Onward to the Final Victory of Capitalism!

You may have come across Atul Gawande's informative piece in The New Yorker, if not I recommend it.

In a pistachio shell, Gawande identifies a key reason for excessive spending on medical services as what ought to be the obvious incentive that doctors have to do more stuff to people so long as they are paid by the procedure. Proponents of "market based" health care have this notion that if we had to pay for at least part of it out of our pockets we wouldn't buy all those unnecessary diagnostic tests and gall bladder surgeries but they are missing -- or more likely deliberately ignoring -- the obvious fact that I have no idea whether the PET scan or the gall bladder surgery is really necessary or worth the money unless my doctor tells me so, and if the doctor says I ought to do it, I might decide to make the stretch even though in fact, I don't really need it; or alternatively, I might decide not to even though I do need it. Even worse, if I do happen to really need it, and I can't afford it, I'm shit out of luck, which is why we think people ought to have health insurance in the first place. So sorry pals at the Cato Institute, that really doesn't work after all.

Gawande points to a real solution, which is that teams of providers -- not individual physicians -- should be paid for keeping us healthy, not for doing more and more stuff to us. He doesn't think this basic structural change is necessarily related to whether insurance is public and single payer, or private and multiple payer, but I do. That's a somewhat longer story, however. Anyway, this important point, which he makes cogently, is one necessary step in sorting out this whole debate.

Heading for the hills?

So here's the paradox of our present lives. Those of us sitting here on the commanding heights, in the wealthy countries, have the most secure lives any humans have ever experienced. Not even the greatest potentates of older times -- Alexander the Great or Henry VIII -- or the wealthiest of people as recently as the early 20th Century, for that matter, enjoyed the expectation of long, reasonably healthy life and the very low probability of sudden death or disability that the most disadvantaged of Americans take for granted today. We haven't known widespread hunger or deprivation for 60 years, considerably longer than most of us have been alive, and even the Great Depression didn't represent nearly the hardship known routinely by European peasants as late as the 19th Century, for just about anyone.

We don't need to fear smallpox, or polio, or essentially any bacterial illness; wild animals, hunger, war coming to our towns (though we seem more than eager to take it to others); sudden, inexplicable death from causes we now understand to be overwhelming infections, autoimmune diseases, childhood leukemia, and so on. We take it for granted that our water is safe to drink, our food is safe to eat, our streets safe to walk. Even when whole communities are destroyed in wildfires, the people evacuated in time, and they are insured. The exceptions get enormous attention precisely because they are not ordinary.

And yet this is an age seemingly characterized, above all, by anxiety. A couple of days ago the NYT carried a lengthy article about the boom in survivalist supplies. All sorts of well-to-do suburbanites are stocking up on canned graham crackers and home emergency surgery kits because they fear the collapse of the world economy and empty supermarkets. The prospect that more people than usual might catch the flu for a couple of months produced the greatest cataract of hysterical headlines since the outbreak of World War II. The chance that a few delusional guys in the foothills of the Himalayas might send a few pals over to blow up an airplane or shoot up a shopping mall caused the country to spend $2 trillion committing mass murder 800 miles to the west, suspend its constitution, and hold mass rallies to burn the country music albums of people who didn't like all that. Earlier, we had to coax all those people down from the hills who expected civilization to collapse on January 1, 2000 when the computers were going to get confused about the date, and of course half of Americans believe that God is about to bring the world to an end just because it says so in the 2,000 year old memoir of a hallucinogenic mushroom eater.

While all this craziness is going on, yeah, we do have some serious problems to worry about. As I indicated yesterday, and as I'm sure I don't have to convince anybody who reads these rants, we have heedlessly built our entire society and way of life on means that cannot long continue. Oddly, it seems that the same people who are most likely to be obssessed with the imaginary menaces in the preceding paragraph are least likely to take any of these real dangers seriously.

On the other other hand (or the third half of the show), these real problems do not, as many people seem to imagine, threaten sudden, overwhelming catastrophe -- with one exception, and it seems to be the one people have been thinking about the least, lately. Rather, they are all about long, slow emergencies: gradual constriction of essential resources, producing lengthy periods of painful adjustment and harming the health and well being of various groups of people here and there; displacement of populations; massive, but foreseeable destruction in coastal zones, which can be abandoned in advance; wholesale elimination of some industries and livelihoods, with large but surmountable challenges of replacing them and finding new ways of doing things; truly dangerous pandemics of infectious disease (not influenza, which at the very worst will be a brief disruption), that will tax our science, our generosity, and our compassion. None of these portend the collapse of civilization or the decimation of the human population. Things may get really tough for a lot of people but we won't put the genie of science and industry back in the bottle. We know how to solve problems and bend nature to our will, and I'm sure we'll keep on finding ways.

As for that one exception? Our greatest folly, nuclear weapons. We may damage the world and our selves and society by our greed and short-sightedness, but we won't destroy them. We'll muddle through to the post-industrial world. But we can indeed blow it all up through our malice and fear and hatred. Our greatest challenge, and the continual frustration I often express here, is how to get people to focus on the problems that really matter, and take the long-term view that's necessary to address them. It just doesn't seem to be human nature.

The call of the wild

So, a few days out at the rock and poison ivy farm, as I mentioned earlier, were conducive to reflection about a few things. One thing I thought about was how we live today, compared with how we lived not so very long ago, in the 19th Century. My father was fascinated by 19th Century tools and he had a substantial collection of them, much of which now resides in my barn. These include various kinds of axes, bucksaws, wood shaping tools, and agricultural implements. In Windham County back then, there were some small factories powered by the waters of the Shettucket, but most people were farmers. They used animals to plow and haul, and human muscle to do just about everything else. Life was certainly less comfortable in many ways than it is today, and usually shorter, but the people managed to feed themselves well enough and make it through the longer and colder winters without terrible privation.

Their way of life could have continued, in principle, for millions of years. Their crop residues, excrement, and corpses, and those of their animals, returned to the land. Nitrogen, phosphorus, carbon and pottasium cycled continuously among the plants and animals, the system was closed and nothing was used up. (I may be oversimplifying and probably there was some leakage, but it was very slow.)

Nowadays, the human population is literally unsustainable. Energy that once came from the land in the form of human food and animal fodder, and was then renewed by new plant growth, now comes from fossil fuels. But what you may not have thought about is that the nitrogen, pottasium and phosphorus are also no longer generally recycled. They pass through our urine and feces into sewer systems where they are ultimately discharged into the ocean, or they wash off vast muddy farmsteads after harvest into the rivers. One result is that they stimulate vast algae blooms which deplete the oxygen where rivers discharge into the ocean, creating dead zones. Another is that they must be replaced.

