Donning the ALCOA sombrero

We already know the CIA is getting to release the fake Osama bin Laden video endorsing Barack Obama. The one they did for Kerry was pathetic -- the guy didn't even look like Osama and he was wearing a ridiculous fake beard -- but it was good enough to fool Tom Brokaw. This time, I hope they do a little better, because after all, it is our tax dollars at work.

What else is likely to happen between now and Tuesday? Opening up my closet of anxieties we find:

Larry Johnson has been sitting on the "whitey" video the whole time. He releases it on Sunday at 4:00 pm eastern time. It takes two days for people to figure out that it's a fake, by which time it's too late.

All of the electronic voting machines in the country have been programmed to award 71.27% of the vote to McCain. Brian Williams avers that the pattern of voting may seem odd, but improbable things do happen.

The afternoon of election day, Fox News comes up with a bunch of elderly witnesses who are prepared to swear to the following events. Obama's mother unexpectedly went into labor, just outside the South Korean consulate. They took her in and called for an ambulance. As she was being carried out on a stretcher, the baby's head emerged just before her abdomen passed through the gate and onto the sidewalk. The Supreme Court is called upon to rule whether Obama was born on foreign soil and so is not a U.S. citizen . . . . You know the rest.

What are you worried about?

Waste

Not to mention fraud and abuse. Henry Aaron (not Hammerin' Hank, but the Brookings Institution economist) discusses getting the waste out of health care in this week's NEJM. (I'm not sure if there's a free full-text link because their site is down right now -- I'll update if it's available to the rabble.)

As you know, both of the presidential candidates are talking about cost savings by reducing utilization of health care services, albeit by different mechanisms. Senator McCain wants everybody to have crappy insurance that doesn't offer comprehensive benefits and requires high co-pays and deductibles. He figures you won't consume what you can't afford. Also, people who have chronic illnesses or are at high risk won't be able to get insurance at all. This might reduce some wasteful spending, but it will also reduce a lot of beneficial and even necessary spending.

Obama wants everybody to have affordable insurance, but he wants doctors and insurers to have better information about when procedures are indicated on the basis of costs and benefits. That sounds like a better idea to me, but it's a lot trickier than it might seem at first.

First of all, how do we measure benefits? Aaron doesn't actually address this issue in any real depth, so let me take it on as the first problem for this post. Then I'll tackle the other pieces subsequently.

One way is obviously the increased life expectancy you might get from, say, a cancer chemotherapy. This simple measure has been in the news quite a bit lately because the FDA has been approving very expensive treatments that appear to offer only a few months of live, on average, to severely ill people. This is an extreme case and it's actually one of the easiest, but it still isn't easy. There are two major problems. One is that nobody is average. Even if the average benefit in life expectancy is small, a minority of people gain much more. So you aren't buying 2 months, you're buying a chance at a year, or two years -- by which time who knows, there might be an even better treatment available, and you might end up with much more.

Second, how much is too much to pay for that? It seems to me our Culture of Life fanatics, who claim that all human life -- even that of entities with no consciousness -- is infinitely precious, would be forced by the logic of their own position to say that no amount is too much. But of course we don't have infinite resources, whatever we spend on that terminal cancer patient we are taking from some other possible use. Exactly how that works is not clear, but at the first analysis, the opportunity cost is other health care spending.

So how can we compare the value of all health care spending? Health care doesn't only extend life, of course, it also makes people feel better, look better, have better functionality at work and in daily life. So, to get a common measure, analysts often use Quality Adjusted Life Years, QALYs. A year spent really sick with cancer, or in a wheelchair, or in pain, or blind or whatever, is worth less than a year without those burdens and limitations. That seems to make sense at first glance, but wait a minute. If I have a limitation of some kind -- arthritis or a vision impairment or whatever it may be -- this says that my life is worth less than somebody who doesn't have that problem. I don't necessarily agree.

And again, even if we use QALYs or some measure we like better, the average benefit doesn't necessarily apply to me. I might get lucky and benefit more. Beyond luck, it's difficult to specify the full indications in detail in advance. My doctor might have a reason to think this is a better bet for me than it is for the average person, but that reason might not be fully captured in the guidelines.

So, we can get rid of waste that is unambiguous -- procedures that have been shown to offer very little, or no benefit, or to have risks that outweigh the likely benefit. But those are a small part of medical spending. Most waste is not on medical services at all, but on administrative costs. Those we can greatly reduce through single payer health care.

But the question of what constitutes wasteful medical practice is far more difficult. More on this later.

Site News: Pretty soon, I'm going to bite the bullet and switch to the new version of blogger. Chimpy comes down on November 5 anyway, no matter what happens, so I figure I might as well do it. I haven't decided what replaces him yet, the suggestion box is still open. But if the site is down briefly, don't worry. And don't be shocked if it suddenly looks different.

The Fall

As I believe I have previously revealed, I live in the hip, funky and groovy borough of Jamaica Plain. That means Diane Wilkerson is my State Senator.

I have met Her Honorableness on a few occasions, most notably when I invited her to speak at a symposium I organized on state policy to eliminate health disparities. She was co-chair of a legislative commission on the subject, and a long-time champion of health equity. I later edited her remarks for publication.

And they were good remarks. Wilkerson is a good public speaker, among other talents. She was the first black woman (and still the last) ever elected to the Massachusetts State Senate. Her appearance on the political scene inspired people, and moved some people I know very deeply. She was out in front on important issues, including same sex marriage, even though it was divisive among her African-American constituents (although it was a solid winner in JP).

I am now happy to be able to say, however, that I stopped voting for her two years ago. There appeared to be something wrong with the woman. She held up the report of the disparities commission for nearly a year, for no apparent reason, while the coalition of which I am a member was working to advance legislation based on the commission report. She had repeated brushes with the law and ethical regulations, feuded absurdly with colleagues, and started to take uncharacteristic and disturbing stances on land use issues.

