Just some thumb sucking about where medicine is today

When I first began to study medical sociology in the late 1980s medicine was just beginning to undergo a cultural shift that ultimately led to intense self-reflection.



The probability of doctors doing more good than harm didn't really become substantially positive until around mid-century, with the development of antibiotics and other important advances. Finally having a truly effective science of medicine was exciting and in some ways, too seductive, because it led to an era in which medicine was highly reductionist, breaking down the organism into separate pieces and systems and largely ignoring the psychological and social dimensions that are part of an entire human being. Hospitalized people were referred to as "the cirrhosis in room 2010" or "the COPDer in 817." Doctors and patients didn't talk with each other, the doctor just said, you have this and that, take these pills, or maybe didn't even bother to say you have this and that. There was a spate of widely read books that analyzed medicine as an instrument of social control -- Intimate Adversaries, Medical Nemesis, The Second Sickness, Disabling Professions -- and as unengaged with the humanity of patients -- The Discourse of Medicine, the Silent World of Doctors and Patients. None of these were saying that physicians were bad people or didn't want to benefit their patients, but they were saying that the culture and structure of the medical institution were in one way or another defective. Illich came at it from a religio-philosophical perspective, Waitzkin a leftist political perspective, Dundas Todd a feminist perspective, Zola the perspective of disability and the stigma of illness, Mishler and Katz a broader socio-cultural perspective, but one way or another they were all seeing the relationship as too one-sided, as imposing its own values and goals on the people who came in contact with it, to their detriment or disservice.



Fortunately, during the time I have been studying these issues there has been a large and sincere reaction to these criticisms within the profession. Academic medicine has honestly struggled to come to terms with the nature of the physician-patient relationship, the appropriate scope and boundaries of medicine, and how medicine should engage with individual patients, communities, politics and society. But we still have a way to go, both because the old culture is still somewhat entrenched and glaciers don't melt overnight, and also because we just don't know enough about how to heal people instead of livers and stomachs and immune systems. Social science is slippery, because there are too many moving parts -- every person is different even though we're also all the same. But anyway, I do believe that the practice of medicine is getting somewhat better, even as it is becoming more difficult and trying to climb uphill against growing challenges.

I'll continue to try to sort through it all here.

Astonishing breakthrough!

>MGH investigators confirm fundamental laws of physics, conservation of mass is shown to apply to the human metabolism!

Yes folks, it turns out that your body works the same way as my garage. I put in firewood, and I take firewood out and burn it. If the amount of firewood I put in is more than the amount I burn, there is more and more firewood in the garage. If the amount of firewood I burn is more than the amount I put in, there is less and less firewood.

Nineteen people with doctoral degrees have collaborated to prove that if your caloric intake is more than the calories you burn, you will get fatter, and if the amount of calories you burn is more than your caloric intake, you will get thinner. It does not matter whether the calories are in the form of carbohydrates, protein or fat, just as it does not matter whether my firewood is oak, maple or birch.

Well duhhh. The problem is, very few people are able to stick to a weight loss program. Only about 15% of the people in this study had real success, and they tended to gain weight back after a year or so. People found it easier to stick to diets that consisted of food they like to eat, but it's also a good idea to eat a healthy diet.

So that's all there is to it folks. That's all there ever was to it. That's all there ever will be. Eat what you like, just don't eat too much of it. But if you have a weight problem, it won't be easy.

Now can we stop spending money to prove stupid stuff that we already know?

Talk is cheap

Here is the section on health care from the president's speech last night, and my profound comments.

For that same reason, we must also address the crushing cost of health care. This is a cost that now causes a bankruptcy in America every thirty seconds. By the end of the year, it could cause 1.5 million Americans to lose their homes. In the last eight years, premiums have grown four times faster than wages. And in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas. And it's one of the largest and fastest-growing parts of our budget. Given these facts, we can no longer afford to put health care reform on hold.

Mad props to the prez for emphasizing cost as the key to the problem. It's not the whole problem, of course -- but we can't achieve universal coverage, high quality, and the best health outcomes if we don't wrestle the cost monster to the ground. Furthermore, this seems to be good politics -- people are worried first and foremost about the economic catastrophe and lost jobs, and by putting health care into that context he gives us the best chance to get something major done.

Already, we have done more to advance the cause of health care reform in the last thirty days than we have in the last decade. When it was days old, this Congress passed a law to provide and protect health insurance for eleven million American children whose parents work full-time.

Certainly, I was in favor of expanding S-CHIP. But, that really doesn't get us anywhere. When you get into the weeds of eligibility, coverage limits, sliding scales and what not with S-CHIP as with the rest of the patchwork of federal, state and private plans, the mind boggles and the tongue ties trying to sort out the perverse incentives. Expanding our current dysfunctional disease care system adds a small modicum of justice, but no common sense.

Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.

Hoo boy is this ever a can of worms. Electronic medical records systems have a lot to be said for them, but ensuring privacy is not on that list. They create huge privacy problems. Those may be solvable but at considerable cost. EMRs can indeed reduce errors but the biggest payoff comes from a universal system in which an individual's record attaches to the individual, not a provider institution, and is accessible from everywhere, by all providers. Whether we will see anything like that in my lifetime is questionable, and it poses the greatest challenge for privacy. We may get a patchwork in which more and more physician practices and institutions, not just academic medical centers, use their own proprietary systems, but getting these to talk to each other is a nightmare. For small practices, EMRs are just not cost effective, because of the initial capital costs and learning curve, so they'll need substantial subsidies. Fully integrating behavioral health, nursing homes, specialists -- oy. Electronic order entry systems -- a subset of the whole EMR concept -- can reduce prescribing errors, but beyond that, using EMRs to reduce medical errors will require a huge investment in decision tools and has considerable potential to backfire, if we end up substituting one-size-fits all rules for sound physician judgment. Can we really save money this way? I don't think so.

