Iatrogenic Terminal Hassling

If you're lucky enough to have a subscription to BMJ, you can read an essay by Carl May, Victor Montori, and Frances Mair entitled "We Need Minimally Disruptive Medicine." Since you are lucky enough to have a subscription to Stayin' Alive, and if I'd gotten around to it I could have written that essay myself, you can read my take on it here.

For those of us who are basically healthy, health care is -- or at least one would hope it would be -- a minor issue in our lives. Maybe we've had an episode here and there where we we suddenly found ourselves intensely interacting with doctors and health care systems, and then it was over and we were back to checking in once a year. But most of the medical enterprise, in terms of spending, personnel time, and the problems we worry about of cost and resource allocation, obviously concerns people with chronic disease.

There was really only a brief period, from the early 20th Century until maybe the 1960s or thereabouts, when medicine was mostly about acute diseases and curing people. Once we stopped getting carried off by common microbes and conditions that could be corrected by sterile surgery, doctors found themselves dealing more and more with long-term management of incurable conditions such as heart disease, diabetes, and chronic kidney disease. Quite often these conditions occur together and with other conditions such as osteoarthritis, depression, chronic pain syndromes, and on and on.

It is an incredible amount of work to comply with everything the doctors demand of people in these situations. A colleague of mine recently interviewed people with chronic kidney disease and they quite typically had ten or a dozen prescriptions, coming from 3 or 4 different doctors who as likely as not were not talking with each other. Each of these has to be taken according to its own schedule, with or without food, etc. Obviously, nobody actually does this, because it is nearly impossible. The people pick the ones they think are important and forget about the rest. And of course they don't tell their doctors because they'll just get scolded and who needs that?

And then they have to keep multiple appointments at various places, go through diagnostic procedures involving everything from painful needle jabs to barium enemas, follow diets and physical therapy regimens, while coping with the normal demands of life in the face of whatever functional and financial limitations they endure. This is not helping. It is making things worse.

As May and colleagues write, "We need to think about the burdens of treatment. These are different from the burdens of illness." They recommend that we put in place efforts to keep track of the burdens of treatment for patients; coordinate care much better among various clinicians; recognize that clinical evidence and resulting guidelines often do not take into account comorbidity; and ask patients to establish their own priorities and deal only with the problems they find it worth their effort and discomfort to handle at any particular time.

They might have done more to acknowledge the frequently highly detrimental effects of polypharmacy -- drugs that do good on their own may do harm when combined with others -- and of overtreatment in general. It's not just the burden of treatment, but its often directly harmful biological effects, that are insufficiently recognized.

Should I one day enter decrepitude, I am definitely not inclined to spend all my time worrying about my diseases and my pills. How incredibly tiresome. It's far more important to try to enjoy what life we've got. However, this isn't just a matter of personal initiative, it's a fundamental problem with the organization and culture of medicine. Again, we can save money and do better by people by doing less. Call it rationing if you will.

The paradox of desire

So, somehow, in the dark backward and abysm of time, we rather suddenly acquired this imagination, language, culture, and the deep learning that gives us wood framed houses and potted meat products. Wondrous though our brains surely are, they are kludgy creations. Evolution could only create the machinery of our selves by cobbling together the pieces that happened to be lying around already, and the result is far from elegant.

I've spent a lot of time here lamenting and struggling with our relentless tendency to believe stuff that isn't so. Whatever intelligence we have had to adapt stimulus-response type learning -- both from our own direct experience, and social learning -- from the simple associational expectations and habits of other apes to our more elaborate constructs. The result is that we are prone to superstition and folly.

But today I want to talk about a different flaw in our psychic architecture, which is our conflicted relationship with desire and purpose. Now, much of the time we don't get what we want because there just was never any way. Maybe Harvard had to admit so many children of privilege that they just didn't get around to your application while there was still room for you. Maybe your babe done got some other plan.

But very often, we sabotage ourselves. There is a path to the heart's desire, or at least a decent chance to get there, but something in us makes sure we don't walk on it. One reason is the faulty wiring between the more primitive emotional systems and the executive system in the cortex that is much of what makes us distinctly human -- the system that imagines a goal and devises the set of steps to get us there. Desire can be so intense that it just overwhelms us, blows up the plans in a firestorm of urgency and pumping cortisol, scares the people we want to attract, destroys the patience and guile that alone can succeed.

Another is the inevitable consequence of the primitive nature of behavioral learning. Disappointment and rejection can be so painful that our aversion to experiencing them again is stronger than the lure of our heart's desire -- even more so if we might gain our precious object, and then find it after all less than we had imagined. Or perhaps worse, find it as wonderful as we had hoped, but then lose it -- or worse, lose the desire that had given us purpose. Most of the time, we simply have no insight into these processes. We experience disappointment without recognizing that we somehow made sure it would happen.