Well, those of you who live apart from the glorious light of the Hub of the Universe, our Shining City on a Hill, may have missed it, but the FBI led her away in handcuffs yesterday after videotaping her taking thousands of dollars in bribes. Why she's had difficulty paying her taxes and her mortgage when she apparently stuffs hundred dollar bills into her bra every time she eats lunch is unclear.

I have been struggling to figure out the meaning of this sad and sorry episode. It's possible that she's actually just nuts, but I think there is a lesson here about the corrupting influence of power. Wilkerson got in deeper and deeper because her constituents gave her a pass on the first couple of sins. They were loyal to her even though she did not seem fully loyal to them. And as it turns out, she wasn't loyal to them at all. We don't have democracy just because we go and vote every two years. It has to be much more than that.

A new low in the annals of dipshittery?

Some clown let his 8 year old son fire a machine gun and some equally clownish certified "firearms instructor" went along with the idiocy. Result? Kid loses control of the weapon and shoots himself in the head. Dead.

Well, what do you think automatic rifles are for? Their purpose is to kill people. That's why they were invented, that's what they are designed to do, that's what they do. They're no good for anything else. How is that "fun"?

Your God-given right to be a depraved moron. It's what makes America great.

The People Speak

Okay, let me try to sum up some of the comments on what makes for the kind of doc people appreciate, and throw in some thoughts or two of my own.

Number one, honesty is the best policy. I think that has more than one dimension. It includes being up front about the bad news, not being afraid to say you don't know something, and admitting mistakes.

In the old days here, and still to a considerable extent in Latin America, it was the norm not to tell people when their condition was likely to be fatal, the archetypal example being incurable cancer. We certainly have a different ethical norm now, but a lot of doctors still feel that there is something cruel about depriving people of hope. Of course we're all mortal so "hope" is really a matter of degree. How long might each of us expect to have and in what state of comfort and cognition? Answering that question, even for the most technically competent physician, is as much art as science and people do sometimes beat even the most definite prognoses. But doctors should certainly accurately report their best judgment and the true degree of uncertainty.

The second point can be harder for some doctors. The culture imbues them with God-like powers and some of them enjoy that role.

Which makes admitting mistakes even harder, especially with the fear of malpractice suits hovering behind the scene. But the evidence shows that the likelihood of being sued for malpractice has little to do with whether physicians were in fact negligent or incompetent, and more to do with how people feel they were treated. An admission of error and an apology can actually reduce the chance of being sued, and turn away wrath. The fact of the matter is that doctors are human and they all, every one of them, make mistakes. We need to accept that, as long as they are really trying, are not negligent, and are not incompetent. All of which is not the same as being infallible.

Next there's the issue of talking down to people about technical matters, presuming you're just too dumb to understand, or not being bothered to explain. What really frosts my pumpkin is when doctors think they're doing us a favor by explaining things in terms of weird metaphors, like viruses being "intelligent" and able to "outsmart" the medications. It's more difficult to explain biomedical issues accurately to people who don't have a lot of biological education, but it's your job. It can be done, you need to figure out how. Which means not talking down to people, giving them the chance to ask questions and not acting all intellectually superior when they do. Then take the time to think through how to make scientifically accurate, if necessarily somewhat simplified, explanations.

Xine notes that there is a difference between what we expect of specialists and primary care physicians. Indeed, although I'd say it can get a little bit tricky operationalizing this. When people have chronic diseases, or serious diseases that have a relatively long course of treatment, the relationship with the specialist can become primary. In fact, in the case of chronic disease, often the specialist in fact becomes the primary care doctor. It's one thing to see a surgeon for a one time procedure after we've already been diagnosed and gotten the basic 4-1-1 from our primary care doc; but the relationship between someone with cancer and an oncologist is much more intimate. So I'd say this is more of a continuum than a dichotomy.

Roger puts technical skill foremost, and I expect most people would if they were asked. Our problem is that we usually can't really tell how skilled the doctor is. Like Roger, I do know that my doctor is good a freezing warts, which certainly wins him some cred because I know that some of them aren't. He's willing to go right after the earwax and he gave me excellent advise about how to work out a stiff shoulder. So we can pick up on that stuff. But most of it is far from obvious. That's why we go to them, after all -- they're the expert. If they are out to lunch, we really don't know until it's too late.

As Kathy notes, however, doctors have certain performative roles (little technical term their from sociolinguistics) as well as biomedical roles. We need them to sign certifications and excuses and so on. They might think all that is beneath them or a minor part of their responsibility, but people depend on them for it. This is a form of social power that doctors have been known to abuse, as well. Maybe I'll talk about that at greater length at some point.

So people tend to judge their doctors' competency impressionistically. I'd like to know more about how they do it.

Now, as for the compassion/empathy thing versus professional reserve. It's a difficult balance, not just insofar as how it affects patients' feelings and likelihood to follow medical advice, but also insofar as it affects the physician's emotional well being. Remember that it's the biggest thing in the world when one of us has a serious health problem, but doctors see it many times, every day, and sometimes their patients really suffer and sometimes they die tragically, no matter what they do. Doctors have to figure out how to truly care about all those people without lying awake all night and turning to the bottle. That is not easy, and becoming callous or overinvolved are both occupational hazards -- or perhaps swinging between the extremes with different patients, depending on whether they rub you the wrong way or you are attracted to them.

So we need to cut them some slack, while recognizing that meeting these challenges is indeed a big part of their job and ought to be one reason they make the big bucks, as much as their biomedical knowledge and technical skills. That's what I'm trying to help them to do.

Cervantes the Sociologist

I have been discussing with some of my colleagues the question of physician empathy. Presumably, it's good if physicians respond with some form of reassurance or fellow feeling or compassion when patients express concerns, fear, sadness sorrow or pain. That may seem like an obvious proposition but it's actually quite complicated.