It will launch a new effort to conquer a disease that has touched the life of nearly every American by seeking a cure for cancer in our time.

We now know that there is no such thing as "cancer," that is a term for innumerable different diseases characterized by abnormalities in cellular gene expression that cause abnormal tissue growth. There will never be "a" cure for cancer, though we are slowly, sloggingly making progress against various specific manifestations. Unfortunately, as we grow older, genetic abnormalities accumulate in our tissues, so even if we do manage to cure one cancer, the longer we go on living, the more likely we are to get another one. So cancer is never going to go away, and even worse, the more treatments we develop for more and more different kinds of cancer, the more money we are going to spend using them. Expanding cancer research might be something people want to do, but it sure as hell isn't going to save money.

And it makes the largest investment ever in preventive care, because that is one of the best ways to keep our people healthy and our costs under control.

Yes to proposition A -- some preventive measures are helpful in keeping people healthy -- but no to proposition B -- preventive medicine does not save money. I wrote about this recently, and there are two recent articles -- one in JAMA by SH Wolfe (Feb. 4), the other by Louise B. Rusell in Health Affairs -- but unfortunately they are both subscription only (booo!) so I can't let you read them. I mention this only so you don't have to take my word for it. Basically, with few exceptions, you have to spend money, even if it's a small amount of money, on a whole lot of people in order to prevent disease, and it usually ends up costing more than it saves. That doesn't mean it isn't worth doing -- it's often cost effective, but that doesn't mean it's cost saving, it just means we don't mind spending a few bucks to prevent disease.

Cost saving measures are available, but for the most part they aren't preventive care -- i.e., they don't happen in the doctor's office. They are public health measures, like tobacco control and promoting better diets and physical activity. But the president didn't mention the words "public health." Maybe next time.

This budget builds on these reforms. It includes an historic commitment to comprehensive health care reform - a down-payment on the principle that we must have quality, affordable health care for every American. It's a commitment that's paid for in part by efficiencies in our system that are long overdue. And it's a step we must take if we hope to bring down our deficit in the years to come. Now, there will be many different opinions and ideas about how to achieve reform, and that is why I'm bringing together businesses and workers, doctors and health care providers, Democrats and Republicans to begin work on this issue next week.

Okay, so we're going to do something, it's just that so far, we don't have even a hint of what it's going to be. I know we aren't going to get what we really need right away, so I am going to judge the proposal which emerges on one criterion and one criterion only: does it create a path toward universal, comprehensive, single payer national health care? If it makes that even harder to attain, I'm agin it. If it's neutral on that objective, it isn't worth doing. If it takes us a step closer, I'll take to the streets to support it.

I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

Definitely: if we're going to do something good, let's do it right now, before the wingnuts have a chance to get up off the rug. For the next few months, nobody will care how loud they scream about socialism and big government. Now's the time.

Meanwhile, here's David Leonhardt, explaining why conservatives are completely, utterly, abysmally wrong. Not that this will get through to anybody.

The annals of crime

I was reading some interviews a colleague in New York did with people with HIV and I came across something I hadn't heard about before -- crooked pharmacies that buy up antiretroviral drugs from street brokers. My friend sent me this article that lays out the whole thing. It talks about drug addicts who sell their meds, but the interviews also mention people sending money home to poor relatives in the Dominican Republic, or people who can't afford the rent.

Now for sure, one should never be surprised by the limitless prospects for human depravity. But it seems to me the police could stop this dead tomorrow if they wanted to. Do an undercover sale, bust the broker, get him to turn on the pharmacy, and Bob's your uncle. Put two or three of those pharmacists out of business and in the joint, and the rest of them will get the message right away. It's not like narcotics dealing where the market is bottomless: there couldn't be more than a couple of dozen scumbags on the buying end. Any New Yorkers want to yell and scream at the Mayor about this? Of course, it's only killing junkies and desperate poor people, so who really cares?

Molecules and substances

Ana notes, quite correctly, that trust is an important variable in speech act theory. I would go considerably further and say that the elucidation of speech acts is contingent on many dimensions of the relationship between the interlocutors, including not only trust but the rights and privileges the speaker accords the interlocutor, and presumes for himself or herself; the degree of regard or affection (or its opposite) from one to the other; the degree of intimacy and the location of boundaries; and shared history and context between the two.

Many speech acts speak for themselves, but sometimes any or all of those factors can be part of the determination of how to classify a speech act, or greatly affect its import. An example I commonly use is "It's cold in here," which looks like a statemetn of fact but is unlikely to be the kind of speech act we call a representative, because if the interlocutor is in the same room, she or he already knows the temperature. If this is said over the telephone, it might be a representative, but otherwise it could be an expressive -- e.g., a spouse complaining that the other keeps the thermostat too low, or simply a request for sympathy -- or a request to turn the thermostat up, or perhaps to cuddle. We would need to know a lot about the relationship and history of the interlocutors to accurately conclude what is intended.

Fortunately for my research team, physician-patient interactions are highly ritualized, bounded by cultural norms regarding the respective roles, and largely -- though by no means exclusively -- limited to a finite universe of subject matter. We can usually deduce the parameters of the relationship -- such as trust, regard, etc. -- from speech acts which are not problematic, and so have a basis for properly classifying those which may be more difficult. To the extent that norms and conventional boundaries are violated, or the relationship has a large load of history or unusual degrees of personal feeling, we can observe that from the data.

However, I don't know that we can always do this and we may be fooling ourselves a bit. In spite of the vast amount of research that has been done on physician-patient communication, there has been very little which concerns how doctors and patients view their ongoing relationships and how these develop and change over time, as opposed to breaking down invidivual encounters. Of course, encounters with specialists or in urgent care are often one-time or few time events. But other Dr-Pt relationships are extensive and intimate, within certain boundaries and in patterned ways. This is something I would like to understand much better.