Using fossil fuels, we extract nitrogen from the atmosphere, but phosphorus has to be mined. You've heard of peak oil but guess what? We've already hit peak phosphorus, and the consequences could be even more dire. We can replace fossil fuels with wind, sun and biomass, or if need be nuclear fusion, or something. Phosphorus is an element essential to life. There is no substitute.

The reason I bring this up is because hardly anyone ever thinks about it, but mined phosphorus is essential to the sustenance of the human population. If production cannot be sustained, there will be less food. Period. This is a revealing synecdoche for many larger problems that we face.

To be continued.

I don't know what the heck is the matter with me . . .

I'm going to write about the friggin' swine flu. Okay, the reason I can't help myself is because the pandemic of hype and paranoia really did happen, so it needs a post-mortem. Andrew Jack, writing in the BMJ (behind the subscription wall, screw 'em) makes a few good points about what was done right and wrong. Among the wrong (edited by YT into a list):

1. Egypt used the virus as a pretext to cull pigs, most of which are raised by its Coptic Christian minority.


2. Russia rapidly banned pork from Mexico, the United States, and Canada.


3. China imposed aggressive and lengthy quarantine measures.


4. [T]he US, and many other individual countries (and companies) swiftly recommended against "non-essential travel," contradicting WHO’s advice that such moves were disruptive while doing little to prevent the spread of the virus.

I note that the latter measure merely added to the widespread public perception that something important and dangerous was going on, which was not the case. As Jack points out, the U.S. and the other countries mentioned are signatories to International Health Regulations which stipulate that any such measures which go beyond WHO regulations should be supported by scientific justification. These were not.Jack has also reported something in the Financial Times that I had not seen reported in the U.S.:

Tough US import controls on biological materials, introduced after the September 11 2001 attacks, hindered the rapid identification of the H1N1 virus because samples from infected Mexican patients had to be sent to Canada for analysis instead of the US. Health officials said the detour highlighted how bureaucratic attempts to protect the US from terrorist attacks had backfired.

In other words, the paranoia is far more damaging than the threat, once again. And, as Jack concludes, the six-point pandemic scale is particularly misleading. As the WHO kept raising it from 4 to 5 and then talking about raising it to 6, fear mongers such as Daily Kos's DemFromCT fed us breathless bulletins about how the apocalyptic Stage 6 was about to descend upon us. As Jack so aptly observes, "While it is still early to make judgments about the infection and fatality rates of the current virus, some weighting may need to be introduced. To most people, a pandemic with a lower human impact than seasonal flu is no pandemic at all."

Indeed. This was a Chicken Little incident and that has the potential to do great harm. When something real happens, people won't believe it.

Personal Note: It's supposed to be a crime for bloggers to skip a few days. I have found my recent retreat from civilization restorative of perspective. Perhaps I will offer some of that anon.

Dumbitude

I figured I was going to write something today about the corporate media creating a WWE spectacle out of the president giving a thoughtful though highly controversial speech about his plans to resolve profoundly important and very knotty problems of justice and law created by his predecessor; while on the other hand an utterly discredited pathological liar, manifest failure and war criminal who formerly held a constitutionally powerless ceremonial office spewed nonsense, falsehoods and moral depravity. These events were treated as equally significant, deserving of equal respect and attention, and as defining the respectable range of opinion on these issues within the political culture.

The vapid idiocy of the "journalists" and "editors" who present affairs of state in this way has been with us, according to my recollection, since the Reagan administration. Of course there has always been horrible journalism, but journalism didn't have this homogeneously stenographic, mindless and formulaic character when I was a youth. You had your apologists for one position or another, but you also had your crusading investigators blowing the lid off corruption, oppression and depravity. Every kid wanted to be the latter. And it was not, as I recall, a principle of journalistic ethics to report that one person stated A and another stated B without bothering to tell us whether A or B was actually the truth.

I didn't know what the heck I would say about this, however. Fortunately I came across Charlie Pierce, here discussing his book Idiot America on the very page where you can, if you so desire, buy it. I haven't read it so I'm not plugging it, but I am plugging the interview. Pierce says this and that, but I would say that the essence is that one of the two major political parties in this country [and I will interpolate that due structural properties of the Constitution, we will always have two and only two] has spent more than 30 years building itself around opposition to perceivable reality. It is a movement based on rejection of reason, intelligence, logic and facts. Reporters striving to appear "fair" are thus forbidden to name the truth.

Site note: I'll be out of town for a couple of days, expect me when you see me.

The problem of perspective

With the Agora buzzing incessantly over the coming swine flu apocalypse, former president Cheney's jeremiad about how we're all going to be murdered by islamofascist terrorists, and the 76.28 (according to my calculations) detainees previously released from Guantanmo who have returned to unspecified "terrorist" or "militant" activities, I am prompted once again to ponder the hopeless question of why people worry about the stuff they worry about.

One of today's headline, for example, is that "deaths from swine flu" in the U.S. have now reached double digits. Double digits is a meaningless milestone in the first place, an arbitrary property of a numbering system based on the number of digits [sic] on our hands. In the overall context of death, it is a very, very small number.

Approximately 6,650 Americans die every day. More than 1,700 of those deaths are attributed to heart disease. That means that on Sept. 11, 2001 the al Qaeda hijackers were responsbile for less than 1/3 of the deaths that happened in the United States on that day, and that in the period Sept. 11-12, more Americans died of heart disease than died of terrorism. About 122,000 Americans die of unintentional injuries every year. That means that more Americans died of violent trauma the week of Sept. 11 from causes other than the terrorist attack, than died in the attack. As for the swine flu armageddon, it is nothing. Absolutely nothing. Forget about it. Doesn't even deserve to be on page 17.

And yet here we are obssessing about the possibility that somebody somehow somewhere might set off a bomb, and because this prospect is so horrific and unthinkable, we need to repeal the Bill of Rights and half of the international treaties to which we previously subscribed. We are closing schools all over the country because of the prospect that some kids might come down with the sniffles, so what do you think the kids do? They go to the mall. With their cough and sniffles. What else would they do?

Idiotic. Utterly idiotic.

Storebror ser dig.

According to Google translation, that's Swedish for Big Brother is watching you. Perhaps our hordes of Swedish readers can correct me if necessary.