But, there are second chances in life. The trick is to learn the right lessons, which we aren't quite designed to do.

How to build a house

Okay, first you hook up the stereo, then you install the toilet, then you build the roof . . .

Well no, you can't do it in that order, although it would be a lot more convenient.

If you ask people what most distinguishes from the other apes, and for that matter the rest of the metazoans, they'll usually answer that language is what really sets us apart, and then maybe they'll go to culture, which pretty much depends on language for its existence. But I'm not so sure there isn't something else that comes first. I'll summarize it as imagination.

In order to build a house as fancy and functional as the one I just got done building, language and culture are certainly essential. Only through millennia of house building have we learned all the methods that I used, from the concrete foundation to the wooden stick framing system and the glass windows; only a complex society could have delivered all the materials to the site; and if I hadn't been able to talk to -- or more important, listen to -- my friend Mark we would have had a much harder time working together and I never would have learned which end of the saw to hold.

But something else had to come first. I had to have a vision that one day, instead of a swampy patch of woods, there would be a house and a barn and orchards in that place; and then I had to imagine, in a complex chain, each of the events that would need to take place for that to happen; and then I had to make my mouth say the words and my hands do the deeds to turn imagination into reality. Without language, and without culture, I might have ended up with a lean-to made of rocks and tree branches, but I still could have made the imaginary real. Other apes, I suppose, can do that in a very limited way. They can see a piece of fruit and envision it in their mouth, and reach out and grab it. But they will never plant fruit trees.

Somehow, a couple of hundred thousand years ago, our ancestors were changed in several ways at once. Yes, they started talking to each other. Their behavior became much more flexible as they based new ways of doing on learning, and passed this learning on from one to another, and from generation to generation. But most important of all, they began to imagine distant goals, and make plans to achieve them.

This imagination is so powerful and so essential to our nature that we don't even need a real goal or an achievable vision. We devote much of our mental energy to imagining things that never can be, never will be, imaginings unrelated to planning and achieving. People whose only talent is manufacturing visions of the unreal are among the most honored in every time, and in all of history. We build real castles, but we care just as much to build castles in the air.

Astonishing, we are.

Concern trolling

It turns out that not only is the health care reform legislation a plot to destroy capitalism and then murder your grandmother and Trig Palin, it's specifically a plot to murder Republicans.

Of course, we've only gotten this far because the Illuminati smuggled a little Kenyan baby into Hawaii in 1961 so they could make him president of the United States 48 years later in order to achieve world domination on behalf of the Antichrist.

Now, here's what I'm wondering. Is it going to occur to the powers at GE and Disney and Viacom and CBS and Time Warner that the best way to maintain the proletariat in a condition of false consciousness on behalf of capitalist hegemony may not, after all, be to depend on zombies who can't see through the most transparent bullshit to outvote people with 1/3 of a brain? That maybe there just won't turn out to be enough of them in the end? And that therefore it might be in the long-term interest of the ruling class that they stop treating pure insanity with "balance" and offering dignity and respect to the RNC and James Inhofe? Maybe this is not the right long-term strategy after all?

Just a thought. I'm getting out of town ahead of the stormy weather to do some lumberjacking and other honest work like a real American. Y'all keep it real too.

Zap!

Fazel and colleagues use insurance claims data to generate population estimates of the radiation doses that people age 18-64 get from medical imaging procedures. You only get to read the abstract, but that's okay, the whole article is not exactly scintillating reading. Nevertheless, it does stimulate Michael Lauer to riff on it in a more interesting way. You aren't allowed to read that either, so let me give you the 4-1-1.

Radiation doses are measured in millisieverts, which are a composite unit intended to represent the biological effect of exposure to ionizing radiation, i.e. taking into account the total energy, how it was delivered over time and volume of tissue, the type of radiation, and the body part irradiated. OSHA doesn't allow people in the nuclear industry to get more than 50 mSv/year, but that doesn't mean lower exposures are totally safe: as far as we know there is no threshold effect to the biological effects of ionizing radiation, in other words a very low exposure still constitutes a risk, albeit also very low. So it's best to avoid exposure unless there are sufficient offsetting benefits.