Shovel-ready science

I just got off of a conference call with the acting NIH director, wherein he briefed what I presume were 6 gazillion panting scientists about what's going to happen with the $10.4 billion NIH got from the stimulus bill.

NIH will end up with about $800 million for comparative effectiveness research, half of it looped through AHRQ for some reason, which is actually a fulfillment of an Obama campaign promise, as you may recall -- and, bizarrely, a bete noir with a large segment of the right that actually thinks it's a violation of your freedom for you and your doctor to know which treatments work better. Weird, bizarre, and very very strange.

Other money goes for construction programs, like building and fixing up labs -- $1 billion of it to external institutions, i.e. mostly colleges and universities. Maybe Harvard can finish that new stem cell research center after all! (Those of you who don't live in the Athens of America probably don't know that they had to put it on hold because they lost all their money at the dog track.)

The part I really care about -- $8.2 billion -- is to fund actual scientific research. Yay! The director will get an $800 million slush fund to do with as he pleases, it seems. Of the remaining $7.4 billion (believe me, it goes fast when you start spreading it around), it must all be used for projects that will be completed within 2 years and won't create out-year commitments. That's a weird criterion for research, believe me. No large-scale trials or epidemiological studies will be funded, we've all got to scramble to think up stuff we can do fast.

Some of it will go to existing applications that were approved as scientifically meritorious but didn't make the pay line. Rats, I don't have anything in.

Some of it will go as supplements to current projects. That we can do. One idea is to create more post-doctoral fellowships for out-of-work Ph.D.s That will create some job openings on the back end for cab drivers.

Some of it will be for new programs, in what are called NIH Challenge Grants. The solicitations will be out soon.

This is all great -- we're all feeling like kids in the candy store right now -- but it is also quite bizarre. There will be this 2-year torrent of money and then slam, the spigot will be off. Will all those nerds be back in the cab in 2011? Just wondering . . .

Help me out here . . .

I'm having a bit of an ethical dilemma, which is causing me writer's block regarding a proposal. Does it matter why people choose to accept a physician's recommendation for treatment? In particular, is it somehow just wrong if they have misconceptions about their disease or the way the treatment works, don't accurately understand all of the risks or how things might go wrong, or are basing their decision on factors that probably ought to be irrelevant? In other words, how strong should be our commitment to the official doctrine of informed consent?

Here's some background. I interviewed a whole lot of people with HIV about their treatment decision making, i.e. whether or not to take antiretroviral drugs (ARVs). A few of them said they just did whatever their doctor told them to do, and they really didn't want to be bothered to learn a whole lot of scientific stuff about HIV and ARVs. That seems fine to me, if that's what they want, I'm not going to tell them they are supposed to be better informed.

Most of them, however, said that they based their decision on information. They often said they attended educational workshops, read magazines, talked with their doctors and health educators, used the Internet, etc., and came to an informed decision. But then as I continued to interview them it turned out that they didn't actually know, well, much of anything. They often didn't even know what classes of drugs they were taking. (At the time, there were three major kinds of ARVs, called nucleoside analogue reverse transcriptase inhibitors, non-nucleoside analogue yadda yadda yaddas, and protease inhibitors. The first two block the action of an enzyme that writes the viral genome into the host cell's DNA, but in different ways; and the latter blocks an enzyme that cuts the long polypeptide products of the viral genome into their constituent proteins.) They didn't know anything about the possible side effects of the drugs, except for side effects they had actually experienced; they often thought that drug resistance was a change in their bodies, rather than an adaptation by the virus; and some of them had no concept of viral replication. One woman said that viral load was a measure of how many babies the mother virus was having.

Now, is this wrong, as long as they were taking the meds and keeping themselves comparatively healthy? Sometimes their doctors had talked with them in metaphoric terms, such as virions being "enemy soldiers" and needing to keep our soldiers -- the ARVs -- in the field so they couldn't take over. That's complete bullshit, of course, but it seemed to work. Of course, it may turn out that people who have a better understanding adhere better in the long run and otherwise do stuff we like such as not risking transmitting the virus or becoming reinfected -- which is bad because they might acquire a drug resistant strain. But if I can't prove that, should anybody care? Scientifically accurate knowledge was available to these folks, but evidently not in a form they could understand, or maybe they didn't really make the effort but felt satisfied with whatever ideas did get into their heads.

Is that malum in se? Should I be given taxpayer money to figure out how common it is, and how to explain things to people better? Or would you rather I be stimulated in some other way, as long as the people are taking their pills?

Flacked!

Tobacco Free Kids wants me to tout their new report on tobacco industry marketing to women and girls. Done. (Warning: Gigantic PDF. You might just want to go to the TFK home page to get the short version.)

There. I guess I'm easy.

They're still around. And they're still evil.

FDA = Feckless Drug Administration

The Office of Inspector General of HHS recently released a report on the FDA's oversight concerning financial conflicts of interest on the part of investigators involved in new drug applications. (H/T to Bridget Kuehn, the JAMA public affairs reporter, for bringing this to attention.) You may be vaguely aware that when drug companies submit studies to support approval of new drugs, they are supposed to tell the FDA when the researchers were in their pay or stand to benefit from approval. Yeah, right.

42% of marketing applications were missing financial disclosures - sometimes because they were just missing, and sometimes because the sponsors claimed a "due dilligence" exemption. That means they called the researchers twice and sent them two letters, and didn't get an answer, therefore they don't have to provide any disclosure. Uh, since they're the ones who paid the people in the first place, they probably already know. Duhh. But if you don't want to disclose, all you have to do is ignore the requirement, and you're exempt! Gee, do you think that's too easy?