Anyway, Seena Fazel and various people with diacritical marks over their vowels inform us in the new JAMA that schizophrenia is associated with violent crime in the presence of comorbid substance abuse, but otherwise hardly at all or maybe not even. This appears to explain some contradictory findings of earlier studies, and it is helpful in formulating policies to assess and address the risks that people with serious mental disorders may pose to themselves and others. (You're good enough to read the abstract, anyway.)

That's interesting, but what I found provocative about the study was the means by which they were able to figure this out. It turns out that in Sweden, there is a 10-digit personal identification number, similar to our Social Security number. However, beyond that, there are complete national registries, using said ID, for hospital discharges; criminal convictions; the national census; the "multigeneration register" which links you to your parents and siblings; causes of death; and emigration/immigration. As for the crime registry, there is no plea bargaining in Sweden, and not guilty by reason of insanity is still guilty enough to go into the register, as are remands to mental hospitals and sentences short of incarceration. They had to proactively exclude traffic tickets and non-violent crimes such as passing bad checks -- it's all in there. The hospital discharge registry contains all diagnoses, including psychiatric labels, substance abuse disorders, and presumably whatever embarassing stuff you can think of be it fecal incontinence, genital herpes, or toenail fungus.

All this turns out to be very useful for social epidemiology, and evidently the Swedes aren't too worried about it being misused. But imagine if Dick Cheney and Alberto Gonzalez had all of that to work with. What do you think? Good idea, or not so good idea?

Doctor Science Goes Hollywood?

As I have oftimes ranted, science needs to democratize. That means tearing down those ivy-covered walls and letting the people in, and moving the sausage factory out onto the sidewalk. The main reason, in my view, why we at least half the country views science as a conspiracy against their deeply cherished illusions is because it really is something that insular elitists do in fancy insitutions where the commoners' kids can't afford to study. The scientific priesthood speaks its own language, talks only to itself, and doesn't really care what the ignorant idiots who iron their shirts think about biology and cosmology.

So it's a good thing, right, that The History Channel, American Museum of Natural History, and ABC News are throwing a big coming out party for Darwinius masillae, a fossilized primate from the Eocene, about 47 million years ago, found near Darmstadt, Germany.

The find (actually it was found 50 years ago but due to the vicissitudes of private fossil collecting it wasn't recognized and studied until recently) is being ballyhooed as an important piece of the puzzle in human evolution. Even the name they gave to it -- Darwinius -- is a new name invented just for this fossil and obviously intended to make a point. Now there is a lot to be said for taking it to the streets and meeting the Creation Museum and Ted Hagee Hour on their own turf. If these media partners can whip up some popular interest in a 47-million-year old fossil and get kids thinking that discovery is exciting and evolution is way cool, I'm for it.

On the other hand . . .

The truth, which you can read all about in boring scientist talk in PLoS One -- mad props for doing this open access, of course -- is actually not so rip roaring. The specimen is interesting because it is so well preserved and gives us a whole lot of new information about these little critters, which over the coming years paleontologists will work to fit into the overall picture of primate evolution. The fact is, they don't actually know how close this animal is to the ape lineage and hence us. It is not some "missing link," it's just a helpful piece of a big, complicated story that we are trying to assemble from random fragments that happen to come our way.

And that's the trouble with science. I'm sorry to say that it's very rarely about sudden, dramatic breakthroughs that blast us into a new reality. Even the work of Darwin and Einstein, although it was real brilliant and all that, didn't really enter the world that way. It took time for the scientific world to digest it and fit it into the framework of knowledge and begin to see where it led. Hell, it took time before people even believed it. And in the case of Darwin, at least, it took about a century before we found the mechanism of heredity and could even begin to understand evolution from the inside out, rather than just as an organizing framework for an inscrutable process.

I enjoy a fair amount of inspiration and moments of creative insight in my own work, but it comes out of insufferable hours of boredom, managing and planning studies, carefully organizing and tracking data, coding till your eyeballs roll up in their sockets, and systematically crunching numbers over weeks to torture the story out of the data. So how do I, and the paleontologists who study human evolution, convince people that we've got the truth? I suppose a little show biz can't hurt, but the last thing we want to do is juice up those boring, stupid facts to give people a jolt.

Shark attack!

If you are a regular viewer of TV News, a reader of newspapers, or a regular reader of Daily Kos, you will be surprised to learn that among the many afflictions of humanity, influenza is well down the list. You may be even more surprised to learn that it will still be well down the list even if the worst predictions of the ultra-scary H1N1 swine flu turning into a GLOBAL KILLER PANDEMIC come true. Finally, given that much of the raw material for these news reports comes from the World Health Organization, you may be most surprised of all to learn that I depend in substantial part on the WHO to provide the basis for these assertions.

Influenza is the missing white woman/shark attack story of the public health field. Don't misunderstand my point: there really are, from time to time, missing white women, there really are shark attacks, there really is a novel strain of flu going around. I don't think that coverage of these issues is any less factually accurate than coverage of anything else. The question is whether the amount of attention paid to them is proportionate, and whether these stories serve to distract us from what really matters.

For example, it was reported today on the front page of all the major cable news web sites, many newspapers (I can't read them all, but most of the ones I have seen), and Daily Kos, that a man in New York has died of swine flu. Oh no, the killer flu has come to New York! Not only that, but authorities have closed several schools in the city. These developments obviously vindicate the huge amount of attention given to this major threat to humanity, and prove that I have been wrong to try to ramp down the hysteria, right?

It has been reported that, like the vast majority of people whose deaths are ascribed to influenza, this man was already sick and debilitated. Doctors believe that influenza contributed to his dying at this particular time, but is that news? In fact, on average, 100 people in the United States die of complications of influenza every day, and about 100 more from similar infectious diseases (we call them Flu-Like Illnesses, FLIs, because usually nobody ever finds out exactly what the people had). So while this man's death was making the front page, we can guess that about another 200 people in this country were dying under similar circumstances. (It might be a bit lower number given that the peak of flu season has passed, but it's certainly in 3 digits.) So what is the difference? The difference is that H1N1 influenza, something which can be detected only by a laboratory test and which otherwise is entirely undistinguishable for the flu and FLIs that are going around all the time, is the missing white woman of today.

You might also want to know that as of now, in the case of the new school closings in NYC, they don't actually know whether students there had flu at all, let alone the DANGEROUS KILLER H1N1 SWINE FLU! They have FLIs; the school closings are precautionary. And what if they do in fact have the DKHSF? What will happen is that they will spend a few days at home with coughs and sniffles and chicken soup. Then they will be all better. So, should we perhaps be paying attention to other public health issues?

