded tobacco, lead paint, and global warming, in which people's prior beliefs and commitments generally determine which expert they believe. In 2005, Rosengart et al did a new analysis using similar data sources and came to essentially the opposite conclusion: "When a 'shall issue' law was present, the rate of firearm homicides was greater." They didn't look at rape or assault. However, this may be a good time to point out that one of the reasons Lott and Mustard's findings seem odd is that contrary to popular misconceptions, rapes committed by strangers accosting people in public places are quite rare. There is no logical reason to expect concealed carry laws to have any effect on the typical kinds of sexual assaults, which involve acquaintances or family members.

There are various technical reasons why Lott and Mustard's analyses are flawed, all of which are corrected in the analysis by Rosengart, et al. Therefore, I am personally convinced that these laws are harmful and that only law enforcement officers should be carrying handguns around in public. However, ideological commitments are so strong that people who support such laws will not believe me. If I take the time to try to explain the reasons for this conclusion, as better qualified people than I have done, it will just add to the he said/she said din and do no good whatsoever in advancing the cause of truth. (I will do it anyway if there is popular demand, just for the heck of it, but it will be boring.)

This is extraordinarily frustrating, to say the least. When scientific findings get caught up in public policy controversies, views held by only a small minority of specialists get equal weight, so long as there are powerful interests to promote them. That does not mean, of course, that minority views in scientific controversies are necessarily wrong, but ceteris paribus, policymakers should normally treat them as unlikely. That may sound like a weak statement, but it's the strongest one I can make.

Informational Deficiency Disorder

and one way to beat it. Before I do my usual weekend disappearing act, I do want to encourage all you common rabble out there to read at least one medical journal, and the really great news, as I have pointed out before, is that you can do it for free.

Public Library of Science Medicine is linked on my sidebar. If you go to the home page this month you'll see a lot of boring looking technical stuff that you might not feel like reading, but do click on through to the current issue and see what's in the table of contents.

I've already discussed the piece on coverage of medical research in the corporate media, but there's more. Check out Ray Moynihan and friends on disease mongering, you know, making up diseases or extending their boundaries so we'll all realize that we have at least a few and rush out to get the pills to treat them. It's enough to give a guy Intermittent Explosive Disorder. Here's an important report from Australian television on Motivational Deficiency Disorder, which BTW is precisely what's causing me to disappear for the weekend. But I'm not going to take the pills because, well, I'm just not motivated.

David Bellinger discusses two studies published in the issue about the life long consequences of childhood lead exposure. These are quite disturbing and should have gotten much more attention than they have -- and we still need to be doing much more to prevent childhood lead poisoning. You can read the original studies too, if you like, which is the great thing about it. Bellinger can help you understand and interpret them, but you don't have to take his word for it, as you probably would if you read the public access material in the New England Journal of Medicine.

There is also a great deal of material of interest to health care providers, public health officials, and concerned lay people in poor countries -- people who can't afford to subscribe to most medical journals but who can get important information from PLoS.

Even better, you can talk back -- there are reader forums and comments on the articles.

So get in the habit. Develop PLoS addiction disorder.

No apple for the teacher

Our good friend Jean, in response to my asking for contributions to President Obama's "to do" list, proposes honest, effective, and comprehensive health education. I think that's an excellent addition. Although I'm afraid it may be too hot to handle for the campaign, it's something we're going to need to address after the dust settles in January.

If we're going to have honest and effective health education, it has to start with honest and effective biology education. And here, we have a problem. Michael Berkman and colleagues in the May PLoS Biology lay the bad news on us. Sixteen percent of U.S. high school biology teachers admit to believing that "God created human beings in their present form at one time within the last 10,000 years," and 47%, while agreeing that humans developed over millions of years, believe that God guided the process, and one in eight say they teach creationism in a positive light.