For some reason, the companies and investigators do sometimes disclose financial conflicts of interest, but most of the time, the FDA didn't do anything about it. Sometimes the sponsors submitted information to indicate that they had tried to minimize resulting bias, but the FDA doesn't try to assess the validity of such claims. The bottom line is that although independent research finds that about 25% of clinical trials investigators have financial conflicts of interest, only 1% of investigators listed in approved marketing applications include a disclosure. Not only that, the FDA doesn't even require a complete list of investigators in the first place.

That the drug approval process is deeply corrupt is not news, but this crosses the line from tragedy to farce. Maybe we should all just try to stick to aspirin for the time being.

What's next? A cure for baldness?

After my recent rant about the hopeless state of chronic tendinitis, I have to point out that it appears doctors may be onto a possible cure. What's slightly weird about this, however, is that the story appears on the NYT's sports page, even though they happen to have a perfectly good health/science page on the same day.

In a nutshell, the idea is to bombard the afflicted tendon with the person's own platelets. Simple enough. However, we haven't had any corporations funding the big clinical trial for this, instead we have professional sports team docs trying it out on their multi-million dollar charges. Presumably that's because there aren't big bucks in it for Pfizer. Come to think of it it's not clear that there's anything here that's patentable.

This is rather reminiscent of how a lot of important technology doesn't get developed until somebody decides it would be useful for war fighting. Antibiotics, your Intertubes, the Global Positioning System, all came out of military research. Will platelet-rich plasma therapy make it from the NFL to poor saps like me? We'll just have to wait and see. But one more reason why we need to get basic clinical science research out of the private sector and organize it in the public interest.

The stupid designer

Richard Dawkins, of all people, writing in Free Inquiry (Feb/March 2009), summarizes Darwin's Big Idea as:

Given sufficient time, the non-random survival of hereditary entities (which occasionally miscopy) will generate complexity, diversity, beauty, and an illusion of design so persuasive that it is almost impossible to distinguish from deliberate intelligent design.

Ahh, no professor. You have had an astonishing, and quite uncharacteristic brain fart. It is, as you well know, quite easy to distinguish the products of evolution from deliberate intelligent design.

Consider one familiar species, Homo sapiens. Among the innumerable design flaws in this generally splendid product are:

• The baby's head is too big for the birth canal. Prior to modern obstetrics, it was all too common for women to die in child birth.


• There is a vestigial tail, that serves no purpose except to produce excruciating pain if you happen to fall on it -- and it is located precisely in a place where that is likely to happen -- but only to a creature that walks upright on its hind legs.


• There is a narrow pouch extending from the entrance to the colon, which serves no evident purpose except to become infected. Prior to modern surgery, infection and perforation of the vermiform appendix was a frequent cause of death.


• The spine has a structurally defective curvature at the bottom, causing no end of unpleasantness.


• The respiratory and alimentary entrances to the body go through a common portal, leading to frequent accidents in which ingested material gets stuck in the trachea, resulting all too often in untimely death.

I could go on and on, but you get the idea. With a tweak here and there, we could do much better. Evolution, however, had to work with what it had, which was mammals with small heads, that walked on four legs, that evidently had some use for an appendix and a tail, and which didn't talk so that the trachea could be more effectively closed off during swallowing.

Understanding human evolution is very helpful for public health and medicine. For example, it provides insight into the kind of diet and lifestyle which is most likely to prolong good health and vigor, and into the immune system with all the good it does, and the harm as well when it turns against us in Type 1 diabetes, multiple sclerosis, rheumatoid arthritis, etc.

One of the great joys of atheism is that we do not have to contend with the problem of evil. This is the ruination of every theologian, although they swaddle it in sufficient sophistry to stifle its intolerable screams. If God made everything and saw that it was good, why did he make our bad backs and our deaths in childbirth and our treacherous autoimmunities? What a jerk! If he was smart enough to design smallpox, we were even smarter to eradicate it.

The fact is, we do have all sorts of flaws, some of which we're learning how to fix, at least partially, but others of which we still have to live with. That can be a drag, but at least now we know we don't have to take it personally. No intelligence did this to us on purpose, it just happened. And fortunately, unlike the designer, we actually are intelligent, so we can do something about it. Isn't that good news?

Evolution in the News

Yes, Darwin Day is over, but since today is - well you know, a certain date and day of the week - I'll pretend it's still yesterday.

Two interesting news stories today, both with an evolutionary theme. Nicolas Wade reports on progress in reconstructing the genome of Neanderthals. There are some misconceptions about these creatures -- they are not our ancestors, or a more primitive version of Homo sapiens, but rather a closely related species that diverged from our direct line. They lived in Europe, and went extinct about 30,000 years ago after Homo sapiens arrived in the area.

It is possible, sadly, that we outcompeted them or even massacred them. Neanderthals had a static culture which was not as technologically sophisticated as that of their contemporary H sapiens, so that could certainly have been the story. People have speculated whether the species interbred and the conclusion from this work so far is, apparently not. This is all very interesting and will no doubt ultimately yield further insights into human evolution but I just want to comment on a truly weird element of this story, which is that some scientists are speculating about the possibility of resurrecting the Neanderthals.

The idea would be to construct a complete Neanderthal genome by making the appropriate modifications in H sapiens genes, inserting the chromosomes into a chimpanzee ovum and then implanting the embryo in a chimpanzee mother, on the grounds that using a human ovum and surrogate mother creates greater ethical problems. This is actually not possible using current technology, but if Bill Gates wanted to fund a project, it could probably be accomplished. I certainly doubt that Bill would be interested, but there are plenty of wacko rich people out there so you never know.