I have written previously about some of them, actual, real stuff that's happening right now, destroying millions of lives, killing millions of little kids, causing sickness and suffering all over the world and throughout the United States. We don't have to wait for a hypothetical worst case scenario, it's already here. And, if an unusually severe flu season occurs next year and ends up being credited with 50 million deaths -- which is extremely unlikely by the way -- the flu pandemic will end, in one year. And that other stuff will continue. While we were paying no attention to it.

So why do we get missing white women, shark attacks, and influenza, instead of more important stuff? Why do they avoid talking about subjects like illegal wars of aggression justified by lies, and millions of children dying of malnutrition and diarrhea? It's because it's much easier to avoid subjects that are politically meaningful and gall the powerful.

Contrary to what you may believe from reading Daily Kos, the WHO is not principally concerned with influenza. Today, the WHO released the long-awaited report of its Commission on Social Determinants of Health. The background given on the intro page is actually quite well written and substantive, but the executive summary is no problem to download, it's just a 40-page PDF. I could quote it forever, but I'll just pull this:

Our children have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil, 72 years; India, 63 years; and in one of several African countries, fewer than 50 years. And within countries, the differences in life chances are dramatic and are seen worldwide. The poorest of the poor have high levels of illness and premature mortality. But poor health is not confined to those worst off. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

It does not have to be this way and it is not right that it should be like this. Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice. Reducing health inequities is, for the Commission on Social Determinants of Health (hereafter, the Commission), an ethical imperative. Social injustice is killing people on a grand scale.

The Commission wants us to "improve daily living conditions," "measure and understand the problem," and above all, to "tackle the inequitable distribution of power, money and resources." It is the latter which is responsible for most of the premature death, disability and suffering in the world. You may have heard that among the wealthy countries, the U.S. ranks last is indicators of population health. The reason is not that we are uniquely susceptible to influenza: it is that we have the most social inequality of the wealthy countries. Our poor people, less educated people, and members of disadvantaged racial and ethnic minority groups, bear the burden of our failures of social justice, in spite of our great wealth.

Influenza, however, is easy to talk about. It affects people indiscriminately, without regard to wealth or privilege. It does not challenge us to attack the power of giant corporations, or entrenched interests. It speaks no truth other than the universally understood frailty of life. That's why it is the perfect shark attack/missing white woman of public health. And that is also why the relentless, unending, feckless obsession with the subject on the front page of Daily Kos, to the exclusion of all other public health topics, constitutes such a tragic misuse of a scarce resource. And don't tell me well, there has been material about the health care reform legislation. Health care is not public health. It's what we do after public health has failed, after injustice has already taken its toll.

It is long past time to change the subject.

Bob Dylan's birthday . . .

Actually next week, but by then everybody will be talking about it so I thought I'd get a jump. He's turned out to be a strange, inscrutable figure as an adult, but his youthful idealism and unquenchable lust for justice were unmistakable in his art. He recorded Masters of War when he was 22 years old.

Come you masters of war
You that build all the guns
You that build the death planes
You that build the big bombs
You that hide behind walls
You that hide behind desks
I just want you to know
I can see through your masks . . . .

You fasten the triggers
For the others to fire
Then you set back and watch
When the death count gets higher
You hide in your mansion
As young people's blood
Flows out of their bodies
And is buried in the mud . . . .

How much do I know
To talk out of turn
You might say that I'm young
You might say I'm unlearned
But there's one thing I know
Though I'm younger than you
Even Jesus would never
Forgive what you do . . . .

Blowin' in the Wind, Hard Rain Gonna Fall and Oxford Town were on the same album.

I know for certain there are young people today writing songs just as lacerating and just as truthful about the same damn truths that just won't go away. However, it seems the mass culture isn't ready to receive them.

I just got to say . . .

I don't have anything important to add to the current discussion about the crimes against humanity perpetrated by the Cheney administration, but I will state my views just because I think we all must.

There is now a pretty compelling case, on the public record, based on declarations by officials of the former administration -- conservative Republicans all -- that the U.S. executive ordered the brutal, months long torture of at least three people who have been identified, and quite likely many more, in order to manufacture evidence to justify an illegal war of agression. That the president and vice president lied, repeatedly, in public, even without benefit of the false confessions they sought, in order to terrorize the country into that war, is a fact fully established by publicly available information. An illegal war of aggression is a crime against humanity.

We are now having a debate over whether we ought to investigate these matters at all, with the limit of the debate on the one hand being that we should just forget about it, and on the other that we might have some form of legislative inquiry but only on condition that there be no recriminations. The current president, in whome many of us invested so much hope, takes the former position.

The terrorists have won. We have become them. The United States has surrendered to its enemies without even a whimper.

The Camel's Nose

under the tent, that is. Yesterday we saw how the teabagging Sons of Liberty are burning the metaphorical tires in the streets in a heroic stand against the Obamunist plot to use Comparative Effectiveness Research to infringe on your God-given right to be screwed by giant corporations. Today we come to the "public option" in health insurance reform, which is an even more insidious Obamunist plot because it not only infringes on your God-given right to be screwed by giant corporations, it's kind of obvious that it does that, and we wouldn't want people to actually know that their God-given right to be screwed by giant corporations was being infringed upon, because then they might start to clamor for even more such infringements.

The fundamental question is why we need private "health" insurance at all, when, for example, Canada and the UK get along without it and they are healthier than we are and spend much less on health care. Anecdotes about people having to wait six months for a knee replacement or not being given useless treatments that they demand aside, it is obvious that to whatever extent that occurs, it's worth it, because the people overall are healthier than we are, remember? Duhh.

Advocates of private insurance claim that "competition" among plans can save money and deliver more of what people want. Fortunately, we have a natural experiment going on right now, called Medicare Advantage. The aptly named Richard Kronick, in the new NEJM, runs it down for you absolutely free of charge. (NEJM scores a birdie, cancelling last week's bogie.) Medicare runs its own fee for service plan, and it also pays private insurers to cover beneficiaries who elect to join their plans. These so-called Medicare Advantage plans take all sorts of different forms with varying levels of managed care, from HMOs to Preferred Provider Organizations, to straight up private fee for service plans. They compete with each other. And they all cost more than standard Medicare -- actually a lot more, an average of 13% more but even more than that for PPOs and fee for service models, and this is an underestimate distorted by ways in which they game the system. Furthermore, they don't deliver any perceivable additional benefit to their members. We're wasting -- just flat out wasting -- more than $10 billion a year.