In the first place, I use the word "presumably" advisedly. There actually isn't much concrete evidence about the relationship between "empathic" behaviors by physicians and outcomes -- such as adherence to medication regimens, recovery from illness, or patient's sense of well-being -- or even patient satisfaction with their relationships with their physicians. Sure, people say they are happier with their doctors when they also say their doctors "know them as a person" and care about them and so on, and there is also evidence that they take their medications more faithfully when they feel this way, but we don't know much about exactly what kinds of behaviors by doctors cause patients to have these good feelings about them.

Quite a few investigators have used the paradigm of "cues" by patients and physician responses. Essentially they'll identify and count the number of times a patient says something that seems to indicate a concern or a negative affect of some kind, and then give the doctor a brownie point for responding immediately with something they perceive as empathy or support; and a demerit for not doing so.

These studies inevitably find that doctors miss most of these "opportunities" for empathy, and they just think that's a bad thing.

Well now hold on a goldarn minute. Do I really want my doctor weeping and slobbering over me every time I suggest some form of distress or unpleasantness that might be happening to me? The whole point of a physician visit is to try to solve or ameliorate health problems, so of course you're going to mention stuff that bothers you. Sure, I don't want the doctor to be a callous brute but we also have work to do. I'm not telling you these things because I'm looking for a shoulder to cry on, I'm telling them because they're information you need to diagnose and treat, or to figure out what information I need from you.

It seems to me that what we really need is to know that yes, the physician really does care about us, is on our side, really is trying -- and oh yeah, actually knows what she or he is doing and is technically competent. Once I know that -- perhaps because of one or two expressions of empathy at appropriate times -- we can get down to business. As much as overt expressions of caring, what I really want is that the physician correctly understands what is troubling me and comes up with an appropriate response. That means listening, being willing to let me ask questions (and that's a big problem - doctors ask 90% of the questions), and asking me questions about what I want and how I feel about treatment options, rather than just asking about symptoms and whether I do bad stuff like not take my pills or eat wrong or drink too much.

Furthermore, kindness and empathy aren't necessarily manifested in overt utterances; they're something we feel because of a person's tone of voice, body language, and oh yeah -- all of the above paragraph. A doctor who is constantly expressing empathy and caring out loud might easily seem patronizing and infantilizing. I'm not an object of pity, I can handle my problems just fine. You aren't my mommy, you're my doctor.

So how do people feel about this? How do you want your doctor to treat you, in terms of interpersonal process?

Apologies . . .

for not posting yesterday, was very busy. Anyhow . . .

On the one hand, it is really horrifying to watch the self-destruction of John McCain. This guy spent decades carefully constructing a reputation and public image that most members of the journalistic profession, such as it is, swallowed like candied opium. Now he has systematically destroyed it down to the last particle. All the elements of classical tragedy are in there, complete with the chorus of hairhatted talking heads.

But the good news is that we may end up being grateful to the Senator for destroying himself. If we get the electoral blowout that might, just might happen -- if an only if, I should say -- there is a chance to get something meaningful done about health care. We often hear CW to the effect that Americans prefer divided government because they want to restrain government activism. Right now, that is the opposite of what we need to hear. Major changes are urgently needed.

Victor Fuchs, a gray eminence of health care policy, analyzes the political trap in which we find ourselves. The basic difficulty is the intersection of substantial vested interests -- interests which are well aware of their political peril and are very well organized and activated to fend it off -- with a flawed deep structure that will not yield to incremental change.

In a nutshell, we pay for services, not for results; and bad results actually increase the profits of providers, because they generate more services. At the same time, the immense waste built into the system represents income and profit for a whole lot of people, who are determined to defend it. In Fuchs's essay I don't really see a path out of the trap, but I believe there may be one if we get an overwhelming Democratic congress with an Obama presidency.

The trick is to provide a publicly sponsored option, an alternative to private insurance that's available to everyone -- including employers who currently sponsor their employees in private plans -- community rated, with low administrative costs and no need to make a profit, so it has an edge in the marketplace. It may suffer from adverse selection to some extent, but it it's selling to large employers that won't be a big problem. It will be politically difficult for the insurance and drug industries to resist if it's just offered as an option -- the same insurance Joe Biden gets, that you or your employer can buy into. What's wrong with that?

It will become very popular, and then the political pressure will be to sustain it, which will require containing costs, by bargaining with the drug companies, rationalizing care, and changing incentives to support high quality primary care that emphasizes prevention, disease management, accessibility, and evidence based treatment. All the hollering about rationing will ring hollow if the public plan actually delivers what people want and its cost advantage keeps growing. The private plans can hang around as long as they are able, but with proper management of the public plan, they'll become superfluous.

This still requires confronting very powerful constituencies that know how to play dirty. But it must be done.

UPDATE: And right on cue, They are successful pharmaceutical company executives, and both have schools of pharmacy at prominent universities named after them. Between them, they have given nearly $4 million to a new North Carolina-based 527 group that is sponsoring ads attacking Sen. Barack Obama's tax policies.

Chinese puzzle

An important theme issue of JAMA this week, on the health of the nation. Alas, unlike NEJM, the continue to hide material of strong public interest behind the subscription wall. I condemn thee, I condemn thee, I condemn thee!

So, since you can't read any of it, you'll have to trust me to report accurately on what's in there. The problems with our health care system are complex and interrelated. Stuart Altman has compared it to a balloon -- if you squeeze it in one place, it expands in another. But I'm going to use the analogy of one of those 3-dimensional Chinese puzzles. It turns out that if you can find the one or two key pieces, you can take it apart easily.