Whether or not you think the whole idea is unethical, or just grotesque, as a thought experiment it is definitely entertaining. For starters, if someone were to do it, would we owe the Neanderthals the same respect and rights we grant to H sapiens? Okay then, why don't we give the same respect to chimps? They're only slightly more distantly related. We don't know whether Neanderthals could talk, but is that the criterion? African gray parrots can talk, and they can learn to communicate with humans using syntax.

The other major genetic breakthrough of the day, also reported by Mr. Wade, is the sequencing of the genome of all 99 strains of the cold virus. There's good news and bad news. You want the good news first? Okay, there is a region which has been strongly conserved by evolution, in other words all the strains have this in common. Evidently it's necessary for the virus to be successful. That means it could be a target for an antiretroviral drug that would be effective against all cold viruses.

The bad news? No drug company is likely to undertake an effort to develop such a drug. Since colds are just a nuisance for most people, we just wouldn't pay big bucks for it, number one; and number two, it would only take a few doses at most to do the job, so the market wouldn't be large enough for them to make money charging low prices. They're much more interested in drugs that don't cure people, that you need to keep taking forever; or drugs for life threatening conditions that they can charge tens of thousands of dollars for, e.g. cancer chemotherapy.

That does not mean that there wouldn't be a net benefit to society from development of a cure for the common cold, however. So here's one more reason why we need to completely change the drug development process. New drug development should be publicly funded, based on calculations about what's best for the public. Then the government can license the meds to manufacturers. How's that for a plan?

¡Gracias a Dios!

A special court ruled Thursday that parents of autistic children are not entitled to compensation in their contention that certain vaccines caused autism in their children. "I must decide this case not on sentiment, but by analyzing the evidence," one of the "special masters" hearing the case said in denying the families' claims.

This largely disposes of the problem from a legal standpoint. These families had claimed that MMR vaccine and thimerosal combined caused their children's autism; other claims are based on one or the other agent alone, and logically, if the court ruled against these families, the remaining cases are hopeless.

I'm afraid, Mr. Robert F. Kennedy Junior, that you're going to have to find another class action lawsuit to pursue. Not that you aren't wealthy enough already.

As for these families who struggle with their children's autism, of course they need more support and resources. If we had a sufficiently just society in the first place, people wouldn't have to pursue frivolous lawsuits in order to try to get the help they need.

Let Freedumb Ring

Darwin Day is a day of celebration, but here in the U.S. it's also a day of national shame. PZ Myers disparaged this graphic from The Economist as being plagiarized, but regardless, it tells the story: "In 2008 14% of people [Americans] polled by Gallup agreed that “man evolved over millions of years”, up from 9% in 1982." The graphic actually shows more like 35% of Americans agreeing that the theory of evolution is "true," but it evidently reflects a different wording of the question.

In any event, either way we're barely ahead of Turkey and absolutely last among the wealthy and well-educated countries in the percentage of people who accept the theory of evolution -- and not just by a little bit, either. The country just ahead of us is Greece, and there a majority believe in the obvious truth. From there the majorities become overwhelming.

We're fortunate to have people like PZ who are willing to spend a good part of their days arguing with idiots, but it doesn't do much good. This is clearly not a matter of evidence and logic, or it would be long over. So we need to ask why, in the United States of all places, so many people cling so fiercely to long discredited myths and fables. I have mentioned some possible psychological reasons -- that the idea that we just sort of happened, and there isn't any higher purpose to it all, is somehow unsatisfying to people. But of course people's psychology is the same everywhere, so the discrepancy has to do with our culture.

And that seems paradoxical since we're famous for inventiveness, figuring stuff out, exploration and discovery. For that matter we have the world's largest and most fruitful scientific enterprise, universal literacy and a high level of formal education. Just what is going on here?

Of course the earliest European settlers included a large percentage of religious fanatics, but they were not a dominant influence by the time of the founding of the U.S. The important political leaders in the late 18th Century, those known as the Founding Father, were, in fact, strongly influenced by the Enlightenment and were probably too secular in their outlook to successfully run for high office today. In other words we somehow regressed.

I think the main issue is one of identity. Christian fundamentalism and rejection of science are a way for people to assert a regional and cultural identity -- and indeed this does correlate with the Confederacy, and former frontier states where people may have felt that people in the more developed northeast looked down on them. Secularism and humanism are a threat, not so much to people's existential equanimity, as to their pride of heritage. The divide almost rises to the level of separate ethnicity, we can almost be seen as two nations.

So the coincidence that today is the bicentennial of both Darwin and Lincoln has got to be particularly galling to the losers of the War of Northern Aggression. If my analysis is correct, then we need to try a different approach. Not that I'm entirely sure what that might be.

I control the top line . . .

So I might as well use it. Yes Rachel, I do support space exploration, although for the time being I favor only robotic exploration. The cost is trivial compared to the money we squander on war and preparation for war; and the rewards it brings in understanding our world are immeasurable. Ultimately, once we have gotten our problems here on earth under control, then indeed I think it will be a profoundly rewarding new stage in our development as a species for us to establish ourselves beyond the home planet. That may have to wait until after our own lifetimes, but I kind of hope to live to see it.

(And I hope you'll start up your own blog, since you now have an account.)

As for Mr. Hardy, I'm sure he is very committed to his ideas so I don't expect to dissuade him. Nevertheless I think his comments are interesting for a number of reasons which I will, for now, allow to speak for themselves. Based on my cursory look at Mr. Hardy's web site, it appears he is a proponent of what we call a "steady state" theory of the universe, which maintains that the universe has always existed in essentially its present form. This was quite the controversy in my youth, but ultimately the so-called Big Bang theory, which I prefer to call Initial Singularity, won out.

Mr. Hardy is quite correct that as we look out into space, we look back into time, and therefore the galaxies we see in the distance are long gone from their apparent locations. Cosmologists obviously understand this, in fact its an essential component of their understanding, so I'm not sure what the intention is in raising it.