As Kronick writes:

There remains substantial debate about why competition among HMOs has not produced the benfits hypothesized by private market advocates . . . . Some analysts assert that private plans inevitably create large increases in administrative costs, siphon off valuable resources for executive salaries and profits, create hassles for patients and physicians, and cannot be held accountable by patients or the public. In this view, there is no constructive role for health plans as intermediaries between the government and health care providers.

Count me in, Prof. Kronick. Private health plans "compete" by trying to exclude people who need more services, and trying to screw the members they do have. If you're looking too costly, and they won't pay for what you need, tough luck. They're more than happy to have you go elsewhere. That way they can squeeze out more money for executive salaries and profits, which are their sole reason for existence.

A well-run public health insurance option, available to employers and individuals in an environment in which medical underwriting is strictly limited, there is an appropriate level of subsidy for low income people, and a universal mandate, will eat private health insurers for lunch. It will offer cheaper and better insurance to everyone. They know that. That is why they do not want it to happen.

BTW, is that socialism? You betcha. Sticks and stones . . .

A passing observation: George Annas, writing in the same issue of NEJM on a truly outrageous subject which you ought to read about (I'll let George's unduly restrained essay speak for itself) offers an interesting aside. I wonder if anybody important will notice?

In the area of human rights, the Second Circuit is best known for its 1980 opinion that a physician from Paraguay could sue the inspector general of police of Asunción, Paraguay, in the United States for the murder and torture of his son in Paraguay; the court ruled that he could do so under the Alien Tort Statute because torture is universally condemned as a violation of international human rights law and "the torturer has become — like the pirate and the slave holder before him — hostis humani generis, an enemy of all mankind."

Hmm.

The Fascistic Plot to Seize Absolute World Domination Through the Little-Known CER (and you thought the Trilateral Commission was ruling the world)

Jerry Avorn in the May 7 NEJM has an excellent discussion of the ridiculous campaign by the usual gang of pathological wingnuts against Comparative Effectiveness Research. Inexplicably, although NEJM usually makes this kind of material of broad public interest open access, they've hidden this one behind the subscription wall. I'll have to yell at them louder, I guess.

Anyway, as I discussed here when the American Recovery and Reinvestment Act passed it included a big increase in federal funding for so-called Comparative Effectiveness Research. Columnist George Will checked in from his alternate universe to characterize the provision this way:

The stimulus legislation would create a council for Comparative Effectiveness Research. This is about medicine but not about healing the economy. The CER would identify (this is language from the draft report on the legislation) medical "items, procedures, and interventions" that it deems insufficiently effective or excessively expensive. They "will no longer be prescribed" by federal health programs.

The CER, which would dramatically advance government control – and rationing – of health care, should be thoroughly debated, not stealthily created in the name of "stimulus."

As Avorn enumerates for us, Will was hardly the only right wing bloviator to oppose the provision on similar or even more horrifyingly apocalyptic grounds. For example, Rep. Tom Price sent out an "alert" claiming that the legislation would create "a permanent government rationing board prescribing care instead of doctors and patients. . . Every policy and standard will be decided by this board and would be the law of the land for every doctor, drug company, hospital, and health insurance plan."

Uh, actually no. As in hallucinatory. The bill contains no provision establishing any governmental body or regulatory authority or health care reimbursement policy of any kind. All it does is fund research. So why the right wing war on knowledge? As always -- whether it's global climate change, tobacco, or mercury emissions, you name it -- it's because accurate information might compromise the ability of some rich criminals to get even richer at the expense of the common good.

Currently, in order to get a new drug approved, companies only have to show that it works better than placebo (generally speaking) in fairly short-term trials using homogeneous samples who are unrepresentative of real patient populations in such characteristics as comorbidities, age range, ethnicity, etc. They don't have to prove that it's better than standard, cheaper treatments, and they don't have to prove anything about the product in the real world. For medical devices, approval is even easier, and imaging procedures and surgery basically need no approval at all. In general, believe it or not -- despite the reputation of medicine as being very scientific and learned -- doctors actually do not base their treatments on good evidence about what works best, or even what works at all.

As Avorn puts it, "Vigorous marketing of the costliest new approaches fills this informational vacuum." And that is the essence of the threat posed by CER.

So one way to start to get a handle on health care costs, before health care turns into the Blob that Ate the Economy, is to learn more about what works best and for whom, and whether or not it's worth paying for the most expensive treatments and diagnostic procedures.

Some people argue that this will lead to faulty conclusions, and compromise "personalized medicine," by prescribing one-size-fits-all approaches that ignore variation among individuals. But as Garber and Tunis argue in the same issue of NEJM, the exact opposite is true. Well conceived and well designed CER is the way to find out who will benefit the most from which treatments, and what tests intended to personalize treatment are really worth doing.

With all the rage for genetic testing to personalize drug administration, for example, it turns out that the vast majority of identified variations have only a tiny relationship to outcomes and are not useful in tailoring treatment. Yet they cost money.

Now, ultimately results of these studies will have to be translated into guidelines, and it is likely that insurers will structure their reimbursement policies to encourage evidence-based practice. But that will only help your doctor and you to decide on the best course of action, save you money, and make you healthier. It will hurt Pfizer's bottom line, leaving some of what would have been their profits in your pocket.

It makes a lot of sense, in my view, to create a body similar to the UK's NICE, which is charged with systematically developing such guidelines. Since the UK in fact has socialized medicine, the NICE guidelines do sometimes result in identifiable individuals being denied treatments that they think they ought to get. Well, society's resources are not infinite. Right now we ration by who happens to have what insurance or none at all. That hardly seems better.

How our NICE might work, and exactly how it's guidelines would be implemented out in our more complex world of multiple payers, is a battle we may have to fight in the future. But for now, the claim that even knowing the truth abridges freedom is all the Republican party has going for it. I am inclined to believe the precise opposite.

Oh yeah, that again

Now that the Obama administration has worked down the laundry list and arrived at health care reform, I suppose I need to start writing about it obsessively again. Sort of a civic duty. I really don't know what more I can say about it, but I suppose not every post here has to be completely innovative and new.

As I noted yesterday, the key battles now seem not to be over whether something will happen, but whether that something will include:

1. A public insurance option open to all;


2. Some variation on a National Institute for Clinical Excellence that promulgates guidelines for effective and cost effective clinical practice. As of now, opponents have drawn their line in the sand well in front of the real target, by opposing even trying to learn what treatments work best. Contrary to the imperishable values of Faber College, Republicans once again proclaim that "Knowledge is Bad.";


3. Top-down reallocation of resources away from specialty care and heroic interventions to primary care and preventive services.