Manya Newton and colleagues review literature about overcrowding in Emergency Departments and encounter some common assumptions that it is caused in substantial part by uninsured patients who use EDs inappropriately for routine care that ought to be provided in physician's offices. They find that in fact, uninsured patients aren't significantly more likely to visit EDs for non-urgent care than are insured people. Both uninsured and insured patients, however, do sometimes make visits for non-urgent care because they lack access to primary care services. Yes, insured people can get to see a doctor, but they might have to wait for weeks. Conditions that are defined as "non-urgent" in the sense that they can be treated in doctor's offices are nevertheless frequently much too urgent for a three week wait.

In fact, ED overcrowding is not caused by an increase in uninsured people showing up, it's caused by inadequate payment for emergency care leading to a shortage of services; inadequate numbers of hospital beds causing patients to back up in the ED; and inadequate supply of primary care, as noted above.

There is a severe and growing shortage of primary care physician services. It's difficult for insured people to find physicians who will take new patients; people who have physicians face long waits for appointments; primary care doctors don't have enough time to spend with the patients they do see; and they work long hours for lower pay than other specialists. I say "other" specialists because primary care is a specialty and ought to be thought of as such, not as somehow representing inferior or less advanced training and skill.

And by the way, we also face a severe and growing shortage of nurses, as documented by Buerhaus, Staiger and Auerbach in The Future of the Nursing Workforce in the United States: Data, Trends and Implications, reviewed in the same issue. The fact is we need to provide better pay, better working conditions, and more dignity and respect to both professions.

The two key puzzle pieces for fixing our collapsing health care system are:

1) Universal, comprehensive, single payer national health care,
2) Which increases the rewards for primary care physicians and skilled nursing professionals, and assures an adequate supply of well trained practitioners in both categories, so that we can take care of people properly.

Number 2 is an essential underpinning of the third piece, which is to allocate resources in a rational manner. I have discussed that before but I will have more to say about it shortly.

Meanwhile, there is no room for debate: Obama's proposal is at least a small step in the right direction, McCain's is a huge, radical step in exactly the wrong direction. Anybody who believes this is a matter on which reasonable people can disagree doesn't know Socialism from Rastafarianism.

A message from behind enemy lines

As long-time readers know, I live in one of the most anti-American parts of the United States. Fortunately, there are a few under-cover patriots here, some of whom courageously resisted the rising tide of Communism, terrorism and negritude by courageously vandalizing the Boston ACORN office. But for the most part, the news is not good.

The anti-American movement has already infiltrated the U.S. Congress, sending the Communist Edward M. Kennedy and Frenchified traitor John F. Kerry to the Senate. Our most prominent member of the house is notorious sodomite Barney Fa-- excuse me, Frank. You may not have heard of the rest of the gang but they all hate the troops. They're even trying to make them come home to their families instead of doing what they love, driving around in the blistering desert and getting blown up and shot in order to achieve something that Senator McCain will explain to them later.

Most discouraging of all, the International Negro Conspiracy has already seized state power here, and Governor Devalodinga Denizulu al-Patrick is furthering its sinister ends by supporting investment in renewable energy, instead of patriotic American oil drilling in George's Bank -- I mean come on, the fishery has already collapsed anyway -- and life sciences research, which is code for murdering babies for profit.

I'm sorry to have to tell Governor Palin that even our small towns are infested with socialists and lesbians. Everywhere I go I see Obama signs un-defaced by the patriotic messages, such as "KKK" and "nigger" that we see in the pro-American parts of the country. If it gets any worse, I may be forced to move to North Carolina. Oh wait . . .

Land of the Daft

Maybe when I think I'm awake, I'm dreaming, and when I'm dreaming, I'm really awake or something.

It turns out that Joe the Plumber:

Is not a plumber
Makes $40,000 a year
Is in no position to buy his boss's business, and
Even if he was, the business only clears 100K
His name is Sam

We already know that "Sarah Palin" is also a fictitious character. The real Sarah Palin is fiscally irresponsible -- drove Wasilla deep into debt on a boondoggle sportspalast project -- campaigned in favor of the Bridge to Nowhere, lobbied vigorously for earmarks, and far from being a reformer, she habitually abuses her power and violates the law. Oh yeah -- she isn't even a hunter. Her father makes her buy hunting licenses so he can shoot moose on her tag.

"John McCain," of course, is equally fictitious. The mavericky straight talker who has a strict rule against employing lobbyists in his campaign has a senior staff that consists entirely of lobbyists; radically changed his positions on immigration, the role of religion in public life, and taxes, in order to suck up to the far right; and just makes up crazy bullshit all the time.

But at least 42% of the people already plan to vote for "John McCain" (and he's gaining) because they get computer generated phone calls claiming that Barack Obama is a Communist, terrorist, baby murderer.

And this is the greatest country on earth and we're all proud to be Americans.

I mean come on now. Enough. We're a laughing stock before the entire world. Doesn't that bother y'all wingnuts even a little, tiny bit?

Plumber's Butt

I have made essentially these same arguments here, but you don't have to take it from me, a mere hippiecommiegodlessfreakblogger, when you can take it from David Blumenthal, M.D., M.P.P., Director, Institute for Health Policy, Massachusetts General Hospital.

John McCain emerges not as a maverick or centrist but as a radical social conservative firmly in the grip of the ideology that animates the domestic policies of President George W. Bush. The central purpose of President Bush's health policy, and John McCain's, is to reduce the role of insurance and make Americans pay a larger part of their health care bills out of pocket. Their embrace of market forces, fierce antagonism toward government, and determination to force individuals to have more "skin in the game" are overriding — all other goals are subsidiary. Indeed, the Republican commitment to market-oriented reforms is so strong that, to attain their vision, Bush and McCain seem willing to take huge risks with the efficiency, equity, and stability of our health care system.