As for the other assertion, that according to the consensus theory the light of distant galaxies must shine out beyond the boundaries of the universe into nothing, that is actually a common misconception. Modern cosmology is difficult to understand, but I tried to address this very confusion with the balloon analogy. The universe may be finite, but it has no boundary. It is fundamentally wrong to think that we are somewhere near the center and so distant objects must therefore be near the edge. There isn't any edge, except in time, i.e. the beginning, the IS. And there is no center either. As I said, all observers perceive themselves as being at the center, including those on the edge of our observable universe, which perceive us as being on the edge. Again, think of the two dimensional creatures on the balloon. They see a circular universe, but they are really on a sphere. Within their two dimensional world, the sphere has no boundary, you just go around and around.

So, one reason that people deny some scientific findings is that they are simply counterintuitive. Evolution has equipped us with some intuitive physics which work well for hunting and gathering on the African savannah but which turn out not to be quite accurate when we do sophisticated experiments or study conditions normally inaccessible to our experience, such as very small, very large, very hot, very cold, etc. It may require some long, deep study to understand how scientists arrive at conclusions which they then present to the general public in simplified or even somewhat allegorical form. It does require a certain trust of the whole enterprise to be persuaded, and I agree that is trust the scientific establishment does not earn 100% of the time. This is why the democratization of science is so important.

More of that deep philosophy

Darwin died before we discovered the universe. He figured out the basic idea of how life on earth developed. He knew that the earth was very old by human standards -- far, far older than the biblical story would suggest -- and that life had existed for a very long time before humans came along. That knowledge alone radically altered our place in the world, but it took 20th Century cosmology to completely destroy any idea of the centrality of humanity.

Creationists, obviously, don't just reject Darwin, they reject cosmology as well. I haven't noticed them objecting to the theory that there are billions and billions (and yes, Carl Sagan did to say that) of stars in the galaxy (about 200 billion to be exact) and billions and billions of galaxies in the observable universe, because, well, they can't. Look through the telescope! Those facts alone would seem very much to undermine the belief that humans are important to the creator, but the fundamentalists seem willing to ignore that problem and limit their objections to the claim that the universe is billions of years old, and much older than the earth.

Here is some of what I understand about the cosmologists' universe. By the "universe" they usually mean the observable universe, but there are some vexing metaphysical problems underlying that usage. It is certain that in some sense, the observable universe is not everything that exists, but what does it mean to say that something exists if it can never interact with us in any way?

Here's how we know this: we can only see a radius of a little over 13 billion light years, the distance light has traveled since the origin of our universe in what is misleadingly called the Big Bang. Actually it should be called the Initial Singularity, the IS, but Sky and Telescope wouldn't accept my suggestion for some reason. The expansion of the universe is not limited by the speed of light, because it isn't "going" anywhere. So at the edge of the observable universe, galaxies are actually falling over the horizon -- disappearing from our universe.

From their point of view, it is we who disappear. Every observer in the universe, no matter where they are located, perceives their own location as the center. Got that? It works because the universe is not a sphere, it is a hypersphere. Think of a two dimensional universe consisting of a spherical surface, expanding like a balloon. The galaxies are dots on the balloon. Light rays that appear straight to the flatlanders are actually great circles bending across the surface. So, no matter where your dot is, as you look out you see a circular area, with your dot at the center. We cannot visualize hyperspace, but it works the same way.

So the universe could be infinite in volume. Or maybe not. There is no way to know. But it is finite in time. Nevertheless, from the standpoint of a human lifetime, that is an enormously large finitude. Was the universe created by some sort of intelligence? You know what, it might have been. It could even have been a committee, or a corporation, or a child playing with a toy science kit, or perhaps it was some sort of industrial accident, or a natural disaster, in a predecessor universe. We have absolutely no idea. Maybe we'll get a better idea some day, maybe not.

But whatever the explanation for the creation, it had nothing, and I mean zip, zilch, nada, bupkus, zero, to do with us. We are a minor contaminant in a microscopic layer of slime on a grain of dust on a tiny island in a vast ocean. Less than that. Believe me, that ocean was not created for the sake of that slime.

Is that depressing? Is it terrifying? Not to me. If we are nothing, that means we have no place to go but up. We can become something. We already have, in a way -- we're the creatures whose minds can ecompass the immensity of the universe. Now let's get out there and explore it. What could possibly be more meaningful than that?

Economics 102

NYT's Michael Moss runs down peanut buttergate for you, and yeah, it's pretty gross. Peanut Corporation of America (that's the true grandiose name of this flea-bitten, fly-by-night sleazedog operation) knew it was shipping out contaminated product, but they weren't required to notify Georgia state inspectors or the FDA when they got positive tests for salmonella. Georgia has 60 inspectors for 16,000 food handling businesses, and the FDA doesn't inspect plants in Georgia at all -- it has delegated the task to Georgia, as it has to most states. And you know how they feel about Big Government down in Georgia.

Now here is yet one more reason -- an obvious, trivial reason -- why the Free Market™ ideology taught in Economics 101 is complete nonsense. Actually there are two or three reasons all wrapped up in this single example.

• Reason One: Consumers can't make "rational choices" or "maximize their utility" if they don't know what they are buying. You have no way of knowing whether the food somebody sold you is contaminated with salmonella unless somebody you know you can trust tells you so. And the only way you know you can trust said somebody is if they're working for you, and the only way that can happen in this situation is if a) said somebody is the government and b) the government agency really does work for you and not the businesses it regulates.