What all of these elements have in common is that they are about stopping somebody's gravy train. The medical-industrial complex is more than willing to go along with covering everybody, if that just means 45 million more "covered lives," as they say in the insurance biz, from which to render more gravy. But what we have to understand is that covering everybody is insupportable and unsustainable if we don't put the fat cats on a low-cal diet. (Sorry about that -- you try being clever every morning at 9:30.)

I am truly afraid that we will squander this historic opportunity by settling for a Massachusetts-style reform -- which is already failing in Massachusetts -- that just puts more money into the system; forces people who happen to have just the wrong combination of age and income to buy crappy insurance that just vacuums money out of their pockets and then doesn't pay for their health care; continues squandering a quarter of the whole pile on insurance company profits and boondoggles and half of the rest on ineffective, overpriced, and or futile services; and fails to keep people healthy, is not equitable or consistently humane, and is not affordable. The bastards are just going to rip us off once again, with a good segment of the left cheering them on in the name of compromise and bipartisanship.

I will address each of these elements in turn in coming days, I'm not sure yet in what order. Meanwhile I still have the backlog of Housing First, dog bites, and the length of primary care visits to deal with. Should be busy.

Thanks for nothin' . . .

It seems various components of the medical-industrial complex are offering to restrain rate increases in coming years, ostensibly in "support" of health care reform. What do they want in return? Oh, not much:

The industry groups are trying to get on the administration bandwagon for expanded coverage now in the hope they can steer Congress away from legislation that would restrict their profitability in future years. Insurers, for example, want to avoid the creation of a government health plan that would directly compete with them to enroll middle-class workers and their families. Drug makers worry that in the future, new medications might have to pass a cost-benefit test before they can win approval. And hospitals and doctors are concerned the government could dictate what they get paid to care for any patient, not only the elderly and the poor.

Let me edit that paragraph for you:

Everything.

Couple of Links

I get all sorts of e-mail from publicists, but this is definitely legit. The American Heart Association and the Clinton Foundation are teaming up to combat childhood obesity. As I keep saying, that's a much bigger threat to us all than the swine flu.

And speaking of which, you can listen to my interview on Counterspin here. It starts about halfway through the program.

I keep meaning to add Orac to my sidebar. Until I get around to it, click here.

And Orac turned me on to this by C. Mooney, about why the hell we're still talking about vaccines and autism.

Hey, that wasn't so hard. Maybe I can blog on Sundays after all.

The actual cause of death . . .

. . . and what to do about it.

It is a staple in introductory public health courses to present the leading causes of death as recorded on death certificates -- heart disease, cancer, stroke, etc. -- next to so-called "actual causes of death," which are somebody's analysis of preventable or modifiable factors out in the world, as opposed to inside the person's body, which in the classic analysis are tobacco, overweight and physical inactivity, ethanol, etc. "Microbial agents" are 4th but I have a quarrel with that, which I will defer. Anyway, you can see it for yourself here.

On the one hand, I do think this is a healthful exercise. It would be a big step forward if we could spend less resources on treating heart disease and cancer, and instead got people to stop smoking, exercise more, and consume fewer calories. On the other hand, it reflects sloppy thinking, in two ways. First, you can always go back another step and ask, "Why are people obese?" "Why do people smoke cigarettes?" and perhaps most cogently though of lesser numeric import in today's world (but maybe not tomorrow's), "Why do some people die from 'microbial agents' and not others?" Then your Actual Causes of Death might include, say, advertising, agricultural policy, and television.

But second, and this is the real subject of today's rumination, is it really death that's the problem? Every one of us is born with an inevitably fatal, absolutely incurable disease which, after we reach adulthood, progressively causes our muscles to weaken, our skin to lose elasticity, our immune systems to decline, our arteries to stiffen, and eventually, if something else doesn't get us first, leads to cardiac or respiratory arrest or fatal pneumonia. Then the death certificate will say heart disease or influenza or whatever, but we know the real cause of death: birth. The only way to prevent a person from dying is to prevent the person from being born.

So how should we view this problem? One way, which appeals to me, is through a justice frame. Look at the map above. The problem is not that people die, but that many people don't have the chance at a lifespan which gives them the chance to fulfill their potential. Beyond that, of course, we pay far too much attention to death in the first place. In order to accomplish anything and enjoy life, being alive is a necessary, but not a sufficient condition. We can extend the lives of people with cancer and heart disease, often at great expense, but I would much prefer to live without them. And with or without a spiffily functional body, I need the social context and psychological resources to have a fulfilling life.

Medical intervention plays a tiny role in this big picture. The most powerful determinant of our longevity and our health, however conceived, is our position in society. For example, here's another open door crashed through: "Despite increased attention and substantial dollars directed to groups with low socioeconomic status, within race and gender groups, the educational gap in life expectancy is rising, mainly because of rising differentials among the elderly. With the exception of black males, all recent gains in life expectancy at age twenty-five have occurred among better-educated groups, raising educational differentials in life expectancy by 30 percent." And, again, life expectancy aside, "Among adults over age 25, 5.8% of college graduates,
11% of those with some college, 13.9% of high school graduates, and 25.7% of those with less than a high school education report being in poor or fair health." The latter factoid is from this memorandum from the Prevention Institute, which reviews all sorts of disparities having to do with race and ethnicity and other social factors as well.

Again, this has little to do with doctors and hospitals and all of those astonishing medical breakthroughs by heroic "top docs" you hear about on TV. (Or read in the papers, if you do read papers, which is kinda weird nowadays.) By the way, it also has nothing whatsoever to do with influenza.

This is what we ought to be talking about on Daily Kos and everywhere we can have such conversations. I hope more people will join me.

What ought to be news

I just finished doing an interview for the Counterspin radio program, which will be on tomorrow I'm told, about the media frenzy over swine flu. What troubles me the most about this, if I haven't made it clear already, is the false perspective it created. There are a lot of dangers in this world, that are indeed likely to strike you down before your time -- and would have remained far more likely to get you than any influenza ever will be, even if we really do get THE BIG ONE any time soon.

But you don't see the nightly news leading off every night with five minutes on the obesity epidemic, or the 425,000 Americans killed every year by tobacco, or the 7 year gap in life expectancy between African American and white men, or the immense burden of disease and disability associated with poverty, or the kids dying by the tens of thousands every day around the world from hunger and dirty water and malaria -- real holocausts, here and everywhere, that already are happening, right now. If we had indeed had a raging global pandemic of killer flu, yes that would have been big news. But the mere possibility, a concern that it might happen? That's news once, but it doesn't continue to be the biggest news on earth for two weeks when it hasn't actually happened.