Having a job is clearly one such benefit. Most jobs, from taxi driver to coal miner to medical sociologist, involve non-zero risk, but we tolerate it because a man, or whoever, has to eat, and that includes Homer Simpson (who as I assume everyone knows works in a nuclear power plant). But when you're talking about medical procedures given to millions of people, even a very small risk to each individual can add up to a meaningful population risk. Fazel et al find that in fact, quite a few people get pretty substantial doses from medical imaging procedures. In fact, 1.9 out of 1,000 people in their sample got more than 50 mSv in a year. (Which could potentially get Montgomery Burns in trouble if it happened to Homer Simpson although as we know Burns owns the authorities.) 18.6 out of 1,000 got 20-50 mSv, and almost 20% got lower doses. The biggest doses come from Myocardial Perfusion Imaging, commonly known as "stress tests."

These involve injecting radioactive material into the bloodstream. General Electric, which sells the equipment for stress tests, is pleased to tell you that:

The radioactive materials, MYOVIEW and Thallium, have been shown to be safe with low incidence of adverse reactions. This test and materials are used routinely worldwide, under physician supervision, for myocardial perfusion imaging.

Neither MYOVIEW nor Thallium are "dyes," and there should be no serious side effects from their injection.

Uh huh. Dr. Lauer tell us that it's commonplace for physicians to send middle-aged men with risk factors for heart disease, but no heart disease symptoms, for such tests, and often others as well such as CT angiography. However, "no large-scale, randomized trials have shown that imaging in these circumstances prolongs life, improves quality of life, prevents major clinical events, or reduces long-term medical costs." Furthermore, they expose people to radiation, which increases people's long-term risk for cancer. According to one estimate, as many as 2% of all cancers may be attributable to CT scanning. Cancers attributable to stress tests would be in addition to that.

So what do we need?

A) We need the fascistic, socialistic, ObamaNaziistic Comparative Effectiveness Research, to tell us what benefit there actually is from such imaging procedures under what circumstances, so we know whether they are worth the immediate monetary cost, and the long-term cancer risk.

B) We need rationing, in the form of practice guidelines that will tell physicians and patients when it's worth it and when it isn't to do these tests.

Guess who isn't going to like that? Radiologists, who are among the highest paid medical specialists. Oh yeah, GE isn't going to like it either.

C) We need universal, comprehensive, single payer national health care.

On rationing

Obviously -- and I mean, like duhhhh -- we ration everything. Resources are finite, and rich people have more than poor people, including the stuff we usually think of as necessities -- more and better food, bigger houses (some people have none at all), more and better clothing. Their kids get more and better education, they travel more, they go to more shows, they have boats and horses and they have more fun, they even generally speaking have a wider choice of sex partners.

Conservatives mostly think this is just fine, it's the way God planned it. However, we do still have a pretty broad social consensus -- excluding the radical "libertarians" who seem to have gotten especially noisy lately -- that endorses the Rule of Rescue. Samuel Sessions (in a review of Leonard Fleck's book "Just Caring: Health Care Rationing and Democratic Deliberation" in the new JAMA), gives a succinct illustration of the rule:

Most would consider it morally objectionable for someone driving down a country road not to take a severely injured hiker to a hospital merely out of concern that bleeding would cause $200 damage to the car's upholstery. Many would not find it objectionable, however, if that person chose not to donate $200 to a charitable organization for hunger relief overseas.

So, even conservatives accept the Rule of Rescue in social policy. People who become too disabled to work receive a tiny pension which is sufficient to keep them alive. I haven't heard anyone clamoring to repeal it. Children who are neglected and starved by their parents are rescued by the state, and people get really angry when the state fails in that responsibility.

Food in this country is so abundant and so cheap that soup kitchens and charity food pantries are actually sufficient to keep people from starving to death on the streets; and until recently, at least, most of the visibly homeless have manifest mental illness or substance abuse disorders such that people can rationalize turning away, saying, "Gee that's tough but what can you really do?" There is a broader group of people who don't really have homes but they're managing to get indoors at night one way or another so they don't quite qualify for the Rule of Rescue. As for the Bushville tent cities that sprang up during the recent unpleasantness in the job market it's been possible to ignore them for the time being and anyway, the people have tents and even cars so their basic needs are met, they aren't dying of exposure.

Now, liberals don't think this is the way it ought to be, but I'm just getting inside the heads of conservatives here. If they didn't endorse the Rule of Rescue, they could not possibly show up at civic meetings screaming invective about "rationing" of health care. Of course they are diametrically wrong on the facts: under the current system it is much more likely that someone will be denied desperately needed health care services than it would be under the proposed reform legislation. But facts have never meant anything to conservatives in this country. My point is that they do accept an ethical principle that people in dire straits should be rescued.

Now, obviously they only apply this rule to U.S. citizens, which does not seem very Christian of them, but that's their moral compass, you can't argue with it. But just as obviously, they haven't thought this through very far, in several respects.