• Reason Two: There is a whole chain of purchasing from farm field to your oral cavity. That means that the potential social costs and benefits of all of those transactions along the way are not captured by the transaction because that salmonella is going to land in your blood stream, not the blood stream of the buyer. As a matter of fact, the penultimate customer may be a school or hospital cafeteria, for example, and the person who gets sickened or killed by the food may have nothing directly to do with any transaction pertaining to that item at all. This is called "externality," which economists treat as an exception but which is actually ubiquitous and is a feature -- probably the dominant feature -- of every economic transaction, without meaningful exceptions.


• Reason Three: The market provides no accountability for fraud or negligence in most cases. The only reason we know where this particular salmonella outbreak came from is because the government -- in this case the CDC -- investigated, and they were lucky enough to be able to figure out the source. But in other cases, it might be impossible. No government, no accountability.

So, what do we have to do in order to insure a safe food supply? It turns out it's not just the Chinese, it's us. We have to increase government spending on food safety. We have to effectively regulate businesses. In order to do those things, we need a functional democracy that works for people, not for economic elites who want to take advantage of us. We need to expunge shallow libertarianism, free market fundamentalism, and as a matter of fact the very term "free market," which is a fraud, from our political discourse.

Sermonette

As I promised a few days back, my own contribution to the celebration of Darwin's birthday will consist of some reflections on how the world we have discovered with our senses and our reason is meaningful for us, and hospitable to our happiness. People who reject science in the name of religion say that Darwin's world has no moral foundation and leaves us stranded without purpose. That is simply a failure of understanding and imagination.

In fact, the universe I know, as an atheist and a humanist, is far more grand and wondrous than the cramped, impoverished world of creationists. Best of all, it opens up far more vast vistas of meaning, and infinitely greater prospects of purpose. Creationists find meaning only in a ghost, an invisible, incomprehensible entity that exists outside of the world. For me, meaning is right here, inside me and all my friends and all the world's people. What could possibly be more exciting and rewarding than to be like Copernicus and Newton and Darwin, and discover the universe for ourselves? How wondrous we find ourselves, to know that we arose from the workings of physics and chemistry and probability, acting over billions of years, and here we are with the astonishing capacity to understand, to experience, to choose.

Morality does not come from God, after all. It is part of our nature. It arose because we succeeded in the world as social animals, so our mutual regard and love are part of how we work, part of what evolution made us.

So here we are. We got here by chance, we won the lottery. Hooray! We can look around, discover where we are, become whatever we can accomplish. We are not limited by what has been given to us, we are not beholden to any creator, we are not commanded by any law but our own. How joyous that should make us! We are free.

In coming days, I will say more about how I believe we should use our freedom.

Oh yeah, the rest of the world . . .

It's too soon to tell, of course, what regime change in the United States will mean for the less developed countries. We've been pretty much obssessed with our own problems lately, and I would expect that foreign aid will be an even tougher sell than usual. Still, if we were wise enough to recognize that cutting taxes on the wealthy and deregulating financial markets is not the path to prosperity after all, and that war is not peace and slavery may not be freedom, perhaps we'll be wise enough to realize as well that we have to live on this planet and that what happens in those remote places matters to us after all.

During the campaign, Barack Obama advocated increasing funding for the President's Emergency Plan for AIDS relief by $1 billion over five years, and doubling overall foreign assistance -- to $50 billion a year -- over time. He also called for cancelling the foreign debt of the world's poorest countries. Under the current circumstances, I would be surprised to see all of this happen, although the latter is certainly a possibility. You can't get blood out of a stone anyway. But Obama has already used his executive authority to get some of the ideologically driven nonsense out of the aid we already give -- specifically by ending the ban on funding organizations that offer abortion-related counseling and referrals. Presumably the ban on needle exchanges programs and the favoring of "abstinence only" sexuality education will also go overboard.

We'll be keeping a close eye on policies toward global relief and development. I've written before about the controversies over HIV and other disease-specific programs, vs. investing in broad health care and public health infrastructure. In the long run, what we do to develop renewable energy technology and reduce use of fossil fuels here will also have a big impact on the world's poor, as will global trade policy -- and that includes our agricultural policy which is terrible not only for small American farmers and American consumers, but for poor farmers around the world as well. I'm not counting on the Democratic Party to fix that last one, however, not while the midwest is a major political battleground and Archer-Daniels-Midland and Monsanto are big political players. But we're watching them anyway.

Patriotic Song

I'd rather forget him entirely, but as the famous political philospher Juju Santeria once said, Those who fail to ridicule the past are doomed to regurgitate it, or something.

The tune should be obvious.

Dear Chimpy ‘tis at you,
I hereby throw my shoe,
It’s thee I dis.
You’re the election thief,
The idiot in chief
You’ve screwed us up beyond belief
On thee I pis.[1]

You claimed to speak for God
While on the laws you trod,
You hypocrite.
You lie just like the sod
Your syntax it is odd
Your cowboy accent is a fraud
You’re an upper class twit.

At oversight you sneezed,
Your greedy friends to please,
And the economy crashed.
Iraqis you did croak,
You’ve left our grandkids broke,
You treated war like one big joke
At the journalists’ bash.

You tortured prisoners
Appointed Hizzoners [2]
Far right extreme.
For the polluted air,
Taxes that are unfair,
And inept cronies everywhere,
God save the Queen.[3]

Your place in history
Will be no mystery:
You are the worst.
Upon your neck we’d hope
To find your head but nope,
You’d nee -eed a-a proctoscope[4]
Of fools you’re first.

[1] Unless of course you happen to be on fire.
[2] Okay, it's a bit of a stretch, but rather clever in a groan-inducing way, don't you think?
[3] Whoops, wrong song! heh heh.
[4] Sorry about that.

Preventing our way out of bankruptcy?

Health care reform has been pushed to the back of the room while all wait to get stimulated, but it's still on the program here. As I have mentioned from time to time, there is no serious cost containment in any of the proposals coming from the Obama administration or congress right now. The president (and it is at least a relief to be able to type that word without pain) has said that more emphasis on prevention can save health care spending, but is that really true?