The true facts about the way health insurance markets work are very difficult to explain in the 30 seconds that candidates get to put across an idea in a debate, and they certainly don't fit on a bumper sticker. If that were not the case, McCain's bamboozlement on this issue would have long ago utterly destroyed his candidacy. But let me try one more time to get the bullet points to a manageable, comprehensible few.

1. In deregulated, private insurance markets, insurance companies will either charge a lot more to people who are sick or are at risk for getting sick; or they won't sell insurance to those people at all.


2. In deregulated, private insurance markets, insurance companies will do everything they can not to pay claims.


3. If you make people pay more out of pocket for their health care, they won't end up reducing costs by making wise choices about expenditure, because the vast majority of medical spending is already for serious needs, i.e. stuff like cancer treatment and heart surgery. What people will scrimp on is stuff like screening and preventive care, which will just make us sicker and cost more in the long run; while people who do get sick will end up being punished for it financially.


4. John McCain's health care "reform" proposal will make it impossible for older people or people with chronic diseases to get health insurance; will make the insurance that people can buy less comprehensive; and will increase administrative costs and waste.


5. It will mean fewer people have insurance, people with the greatest need will get the least and people with serious illnesses won't be able to get treatment at all, so they'll just die. It will be the law of the jungle.


6. John McCain is a radical extremist who does not share the values of most Americans.

Those are the facts. Let's see if CBS will report them.

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But it's worth it. Roll the mouse around, click here and there, and see what happens. But whatever you do, don't answer the red phone.

Alright, you try to think of something to write about every day

I had a strange dream last night, based on the following fact: there is exactly one way to flip a coin one million times and have it come out heads every time. There are one million ways to flip a coin a million times and get exactly one tails. In other words, your chances of getting one tails and 999,999 heads are one million times as great as your chances of getting one million heads. That's a fact! And yet your chance of getting exactly one tails is so small as to make it, for all practical purposes, impossible. The total number of possible ways to flip a coin one million times is 2^1,000,000, a number with more than 300,000 digits.

My brain usually produces bizarre dreams, but every once in a while reality intrudes in a straightforward way. Believe it or not, last night I also dreamed that I had a private conversation with Senator McCain. I told him exactly what I'm sure all of you would have: that he's highly unlikely to become president, and he needs to be thinking about something much more important right now, that is his place in the national discourse after November 4 and his place in history after he is gone. Right now, he's destroying his own reputation and turning his historic legacy into one of disgrace and shame. Is that really worth it? Naturally, he was completely impervious.

What have you dreamed about lately?

ACORN

A major piece of the newest offensive of lies by the McCain campaign is an effort to demonize the organization ACORN as a criminal enterprise bent on committing voter fraud and stealing the election in key states. They are actually trying to explain away their pending defeat on November 4 as the product of fraud by this massive criminal syndicate. Of course, as I'm sure you know, there has never been a single incident of fraudulent voting connected with ACORN's voter registration campaign, nor is there likely to be. If Mickey Mouse shows up to vote, he's going to have to produce ID, obviously.

ACORN has registered more than a million new voters, and in the process, a few bogus registrations -- whether because of pranksters, or voter registration workers trying to exaggerate their productivity -- have slipped through. ACORN flags these for election officials when it catches them, but is required by law to submit them anyway. That's all there is to it. A completely fraudulent story. But that's not what I want to talk about today.

Shortly after I graduated from college, I was an ACORN organizer in Philadelphia. That meant knocking on doors in poor neighborhoods and asking people to become active in fighting for the interests of their own neighborhoods and, ultimately, low and moderate income people everywhere. I wrote about my experiences in Radical Teacher magazine, January 1988, "Taking it from the streets: an organizer goes back to school." (I leave it off my CV.)

I started working in Fishtown, a poor white neighborhood on the Delaware. The people in Fishtown were nearly incapacitated politically by their racism. To quote YT:

We had a hard time finding a place for the first neighborhood meeting. None of the churches would give us space -- the Civic Association got to all the preachers. The local Methodist minister didn't mince words: "People here don't want to see more benefits coming into the neighborhood, no more federal money, no more services. That would just end up upsetting the traditional ethnic balance here."

Finally we arranged to meet in the Fishtown Civic Center. Our legal services lawyer had to threaten to sue the city before we got permission. . . . Six or seven of the fifty people in the room were boys from the Civic Association, come to make it even hotter than a Philadelphia August ought to be.

One of them stood up after John and Charlie had made their speeches. "Okay. We've all heard how long you guys have lived here. . . I'm gonna be honest with you. I haven't lived here all my life. I moved here ten years ago from the other side of Front St., and you know why too." He slapped his bare forearm with two fingers, indicating the color of his skin. "Before I moved to Kensington, I lived in North Phillie near the park, and now that's darkest Africa. I moved here because Fishtown is white and I figure it's staying white. But now I'm not so sure."

On the doors, we'd ask people what issues concerned them the most, and number one, most of the time, was "the niggers." They didn't like to work, they were all on welfare, and they were taking all the jobs. Also, they were going to push us into the river. I had much better experiences organizing in Black neighborhoods, where I never felt the least unwelcome, by pigmentation didn't matter, and there was a tradition of social protest that it was easy to tap into. We worked with the leadership in Fishtown that was willing to look past race to get things done, even if they did have a distance to travel in confronting their own attitudes, and over time we built a multiracial organization in Philadelphia that won some small victories in the neighborhoods and, I'd like to think, contributed to a gradual transformation of the political culture from the straight up racism of the Rizzo years to the more issue-based politics of today.

Working for ACORN taught me that the biggest obstacle to effective class based politics in this country is racism. That's why we have never had a labor party or a true party of the left as in every European country. That's why we have had predominantly Republican rule since Nixon. ACORN organizes poor people and working class people across the racial divide, and it confronts race baiting as the principle establishment strategy against it everywhere it goes. Now the Republicans have elevated their attack on ACORN to the national level, and once again, the subtext is racial: they're trying to set up a whole lot of darkies to cast fraudulent votes for their dusky radical black nationalist candidate.