So that's why I'm still pissed off. If they had to talk about it so damn much, they could at least have put it in perspective, use it as an occasion to teach us some things we need to hear. But instead it was all about the horror, the horror. And it's not just the corporate media that's to blame -- this was a web frenzy as well, and more so on the left than the right. How can we straighten them out?

JAMA says wonk you out

Unfortunately, they have yet to succumb to the ordinarily awesome influence of Stayin' Alive and make the articles available to you, the wretched refuse, but the editors of JAMA have given us three commentaries on health care reform prospects, and four if you count the one about China, which is not entirely irrelevant. You can't read the articles because you are worthless trash, but you can access the first 100 words of each of them here, along with full citations.

It would be feckless for me to try to adequately summarize these discussions here -- I may write a long-form article on the subject and try to get it posted somewhere -- but I'll make a few observations. These writers all pretty much give up on doing what's right before they even get started. We face two categories of obstacles they all consider more or less insuperable -- the political culture, in which tropes such as "individual responsibility" and "private enterprise" suffice to abort all rational discussion; and the power of vested interests, notably insurance companies, pharmaceutical manufacturers, and highly paid medical specialists. So we're looking for workarounds that can get us at least two steps ahead and only one step back.

Samuel Sessions and Allan Detsky discuss the obvious downside of cost containment -- it means people lose jobs and/or income. So-called health care (a misnomer in my view but I've just about given up fighting it) now consumes 16% of the economy. If we don't get costs under control, Medicare and Medicaid spending alone will consume 8.4% of GDP by 2030, which will be 40% of the projected federal deficit. (Forget about Social Security, there's no crisis there.) Ten percent of the workforce is in "health care," of which more than 1/4 of the jobs are clerical. Most of these people, of course, aren't helping to provide "health care," they're busy doing things like denying it, figuring out how to game the billing, marketing, etc. But anyway, if we wring waste out of the system, those people will be out of work, and they don't tend to have skills which are much good elsewhere. (You can get an Associates Degree in medical billing, believe it or not, but it's not much good in rapidly growing industries like guns and ammunition, or debt collection.) As a component of any successful reform, we'll have to reduce the incomes and probably the numbers of many highly paid medical specialists, and pay more money to more primary care physicians. But the cardiac surgeons aren't going to like that.

So, in other words, we need a plan, and we probably will have to settle for a gradual transition. Which is where Troyen Brennan and Michelle Mello come in. They want to expand Medicare to cover people under 65, to provide competition for private insurance, while expanding regulation of private insurance to limit medical underwriting, while implementing an individual mandate with subsidies for the near poor. That's more or less what Massachusetts has done except for the expanded Medicare, which is necessary to soak up the much larger numbers of uninsured working poor outside of the People's Republic of Massachusetts. Our reform, as such, wouldn't work in Texas. (Actually, it won't work here either, but I won't go into that.) This is more or less Obama's proposal, but unfortunately, they have touched the third rail here, because it is precisely that public option that the Republicans have vowed to filibuster into oblivion. And whatever Arlen Specter wants to call himself, he won't vote for cloture, it won't happen. That's why Obama wants to use the budget reconciliation process to avoid the filibuster, but "Democrat" Specter says he opposes that as well.

Finally David Orentlicher, in an essay entitled "Health Care Reform: Beyond Ideology," undertakes a rational, pragmatic analysis which is intended to dodge the rhetorical brickbats from all sides and take us to the reasonable, pragmatic, common ground truth. Which turns out to be universal, comprehensive, single payer national health care. Except that he can't call it that. Oh well.

Kathy the cat fancier turns us on to this interview with the Prez by David Leonhardt, in which he addresses health care near the end. It's very strange to have a president who produces syntactically well-formed utterances arranged in logical, well-informed discourse. But there you have it. He dodges and weaves a bit, but do check out his ruminations on end of life care. He doesn't have the answers, but he says we need to have a discussion. Yes we do. But we'll have to cross that kettle of fish when we come to it, after we've got a payment system in place that can deal with it.

Tom Tomorrow

Hits it flush at the expense of our mind is on vacation, mouth is working overtime VP.

Eeek! A mouse!

Fear is good, obviously. If not for fear, I wouldn't be sitting here typing this drivel because my ancestors back on the African savannah wouldn't have made it to reproductive age. Unfortunately, the primal emotion isn't as adaptive as it used to be in the wondrous world of today.

I'm not a psychologist, so I really just have a drive-by perspective on the basic mechanisms, but here's how it seems to me (for whatever it's worth). We have some hard-wired propensities to fear the obvious stuff like snakes, large arachnids, big animals with claws and sharp teeth. Of course we have more abstract fears of death and pain and - now this is important - one of our most common and strongest fears is of loneliness and social isolation. That's because we are fundamentally social animals, we aren't built to make it on our own.

The dangerous animals thing isn't generally relevant any more. The abstract objects of fear, except in rare circumstances when, for example, the bus is headed straight at you, don't present themselves directly. They are socially constructed. Chimpanzees have alarm calls which set the whole troop panicking. We have much more elaborate vocalizations with syntax and thousands of symbolic elements, so we don't just yell "leopard!" or "baboon!" We tell each other elaborate stories about what to be afraid of.

This sounds like a useful adaptation, right? "Don't walk in the south end of the park after dark" is quite specific. You can still go there during the day, and you can go to the north end in the evening. But this faculty works very weirdly.

Here, for example, are two stories from today's news about actions by the Chinese authorities. In Hubei province, government officials have a policy of promoting cigarette smoking to boost the local economy. Departments have to budget for the purchase of half a million dollars worth of cancer sticks every year, and state employees are tasked with a goal of personally consuming a quarter of a million packs a year of locally produced brands. At the same time, Chinese officials elsewhere have essentially imprisoned dozens of foreign travelers over swine flu fears, even though the people have no symptoms.

This may strike you as odd public policy, but the analogous individual behavior is commonplace here in the United States. Doctors routinely threaten people with death if they don't take the pills, stop smoking, lose weight, etc., but it does little or no good. But the same people want immigration stopped because they are convinced that Mexicans import diseases. That didn't start with the flu scare, by the way. I would not normally link to World Net Daily but when they are making fools of themselves this profoundly I'll make an exception.

"[M]any illegal aliens harbor fatal diseases that American medicine fought and vanquished long ago, such as drug-resistant tuberculosis, malaria, leprosy, plague, polio, dengue, and Chagas disease."