Even those teachers who aren't creationists face pressures to give short shrift to evolution. Seventeen percent don't cover human evolution in their classes at all, and more than 3/4 give it less than 5 hours. Only 23% agreed that evolution served as the unifying theme for their biology or life science courses, even though evolution is in fact the unifying theme of biology.

Now, it's no wonder that most American adults don't believe in the reality of evolution. They've been miseducated. Even if their teachers haven't actively taught them falsehoods, if you omit or scant evolution in what purports to be an introduction to biology you misrepresent biology. Since Obama spends an inordinate amount of rhetorical time and energy proclaiming his Christian faith, maybe he can be like Nixon going to China on this issue. Maybe president Obama can establish a policy that in order to be accredited to receive federal education funds, school districts, even in Texas, must adopt curricula that include teaching children the truth about the history and nature of life on earth, including human beings.

Maybe that's just too much to hope for.

News of the Weird

I'm like, scratching my head. Barack Obama won the Democratic nomination for president, correct? The nomination will be awarded officially by delegates to the Democratic National Convention, the delegate selection process is over, and the majority of the delegate votes at the convention belong to people who will vote for Obama. Ergo, QED, therefore, ipso facto, a fortiori and you can take it to the bank, Senator Obama will be the nominee.

So Hillary Clinton takes the occasion to announce:

She is the candidate who will be the best president;
She is asking people to continue to donate to her campaign;
She will decide on the future of her campaign in the coming days, based on what the people who voted for her want her to do;
That the voters of South Dakota have had the last word in the primaries, even though the polls in Montana were still open at that very moment;
That more people voted for her than had ever voted for a candidate in a primary -- even though more people voted for Obama than for Hillary Clinton.

What on earth is the motive for this speech? What does it all mean? Andrew Sullivan, who used to be wrong about everything but has woken up and smelled the coffee, says "The way she is now doing this - by an implicit threat, backed by McCain, to claim that Obama is an illegitimate nominee if she does not get her way - is designed to humiliate the nominee sufficiently to wound him enough to lose the election. . . . She will not go away. The Clintons will never go away. And they will do all they can to cripple any Democrat who tries to replace them. In the tent or out of it, it is always about them. And they are no longer rivals to Obama; they are threats."

Noam Scheiber says, "What good could possibly come of this? With Hillary proclaiming herself the legitimate winner, they're clearly going to say "keep going." If she actually does keep going, that's a disaster for the Democratic Party. And if she doesn't, you've just drawn a ton of attention to the fact that a large chunk of the party doesn't accept Obama as the legimiate nominee. No, worse: you've encouraged them to think that, then drawn attention to it."

Steven D says, "So she's still in it to win it! Or maybe she did win it? Who needs delegates anyway. She's strong, she's tough, and she only cares about you. You and your health care. That's why she ran for President. It was all about you. And Terry McCauliffe apparently. . . . And she she did promise to unite the party. I know because that was one sentence in her speech. Which I thought was really cool. She's a uniter not a divider. Who knew? Oh, and yeah, it was a great honor to beat Obama. She said that too (if you read between the lines in my opinion). So good for her."

Wacko. Nutty as Planter's Party Mix. And no, Senator Clinton, if you succeed in sabotaging the Obama campaign this fall, you will not be the nominee in 2012. It's time to think of Plan C.

Our long national nightmare is over

Like you, I really don't have a clue what exactly TF Hillary Clinton thinks she's been doing for the past couple of months, or why she's been doing whatever it is, but in any event, no matter what she says tonight, starting right now Barack Obama and the Democratic Party -- with the possible exception of Hillary and 182 fervent supporters who will continue to hold out in caves on some remote Pacific islands -- will start to run against John McCain for the office of prezneh unigh stay, as Sen. McCain pronounces it. That means that if we are very lucky, we just might hvae some conversations about public policy.