Well, to ACORN I say congratulations: there's no such thing as bad publicity. It's the same old evil crap you're confronting, but now you've made the big time.

The people united will never be defeated.

My fellow prisoners . . .

The prospect of hard times raises lots of concerns, obviously, but lean years turn into catastrophe when they create civic and political collapse. The economic catastrophe in Germany gave us Hitler, Mussolini and World War II. Soaring unemployment in Europe today will exacerbate an already tense climate of anti-immigrant sentiment and who knows where that might lead?

Then there's the U.S.A. The Great Depression gave us FDR and the liberal approach to saving capitalism called the New Deal, which in turn gave us almost half a century of post-war stability and rising living standards. But what few people today remember is that there was a countervailing fascist movement in the United States as well, exemplified by the "father of hate radio," Catholic priest Charles Coughlin.

As the gravest national challenges approach since the height of the Cold War and the attendant era of social unrest, the McCain campaign for president has descended into depravity, whipping up racism and tribalism, and accusing the man who is likely to become president, and members of his party, of treason -- of being allied with enemies of the United States and dedicated to the destruction of this country. Literally. And the followers of Sen. McCain and his running mate -- who is in actual fact an ally of enemies of the United States and quite likely is covertly an enemy of the United States herself -- are incited to murderous frenzy by their rhetoric.

Here is Sen. McCain apparently threatening to prosecute Barney Frank and Chris Dodd for causing the financial crisis. And here's the New York Times on the McCain campaign's obsession with William Ayers:

Senator John McCain joined in the attacks on Thursday on Senator Barack Obama for his ties to the 1960s radical William Ayers, telling an angry, raucous crowd in Wisconsin that “we need to know the full extent of the relationship” to judge whether Mr. Obama “is telling the truth to the American people or not.” . . .

But what has been most striking about the last 48 hours on the campaign trail is the increasingly hostile atmosphere at Mr. McCain’s rallies, where voters furiously booed any mention of Mr. Obama and lashed out at the Democrats, Wall Street and the news media.

“I’m really mad!” shouted a man in the audience in Waukesha, where Mr. McCain and his running mate, Gov. Sarah Palin of Alaska, were conducting a town-hall-style meeting. “And what’s going to surprise you, it’s not the economy. It’s the socialists taking over our country.” . . .

Mr. Ayers is now a professor at the University of Illinois at Chicago and lives in Mr. Obama’s neighborhood. He was named citizen of the year in Chicago in 1997, has worked with Mr. Obama on a schools project and a charitable board, and gave a house party when Mr. Obama was running for the State Senate.

Sarah Palin, as we all know, calls this "palling around with terrorists," and McCain campaign advertisements also accuse Obama of consorting with a terrorist, while campaign surrogates essentially say that he is a terrorist. As we have all heard and read, people at McCain and Palin rallies have screamed out that Barack Obama is a traitor and terrorist, and called for his murder, all without the slightest response from the candidates. The polls so far show no indication that this is working to win over voters, but we should all fear the consequences after November 4 when Obama is elected president and a substantial proportion of the electorate actually believes, because the Senator from Arizona and leader of the Republican Party has told them so, that a terrorist enemy of the United States is preparing to seize state power -- a terrorist enemy who also happens to be part of a long-oppressed and marginalized ethnic group, the son of a foreigner who adhered to a religion seen as alien and hostile.

What will happen to civil order and national unity then, when we need it the most? And who then puts country first?

This is kinda weird . . .

But I'll pass it along anyway. Our friends at the Robert Wood Johnson Foundation (disclosure alert: they funded research of mine many years ago) offer an "'calculator' that explores the link between education and mortality in America". "The tool allows users to adjust the education level where they live – on a county-by-county level – and see how many lives could be saved if education were improved."

Now, it's true that education correlates with health and life expectancy, and improving educational effectiveness, retention in school, and providing universal access to higher education should be a very high social priority. I've said before that I wish President-elect Obama would say more about education, including higher education, which is still an assortive mechanism that functions more to reproduce the ruling class than it does to offer opportunity and equality.

On the other hand the RWJ calculator strikes me as rather simplistic. Education is a proxy for social status more broadly. If everybody had a college degree, then a lot of people would end up in jobs that were not commensurate with their skills, because after all we would still have inequality and somebody would still have to clean the toilets and pick up the garbage. In fact this is exactly what has happened in many developing countries where college graduates find themselves without work opportunities, and the result is often social unrest and alienation.

So we need to think more broadly about the the organization of work and the expansion of opportunity. Not everybody can or should go to Harvard. Lots of people are happy and well suited to put their talents to work as electricians, carpenters, automobile mechanics, and in other jobs that require vocational education rather than a B.A. More menial jobs can be done by teenagers and people working their way through school, and by people with cognitive limitations, or the responsibilities can be shared by people who also have more challenging responsibilities. Even in my own office setting, technology has largely replaced what used to be pink collar work and I do my own copying and typing and filing, for example. But how to create a society in which everybody has the opportunity for fulfilling and decently remunerative work is much more complicated than just getting everybody through more grades of school.

A lot to think about.

Moral Values

As I have noted upon occasion, the moralistic approach to public health is about as immoral as you can get, because it kills people. I'm talking about murderous policies such as abstinence only sex education, banning use of HIV prevention funds for condom distribution, that sort of thing.

Rep. José Serrano of New York has sponsored legislation to overturn the ban on using federal funds to support needle exchange programs. Update: Link corrected (Actually the ban goes further than that -- Substance Abuse and Mental Health Administration officials have privately warned grantees not to advocate for needle exchange programs, even locally, if they want to keep their funding. No, I can't give you a link or documentation -- this is direct, personal knowledge.)