In other words, people can flat out lie in order to manipulate our fears. George W. Bush told us that if we didn't invade Iraq, Osama bin Laden would destroy our cities with nuclear weapons. Even the most mildly enterprising skepticism could have completely debunked this absurd claim, but doubt was not permitted. Instead, Dick Cheney's lieutenants told it to Judith Miller, she wrote it down, they printed it on the front page of the New York Times, and then Dick Cheney went on TV and said "You don't have to take it from me -- it's in the New York Times!"

The only explanation I can see for such a profound institutional failure is that lots of people, including the editors of our major news media, wanted a specific object of fear. They had vague anxieties after the Sept. 11 events, and that was just too uncomfortable. They needed a focus, a simple story that could lead to a dramatic resolution. Let's just bomb us some Arabs and get this thing over with.

So I think there's a generalizable social psychological mechanism here. We live continually with anxiety. This is an era of continual, rapid change; there are a lot of vague threats out there that most people barely grasp; people's lives are often unstable and insecure. So these fear fads erupt, possibly as the result of a plot, as in the case of the Bush administration; often more or less stochastically, as with shark attacks and infectious disease scares. In the latter case, it sometimes starts with some legitimate concern by authorities but their precautionary actions and pronouncements get amplified by the mass media into a prophecy of doom. Sometimes, as with the West Nile virus obsession of a few years ago, it's pretty much a crock from the beginning, intense, hyperventilating perseveration on a minor problem.

The fact is, we like to be scared. That's why we go to horror movies and go on thrill rides at amusement parks. That way we get it over with and we can go ahead and light up the Camel. Or something.

The End Times

A writer with whom I have a great deal in common discusses the media hoopla over the swine flu on Alternet. This has got me to thinking more generally about apocalyptic fantasies, which seem to be a cultural staple for as long as people have been writing stuff down, and presumably since before then. Unfortunately, religio-mystical eschatology is not only still with us, but may well be as strong as it has ever been. Here's a polling nugget from 2002 -- and note that this after we had safely made it through the bimillenium:

A TIME/CNN poll finds that more than one-third of Americans say they are paying more attention now to how the news might relate to the end of the world, and have talked about what the Bible has to say on the subject. Fully 59% say they believe the events in Revelation are going to come true, and nearly one-quarter think the Bible predicted the Sept. 11 attack.

We've had plenty of secular millenarian frenzies lately as well -- from survivalism based on various analyses of how the elaborate interdependencies of modern society were a set up for catastrophic collapse, to predictions of imminent ecological doom, to peak oil enthusiasts, to the Y2K bug, and so on. Some of these, I will be the first to tell you, have a connection to perfectly reasonable concerns, but there are schools whose insistence on the imminence and radical scope of catastrophe seems to be more about faith than reason.

In this category I will place the problem of emerging infectious disease. It's obviously not crazy to hold that one day, somehow, a great plague might devastate humanity and profoundly change society. After all, it has happened before. The Black Death of the 1300s is variously estimated to have killed from 1/3 to 1/2 the population of Europe, and by most analyses radically transformed society -- ultimately, from our point of view at least, for the better, in fact, because it elevated the status of the peasantry, destroyed feudalism, and created the conditions for the Rennaisance and the Enlightenment.

In marked contrast to the 14th Century, today we understand the nature of infectious diseases and we have effective methods available to combat them. Therefore it pays for us to be vigilant and have systems and plans in place to respond if a new infection poses a new kind of threat. We can do something about it. I am 100% for that. Yes, the world is overpopulated, but we need to solve that by reducing the birth rate, not raising the death rate. I hope nobody wants to argue with that.

Is it conceivable that some really nasty infection could get loose that it is resistant to all our antimicrobials, spreads like brushfire, and wipes out civilization before anybody can figure out a way to stop it? I suppose so. Can't rule it out. Then there's nuclear war and widespread global famine and a lot of stuff that might indeed happen.

But what I find odd and disturbing is that there are a substantial number of people out there for whom the prospect of a massively deadly and disruptive pandemic of some sort seems to represent wishful thinking. The recent swine flu outbreak struck me as likely to turn out to be a whole lot of not very much from the beginning, but I was careful to avoid making predictions. What I did insist upon was that it made no sense to start a massive public frenzy over the situation until and unless we knew that drastic measures were warranted.

What I found, in my sorties through the blogosphere, was a considerable faction that wanted to obssess about it, absolutely convinced that this was The Big One, that world commerce was going to shut down, developed economies would come to a halt, cities would empty and we'd all be huddling at Aunt Betsy's house in Wyoming writing the Decameron, and anybody who said otherwise was a wacko right-wing conspiracy theorist. We had two or three big front page posts on Kos every day consisting of elaborate influenza wonkery, and every time I made a comment suggesting we scale it back I'd attract replies accusing me of not knowing about 1918. I even got one of those here.

My diagnosis is that there are a lot of people who want something armageddonish to happen, and they want it so badly that their desire has morphed into belief. For a few of them, it's because they have a true vested interest -- their career prospects and/or their public prominence depend on pumping up the worst case scenario. They attract a lot of followers who just want something big to happen, because life is oppressive or perhaps merely boring. That's undoubtedly going to continue, we can't stop it. But what I want to make absolutely clear is that it is anathema to progressive politics and particularly to progressive public health activism. It belongs in the far fringes of wingnutosphere, not on the front page of Daily Kos.

Now that the apocalypse has been cancelled .. .

(details here) I can get back to more congenial business. Friend Rachel sent this link, about how physicians often fail to call for an interpreter when they don't speak the patient's language.

There are some important points made here, one of the most important being that doctors tend to see the function of communicating with patients as essentially being to meet the physician's need for information. In my own research, I have observed that doctors ask nearly 10 times more questions than do patients, while patients give twice as much information to doctors as doctors do to patients. So who needs an interpreter if you don't need to take a history? Or, maybe you should be a veterinarian.

When I was hospitalized some years ago, I had for a while a Russian roommate who spoke no English. The doctors would come on morning and rounds and stand at the foot of his bed talking about him. He had no idea what they were saying. I knew that he had terminal, inoperable bladder cancer, but he did not. They went to discharge him, and got an interpreter for the nurse. The interpreter said to the nurse, "He wants to know about his disease and his prognosis." The nurse said, "Oh for chrissake, I need the bed." But she sent for a fuzzy-cheeked resident who told the guy, for the first time, as he was being kicked out the door, that he had less than six months to live.

And that's why I'm sitting here today, doing what I do. Just so you know.