Steven Woolf in the new JAMA reviews the issue. Unfortunately it's subscription only, but I largely agree with him and I can summarize it more quickly for you anyway.

If we spend money on preventing illness, we might end up saving money on medical treatment down the road, but is that really the only reason to do it? In fact, while it is unquestionably true that if fewer people smoked, more people ate a healthy diet and were physically active, the air was cleaner, etc., we would spend less money treating cancer, heart disease, and diabetes. However, it does not follow that every dollar spent to achieve those ends will save more than a dollar plus interest, since we're looking toward the future, in eventual health care spending. Interventions directed at a large population will be successful with only a percentage of individuals, and so the cost-benefit calculus is uncertain. The fact is there are few interventions that really save money in the end.

When it comes to preventive medical services, per se, there are really very few interventions that ultimately save money, and a lot of them, such as universal childhood immunization, are largely in place. There probably isn't a lot of room left to save money by investing in prevention -- certainly not enough to reverse or substantially slow the growth in health care spending.

However, that is not an argument for not doing more prevention. We don't spend money in order to save money, we spend money in order to get stuff that's worth it. And better health and longer life are worth spending money on. The issue is not just investing more in prevention -- it's allocating health care spending efficiently. As Woolf points out, insurers pay for many services that cost more than $100,000 per quality adjusted life year (QALY -- I've criticized the concept previously but we need some way of comparing benefits of various interventions); but there are services that cost much less that aren't universally utilized. For example, colonoscopic screening for cancer is estimated to cost less than $25,000 per QALY, but most people don't get it. Other preventive services cost even less. However, they still have a net positive cost.

Therefore, if we spend more on screening and prevention, in general we will end up spending more in total, not saving money, although we will prevent suffering and disability and extend lives. If we want to actually save money, we have to spend less on less cost effective services, and reallocate the spending to others that, while they still have a net positive cost, give us more for our money.

This means -- drum roll please -- we must have rationing. The so-called Free Market™ does not allocate health care resources in this way, and generates almost no public health resources at all, because they are public goods. The best way to achieve the rationing we need, from which we will all benefit (and I'm not one who believes that a terminal cancer patient actually benefits from $150,000 worth of chemotherapy that yields three months of sick and suffering life) is to have universal, comprehensive, single payer national health care. Yeah, socialism. There, I said it. When it comes to health care, capitalism is what ails us.

Power Play

Okay, so I started to write the book, and much to my surprise, it turns out to be about conflict in a setting of unequal power. Here are some of the distinctive features of the physician role vis a vis the patient role:

• Physicians want to invade our privacy, and they have cultural authority and license to do so in ways that just about nobody else does.


• Physicians have license to invade our bodies, to see us naked, to touch and enter our most intimate orifices, and even to cut us open and dismember us. No-one else in the world has such license.


• Physicians judge our behavior.


• Physicians try to control our behavior.


• Physicians control the prescription pad; they alone decide whether we have access to most medications.


• Physicians may have power over our very sustenance, as by certifying for disability or worker's compensation.


• Physicians may control whether our insurance plans will pay for us to see specialists.


• Physicians can ask a judge to have us imprisoned in a mental hospital, and will almost always get their way.

Under the circumstances, it is a considerable credit to the profession that most people say they like their doctors, and that we generally willingly submit to the indignities and infantilization inherent in medical care. We place immense responsibility on physicians not to abuse these privileges, and most of them do their best to earn our trust. Nevertheless, it is very difficult, when handed such direct power over people, always to wield it harmlessly, let alone for the maximum good. However benign and cooperative the relationship appears on the surface, there is always a power struggle going on underneath. Medical ethicists talk about the physician's obligation to be beneficent, to grant patients autonomy, and to respect persons. Yet those principles are often in conflict with each other, and with the physicians' own experience of being locked in combat with disease -- a combat in which the person who has the disease, or the risk for disease, is an uncertain ally or even an enemy.

So Collaboration, Conflict and Power, with a suitable subtitle. How's that?

Are you illiterate?

So, NIH is putting a lot of vigorish out on the street, some of which I may just try to collect, to study what they call Health Literacy, by which they mean "the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions." According to NIH, not having enough of this stuff is a serious problem, apparently affecting 90 million adults in the U.S. -- This according to the program announcement I'm reading now. For those of you who have never checked out how the NIH gives away money, you might want to check it out, these are your tax dollars at work.

I think this particular cause is a good one -- we do need to figure out how to help people better understand information that affects their health, including being able to come to the right choices about treatment for them, as individuals. But I do have a problem with the "Health Literacy" frame, which is that it locates the problem in the average patient or citizen who is presumably too dull or ignorant to figure out which end of the fork to hold. While that description does indeed apply to Don McLeroy, D.M.D., I think for most people who don't necessarily grok all the stuff their doctor is thinking when he refers them for a throgsneckbridgectomy, the locus of the difficulty lies elsewhere.

Figuring out how to communicate technical and specialized information effectively to people who might want to know it because of its relevance to their own health is important, and I certainly want people to do a better job at that. But this is really a two way street. The kinds of information that matter in providing health care, treatment decision making, and managing disease aren't just the stuff the doctor learned in medical school that is just way too complicated for you. It includes a lot of stuff you know or care about that the doctor doesn't know and doesn't know enough to care about. The goal should not be to get you to do what the doctor wants you to do, but you're too stupid to know is good for you. The problem is how everybody can work together to come to some sort of a consensus about what is good for you, or to agree to disagree in an open and honest way.

I'm sorry that this is all a bit abstract, but I'm too busy today to anything more than bloviate. Still, if anyone wants to add some concrete examples that seem to be in order I'll be delighted to hear them.