Rep. Serrano, unlike a lot of politicians these days, , even gives detailed, specific reasons and logical arguments for his proposal. Excerpt:

Since 1988, Congress has banned federal funding of syringe exchange programs. We must lift this ban.

At the end of 2006, nearly one-third of all U.S. AIDS cases -- more than 300,000 -- were linked to intravenous drug use. These are not just numbers but thousands of Americans -- friends, relatives and colleagues -- struggling with what can be debilitating challenges. Drug addiction can ruin lives, but even its enormous power pales in comparison to the havoc wreaked by HIV. While we strive to help people overcome drug addiction, we must also help them avoid HIV-AIDS and other infectious diseases.

Last year, in an annual spending bill that I wrote, I was able to lift a congressionally mandated ban on the District of Columbia using its own funds for syringe exchange programs. I believe that this was both a home-rule issue and a positive public health initiative. During debate on this measure, critics trotted out the tired claim that syringe exchange programs encourage drug use.

The facts do not support this claim. Consider what Elias A. Zerhouni, the respected director of the National Institutes of Health, wrote to Congress in 2004: "A number of studies conducted in the United States have shown that syringe exchange programs do not increase drug use among participants or surrounding community members and are associated with reductions in the incidence of HIV, hepatitis B, and hepatitis C in the drug-using population." Despite overwhelming scientific evidence, legislators and others opposed to syringe exchange continue to ignore the proof that contradicts their claims.

Obviously, it's too late for the legislation this year. But next year, this will be one more bit of toxic waste from the last eight years that we'll be able to dispose of properly. I know which of the presidential candidates would sign this bill, and which of them would not. So do you.

What are you afraid of?

Since I'm going to give a little talk about this today, I might as well conserve my dwindling intellectual resources and talk about it here. We face innumerable risks in daily life, from being hit by a bus to breathing in invisible ultra-fine particles from the bus's exhaust, to eating trans-fat in our morning muffin.

Scientific and technical type people -- engineers, epidemiologists, policy analysts, physicians, insurance actuaries, etc. -- evaluate those risks using mathematics. They might be thinking about the risk to an individual, as physicians are likely to do, or to populations, as epidemiologists do. There are different complexities in the two cases, but the individual case is perhaps a bit more straightforward. Here I'll concentrate on the population case.

A "scientific" assessment of risk is essentially an equation of the form P X Harm, where P is the probability of harm occurring, and "Harm" is a quantification of its magnitude. To decide whether risks are worth taking, or which are more severe, you need a common metric for "Harm." Popular choices are dollars, and something called Quality Adjusted Life Years, QALYs (pronounced Quahlies).

To value human lives or health in dollars seems intuitively repugnant to most people, but of course we do it all the time. We could be spending four bucks to save a kid in Africa from malaria or starvation, but we don't do it, right? Resources are scarce, we're all gonna die anyway, so yes, ultimately human lives have finite value in dollars. Exactly how to make that calculation, however, and what its ethical implications may be, are highly controversial questions, however.

QALYs, in essence, are years of life, marked down for ill health or disability, for example, a year of life in a wheelchair is some percentage of a year of being able to walk. No, I'm not kidding. But if you ask people -- at least comparatively healthy and young people -- if they would be willing to give up some amount of total life span to avoid a period of disability, most people will answer yes. They'd be willing to die a bit earlier to avoid going blind or whatever. And it's on the basis of that kind of survey data that the QALYs are calculated.

Then there's P. For an individual, it's the probability of it happening to that person. For a population, the probability will be distributed unevenly, so you have to add up all the individual probabilities, multiply them by the lost dollars or QALYs per person, and there's your total cost to the population. If you've made the computation in dollars, you can compare that to the cost of eliminating or reducing the risk, and voila, you know whether it's worth doing. If you've made the computation in QALYs, you can compare the cost of eliminating the risk to other possible expenditures and decide which one is a higher priority.

There are some problems. Valuing lives in dollars generally means figuring out a person's predicted lifetime economic contribution. You can include non-market contributions such as child care and housekeeping, being a friend, etc., but you still end up valuing the lives of higher income and younger people more highly than those of people with lesser earning potential. You could try to fix that by assigning the same dollar value to a QALY, regardless of who it belongs to, but with QALYs, the lives of people with disabilities or ill health, and again, older people, are worth less, whether or not you convert QALYs to dollars.

In fact, while we might say we're willing to give up some life span to stay healthy, once we find ourselves disabled or sick we don't necessarily find that we value our lives less. Whoops, I didn't really mean that after all. Too late, sucker, your insurance won't cover that.

Average people also don't have access to the information to make these calculations anyway, and finally, they don't think in probabilities the same way scientists do -- they buy lottery tickets, for example, and it gets a lot more complicated than that when you start to weight potential gains vs. potential losses. Most people's assessment of risk is based on heuristics -- rules of thumb, readily available decision rules -- that have to do with characteristics of risks that are quite different from their probabilities and quantifiable harms. These include whether they are assumed voluntarily, whether they are catastrophic -- concentrated in a single notable event, such as a plane crash, vs. spread out into smaller events such as automobile accidents -- whether they are natural or human caused, etc.

Many academic analysts call people's views of risk "irrational," but maybe that's arrogant and elitist and all that. Maybe people's views incorporate an instinctive view of fairness and an ethical accounting for agency that ought to be acknowledged in the way we make these calculations.

These are convoluted questions but they are at the heart of much political disagreement, and need to be discussed more openly and in terms that people can understand and relate to.

Exactly how fucked are we?

On the one hand, we are so fucking fucked it isn't fucking funny.