The first is drawing the line as to where the Rule of Rescue kicks in. By the time people are dying of, say, kidney failure, they've usually had a long course of diabetes or hypertension of lupus or whatever the underlying cause is. Shouldn't we have started to rescue them long before? The same goes for cancers that can be treated better if detected early (actually a debatable proposition but I'm a contrarian on that one), heart disease, stroke, and so on.

The second is drawing the line on futility. Remember, they aren't talking about people spending their own money, they are talking about the pooled resources of people who pay insurance premiums, or taxpayers who pay for Medicare. Should we pay $10 million for a one percent chance of prolonging somebody's life by one week? Again, obviously, they are wrong on the facts, we don't do that right now. But the point is, conceptually, we have to draw that line somewhere and we always will draw it. Humans are mortal, and there comes a time when we have to surrender to Thanatos.

There are other respects in which they have failed to think this through, but I'll stop there for now. What troubles me is that no prominent figure -- be it politician or pundit -- is willing to say these things in public. The fact is, reform or no reform, these problems are with us, will always be with us, and are much better discussed in public, acted upon democratically, and dealt with openly and transparently. That's how they do things in the civilized countries. That's how we ought to do things here.

Mundo extraño

Every evening when I leave work I just miss the subway. (Yes, the universe is against me. I'll have to remember to start leaving 45 seconds before I actually intend to.) So last night, as usual, the train is just pulling out as I get to the top of the stairs. On the platform, I passed a young woman of college age or just past, with the requisite backpack and stud in her nose, on her way to the escalator. A minute later, I glanced to the top of the escalator and saw she had turned around and was heading back down the stairs. Passing in front of me at that moment was a man pushing a middle-aged woman in a wheelchair.

"Do you know her?" the young woman yelled. "Stop pushing her! She walks! She can walk better than me! She's just lazy!" and so on. The guy looked nonplussed, but he finished pushing the woman to the elevator and headed on up the stairs himself, with the young woman walking alongside and continuing to berate him.

That all seemed sufficiently odd (to say the least) that I did some googling. It turns out there is a well-recognized phenomenon of disability pretending, and, you guessed it, on-line communities of people who are into it. The motivation is not, in fact, laziness, but it is somewhat mysterious. I read a case history of a woman who experiences powerful sexual arousal after rolling around in public in a wheelchair pretending to be disabled. Indeed, the proclivity seems to be closely associated with attraction to people with disabilities, and actually desiring to become disabled, as by having an amputation. There's even an acronym, DPW, for DesirerDevotee, Pretender, Wannabe, which is thought to be some form of continuum -- and the basis for virtual communities.

I find this a bit disconcerting, but whatever my -- I don't know what the word is, aesthetic reaction, I suppose -- it is an extreme case that demonstrates the complexity of defining health and quality of life. What would be a physician's patient-centered approach to such a person? How would we evaluate her responses to a health status/quality of life questionnaire? She's not actually disabled enough to be happy? Or should we impose our own judgment and decide that she's mentally ill and she needs her brain fixed, therefore we should ignore her wishes?

Perplexing indeed.

We don't deserve health insurance

Count on a Canadian newspaper to inform us that:

The chemistry whizkids at what used to be called Kentucky Fried Chicken before 'fried' became a word with negative connotations have come up with what they believe may be the year's big fast food burger seller - and it doesn't include bread. Behold, the Double Down. The creation features a dollop of the Colonel's secret sauce wrapped in a slice of both Pepperjack Cheese and Swiss Cheese, between two slices of bacon and two filets of KFC original recipe chicken that serve as the 'bread' of the burger. . . .we here at The Vancouver Sun have taken out our chemistry set and rebuilt the Double Down in our underground lab with a view to figuring out how it works.

The results show this one menu item can be estimated to supply more than the daily recommended allowance in fat (124%), saturated fat (117%), cholesterol (105%), sodium (125%) and protein (194%), as well as 61% of your daily recommended calorie intake.

It sells for seven bucks. I guess that would be $8.50 with 36 ounces of sugar water. Start saving the change, because as soon as you have your first heart attack, the insurance company is gonna dump you.

In the beginning

I took the opportunity over the weekend to catch up on some reading and try to do some thinking. At least I was somewhat successful with the first project. The new Scientific American -- it's here, but you can't read the full articles unless you have a subscription -- is organized around a theme of "origins." It's kind of bogus as a frame -- the issues don't really have a lot in common -- but there is something about the Big Three that hangs together for me.