So here's my list of public health priorities. It's difficult to put them in order, and I might change my mind five minutes from now, but as of 1:42 pm eastern time they are:

1) Social inequality: The most powerful determinant of health inequality is social inequality -- income and education are the most salient measures, but having a sense of control over one's life, meaningful work to do, and other less tangible measures like that are just as important. The growing inequality in society, the closing of opportunity to more and more people, rising deprivation, are our biggest problem. And there are some obvious things the federal government can do to address this. A more progressive tax system -- eliminate the payroll tax on the first $20,000 or so of income, eliminate the cap on income subject to the tax, reinstate the estate tax, provide universal access to affordable higher education, expand nutrition support programs, etc. All that basic, hard core, dollar based redistributive policy stuff that has gone away -- starting, by the way, with WJ Clinton. We certainly don't need to go back to the worst features of AFDC, but -- oh, it's a long story.

2) Universal, comprehensive, single payer national health care. (Which also helps a lot with number 1, BTW). No, Obama isn't going to campaign on this -- who needs Harry and Louise messing with the election? -- but the way he talks about health care can be honest, educational and supportive of improved understanding of the issues in ways which will ultimately move us closer. Or they can be largely bullshit.

3) Climate change. Done right, by the way, it also helps with air quality and social inequality. E.g., much better public transit, development patterns that promote walking to store, school and work and/or using mass transit, solar energy, bicycles, all sorts of stuff that's so good and good for you and helps people live better on their incomes is also good for el planeta. Let's have a progressive, people positive green philosophy. Oh yeah, using less oil means less chance for . . .

4) War! What is it good for! Absolutely nothing! Say it again! We can't afford to be spending more than the rest of the world combined on soldiers and weapons. And blowing up people and stuff is bad for public health. As far as Iran is concerned, we need an honest discussion about nukular weapons, which we aren't going to get from Sen. Obama, unfortunately. Talk about rogue states? How about the U.S., which is in violation of its NNPT obligations, and Israel, which never even signed the treaty in the first place.

5) Emergency preparedness. With justice as well as good sense. That means a democratic discussion of stuff that just might, possibly happen. Which we don't have.

6) Democratization of science. People need to know what's going on with biomedical research, how their own bodies work, where their food comes from -- all kinds of stuff that they don't know enough about because the teevee fills their hours with bullshit and the public schools don't teach science worth a shit, and scientists work in isolation from the people. Knowledge is power. Let's spread it around. Again, I'm not sure Obama is going to talk about this. But we'll see.

What do you want to add?

The Unalive

It's time to wind up my little tour of biology with an odd little subplot. You can find plenty of arguments over the definition of life, what it is exactly that makes us call something alive. This is all very interesting as we think about what we might encounter out there, beyond the earth; and it was at one time all very interesting back when we didn't understand very much about life here on our little rock. But nowadays, the answer to what constitutes life on earth is simple and unequivocal: life is cells.

A cell is a comparment enclosed by a phospholipid bilayer containing a chemical system in a salty solution that includes polypeptides -- long chains of chemical units called amino acids -- shorter peptide chains, and polymers of varying length called RNA and DNA, among other important kinds of chemicals. Some cells, such as your own, also have smaller membrane-enclosed comparments within the larger compartment, in which specific processes take place, but that's optional. Y'all ought to know by now about the system in which information stored in DNA is read out onto RNA and translated into polypeptides. If you don't, look it up. Cells use a chemical process to extract energy from sugar to fuel all that chemistry. They get the sugar in various ways, and they can burn it with or without oxygen, but those are just details.

That's life. (And I can't deny it, many times I thought of cutting out, but my heart won't buy it . . .) But there are these other things floating around, teeny weeny particles with no cell membrane, no salty solution, no sugar burning, no nuthin' -- except DNA or RNA, in a teeny tiny compartment made of a few protein molecules. Are they alive?

Take it from me. No. No way. Nohow. Absolutamente no. Not. Never. Not a chance. Why do I say that? No chemical processes take place in a virus. Viruses do not and cannot eat, metabolize, or even reproduce. They don't do anything. Put a bunch of viruses on a nutrient solution and they'll just sit there for a little while, then they'll dissolve and be gone. That's it. So why are there so many of them around?