However, we do have choices. Even with reduced means, we will still be the wealthiest, most powerful nation that has ever existed, and we will have far more at our disposal than our grandparents during the Great Depression. We don't have to let people starve and freeze. We don't have to accept massive homelessness. We can still educate our children, still heal the sick, still succor the afflicted. We can still offer dignified work and self-sufficiency to everyone. We can still have music, and art, and meals in restaurants, and family farms, and community, and everything we need and most of what we want.

That is, if we make the right choices, but so far, we have shown no signs of having the wisdom to do so. We do have to give some things up, starting with war, and the nearly invisible global empire of military bases that most Americans are barely aware exists.

Wealthy people -- and there are still quite a few of them, in spite of everything -- will have to pay more in taxes to secure the future of the nation that they looted to get what they have. As Joe Biden says, it's the patriotic thing for them to do.

Lenders will have to deal wisely with people who are behind on their mortgages, and accept some losses to prevent the destruction of communities and countless lives. And oh yes, they'll actually be better off than they are foreclosing and ending up with worthless property.

We can still borrow money from the Arab oil potentates, but we have to invest it wisely, instead of squandering it on profligate consumption and world historical crimes against humanity.

We have to completely rebuild our largest industry, health care, to meet human needs instead of feeding corporate profit.

We have to mobilize the energies, wealth, and good will of our people, come together in a time of terrible crisis, and turn urgency into opportunity. It will be tough, and there will be some suffering, and most of us will have to give up something. But we can certainly survive and emerge stronger. We can. We might not.

The malignant dwarf who fraudulently occupies the office of president has nothing to offer us but fear and more fear. His designated successor is even worse. In the next month, we'll be engulfed in a torrent of filth spewed by the desperate and dying remnants of the criminal order that brought us to our present straits. Will the people drown in it, or climb above it? This is one of the most critical moments in our history, have no doubt of it.

A low-cost/no cost public health agenda for President Obama

We know that he will take office with some very big problems. Even though he hasn't been willing to specify what he's going to give up because of the economic and fiscal catastrophe he will inherit, we all know that there will be no choice but to scale back the ambitious policy agenda the Obama campaign has laid out.

So what can we accomplish in a first Obama term?

Health care reform: That absolutely must go forward because it is essential to the long-term solvency of the federal government, the viability of the economy, and the preservation of a political culture that values justice and equity. The Republicans will claim that it costs taxpayer dollars and it's creeping socialism and government intrusion into our lives and all that idiotic lying jive, but the people don't want to hear it any more. It will actually benefit to the government's fiscal condition, if it's done right, but that will mean keeping the drug and insurance companies big fat snouts out of the trough. That's going to be the real challenge.

Renewable energy: Will require an immediate investment, but that kind of investment will be essential to prevent Great Depression II, so borrowing money to do this can be justified on multiple grounds. From a public health point of view, motor vehicle emissions shorten the lives of millions of people. You would be astonished how dangerous it is to live near a major highway or to spend a lot of time communting or driving a truck. Sustained exposure to near highway pollution increases your age adjusted risk of AMI by more than 30%.

Also will mean reduced emissions from coal fired power plants, less mercury in the environment and less particulates in the air.

Raise the federal gasoline tax: Helps achieve the above, also means fewer highway miles traveled. Invest the proceeds, not in new roadways, but in maintaining existing roads and building mass transit. Give a refundable credit to low income people so they don't suffer. You can make it revenue neutral, but we really need to bring in more money.

Tobacco control: Little or no federal money has to be spent, all we need is legislation allowing the federal government to encourage state and local tobacco control measures such as workplace smoking bans, higher tobacco excise taxes, and anti-tobacco marketing campaigns, by making existing federal grants to the states contingent on such laws. If a state doesn't want to go along, the federal government actually saves money. Long-term, we save money on health care and we have a more productive workforce.

Criminal justice reform: We need fewer people in jail, and that starts with a rational drug control policy that decriminalizes addiction. It costs a whole lot less to treat people than it does to incarcerate them, and it also means they don't commit crimes and they do go to work and pay taxes. Smart all around.

That's my short list for starters. What else?

Political Science

When Sarah Palin was anointed of God to become president when John McCain's anger worm or whatever it may be finishes eating his brain, I read a little bit about her and I found that she is a far right religious extremist who is associated with a movement that is literally trying to raise an army to conquer the earth on behalf of Jesus and install Christian dominion over every land. Personally, I can't support that, I don't know about you. However, I was surprised to learn that she is also a blithering idiot.

It turns out that's not necessarily a bad thing. According to all the analyses of the upcoming debate that I've been reading, all she has to do to "win" the debate is ignore the actual questions and spout memorized attack lines against Barack Obama. It turns out that Gwen Ifill isn't allowed to follow up and point out that she didn't answer the question, because she's a member of the negro conspiracy to seize state power. Other than that, Palin just has to refrain from rolling her eyes and sighing, and she has to pretend to take notes while Biden is talking.

Meanwhile, Joe Biden will display astonishing erudition and a profound grasp of history, economics, international affairs and social policy. He will spew facts, figures, historical analogies, acronyms and the names of foreign leaders great and small like an intellectual power washer. His arguments will be concise, well-crafted, logically impeccable, and built on a solid foundation of fact. This means he will be an arrogant, out of touch elitist who cannot possibly understand the struggles of ordinary people and who is a mean bully who is trying to make poor little Sarah look stupid. Even though she is stupid, and that's why we like her.

Only in America is ignorance and indifference to truth and logic a qualification for high office. I would assume that people who don't know a whole lot about medicine don't seek out an incompetent doctor because somebody who actually knows medicine can't possibly understand their problems. I presume that people who don't know anything about plumbing or electrical wiring do not look for the most inept, alcoholic layabout they can possibly find to work on their house because they can relate to that person so much better than an arrogant elitist who went to trade school. But that's been the Republican presidential brand for as long as I can remember. Vote for Ronald Reagan, Vote for George W. Bush, they're just as dumb as you are. And it works.