They're around because that DNA or RNA inside the little compartment consists of the instructions for making more of them, should it somehow get inside a cell. And the protein jacket is of a nature that it can dock with one or more of the various kinds of receptors that stick out through cell membranes in order to selectively let stuff in, and have the genetic material of the virus slip through. Most viruses contain DNA. The ones with RNA are called retroviruses, because in cells, RNA is usually constructed on a DNA template, but retroviral RNA serves as a template for creating DNA, which gets inserted into the host cells genome. In other words they work backwards, i.e. retro.

Now, as you can readily imagine, if a cell starts getting wrong instructions -- in this case, instructions to just start making virus particles -- that's bad news for the cell. Instead of doing whatever it does, it's just manufacturing bajillions of virus particles until it's full to bursting and then POW! it busts apart and all those viruses are out there. If the cell is one of yours, the viruses are now floating around in your bloodstream or your lymph or your cerebrospinal fluid or whatever. If one of them should happen to bump into the right cellular receptor, in goes the genetic material and another one of your cells is done for. As a result, you are sick.

Note that people talk in metaphorical terms about viruses all the time, in ways that make them seem alive, even purposeful. They talk about viruses "attacking cells," for example, but that really isn't accurate. Viruses just float around, and if they happen to bump into the right receptor, chemical forces cause them to dock and insert the viral genetic material. But they aren't actually doing anything, it's just chance. Similarly, because the cells don't reproduce the viral genetic material perfectly, the viruses mutate, and that means they can evolve. But that also is a random process.

I got very annoyed a few years back when I heard somebody I admire, the founder of the AIDS Action Committee of Massachusetts, saying on the radio that HIV is "intelligent," that it can "figure out how to get around the drugs." I wrote to Larry and complained, but he didn't seem to understand why I was so ticked off with him. (Hey, he said it in public.) A lot of people living with HIV have this idea that it's somehow malevolent and wily, and out to get them. One guy I interviewed even told me he decided not to take his nutritional supplements, because he didn't want to feed the virus. Nope. It's just like a little piece of computer tape, just some simple instructions for making a few proteins, consisting of 9 genes and about 10,000 genetic "words." That's all it is. (And here's a picture, and a description. Pretty interesting, so check it out.)

Since what really defines the virus is just the set of instructions, the DNA inserted into a cellular genome by a retrovirus is the virus, fundamentally. The free floating virus particle is called a virion. The virus as it exists in the host cells genome is called a provirus. A very interesting discovery in recent years is that eukaryotic genomes, including our own, appear to include quite a lot of junk that has been inserted by retroviruses over the eons and ended up stowing away for the long term. Most of this doesn't do anything, but it's quite possible that some DNA that gets inserted by viruses actually does end up functioning in the cell and its descendants, which means that there is a previously unknown mechanism of evolution. In addition to mutation, genes just might get moved around from one organism to another by viruses, which opens up all sorts of interesting possibilities.

But here's the tough question. Where in tarnation did these awful little things come from in the first place? If they were intelligently designed, that's a pretty nasty trick, don't you think? Actually, there would seem to be two basic possibilities, and quite likely both of them have happened:

a) A bit of genetic material gets loose from a cell, stuck to a piece of protein in such a way that it can persist long enough to get into another cell, and off you go;
b) A phage -- a parasitic bacterium that infects other cells -- goes through an evolutionary process called degeneration in which it gives up more and more of its own functions to its infected hosts, until it's whittled all the way down to a virus.

Either way, once a virus is out there, even though it isn't alive, it can evolve, and diversify. So from a small number of beginnings, you can ultimately get a huge diversity of viruses. The DNA viruses and the retroviruses are sufficiently different in principle that they must have different origins, I would say, but beyond that, there don't need to have been many originating events. So viruses really are not improbable. But even though they aren't alive, they are an important part of the biome.