The Big Three are of course the origin of the universe, of life on earth, and the human mind, which are addressed respectively by Michael S. Turner, Alonso Ricardo and Jack W. Szostak, and Marc Hauser. They're big only because they happen to be important to us, but that's what matters to me because I'm one of us. I'm sorry to have to say that I found all three essays rather unsatisfying -- not because I was expecting them to have the answers, but because the discussions were limited to reprocessing the already well-known (to the scientific literati) wonkery around the details of these processes without acknowledging the problems of meaning which seem deeper to most people.

It seems pretty obvious that one of the reasons people are drawn to religion is because they can't be satisfied with the mystery that still surrounds these questions. Of course "God did it" isn't really an answer, because you would still need to explain the origin of God and there isn't any evidence for God anyway, unless you simply define God as "whatever it is that made these things happen," which obviously isn't getting you anywhere.

But it nevertheless feels better to many people to attribute the universe and whatever there is in it that matters to us to some sort of sentience or ultimate purpose, even if we don't have any idea what that is. Apparently it feels even better to some people just to decide that it's a big Daddy sort of superperson that lives in the sky and is going to show us what it's all about after we die.

Alas, this sort of comforting nonsense isn't harmless, because once you start believing in something that is illogical and without evidence, you can believe anything; and you'll end up believing whatever the people tell you who you depend on to feed you the original comforting nonsense.

Of the Big Three questions, I find the origin of life on earth actually the least interesting and the least problematic. You just need to get some sort of self-replicating molecular system happening. It's not a problem if the requisite events have a low probability, because it only has to happen once, and you can sit around and wait for millions of years. I actually think it would be surprising if it didn't happen. Since nobody can go back and observe what was going on 3 billion years ago, the best investigators can do is muck around until they get something to work, which will constitute a proof of principle but it will be forever impossible to prove that is what actually did happen. So it seems rather feckless to me.

But the origins of the universe and of the human mind are more puzzling, and also offer more opportunity for real discovery and revelation. The curse of cosmology, as a cultural artifact, is that the more we learn about the universe, the more pointless it seems from our own point of view, and the harder it gets even to formulate the question of "Why?" As for the science of mind, even if we're willing to live with its unavoidable circularity, it seems to diminish us, compared with our intuition of ourselves as miraculous and transcendent. I think any discussion of the science surrounding these questions needs to acknowledge the discomfort they cause, and that it is as essential to confront the problem of meaning as it is to explore the problem of what is.

Just because the world needs to know

Bernie Madoff's mistress reveals that Bernie had big houses and big yachts but:

"Bernie had a very small penis," she wrote. "Not only was it on the short side, it was small in circumference. That he was now pointing it out to me was telling. It clearly caused him great angst. I wanted to be careful how I responded. Men and their penises have a strange and unique relationship."

Still, she said: "I liked this man and didn’t want to emasculate him. His tiny penis hadn’t prevented me from climaxing."

"On the bright side," she concluded, because of its size, "oral sex would be a breeze."

No, this is not The Onion. I only wish.

A harmonic convergence

It can be difficult to come up with something intelligent to blog about every day (as you have no doubt noticed) but sometimes the posts write themselves. First thing this morning I had a meeting with a colleague who is a resident in internal medicine here so I asked her what bugs are going around. She said oh, I feel like I must be covered in MRSA. After backing away slowly to a safer distance, I allowed the conversation to continue. She said she's paranoid every time she gets a pimple.

MRSA, in case you didn't know, is Methicillin resistant Staphylococcus aureus, which is just good old staph except that eats antibiotics for lunch, in particular the most commonly used family of antibiotics, called beta lactams, which includes penicillin-like drugs and many others. It used to be mostly found in hospitals but it's all over the place now and my colleague spends much of her typical 34 hour day trying to kill it with exotic chemicals.

Then I found in my e-mail a message from Whisker of Iraq Today about three Canadian soldiers returning from Afghanistan who have been isolated with drug resistant Acinetobacter baumannii. This too was previously thought of as a nosocomial infection, i.e. one associated with hospitals. However, soldiers wounded in Iraq started showing up with A. baumannii infections that were sometimes nearly impossible to eradicate, and now we're seeing it with Afghanistan vets as well. The consequences can be ugly:

Staff Sgt. Nathan Reed was escorting a CBS news team through Baghdad for a Memorial Day visit in 2006 when the car bomb went off. Reed survived, but his right leg was severely injured. He was rushed to military hospitals in Iraq and Germany, then to Brooke Army Medical Center in San Antonio. The injured leg developed an infection from a bacterium called acinetobacter baumannii. Reed had to decide whether or not to have his leg amputated. He consulted his doctors. He weighed his options. Finally, after getting all the information he could, he went ahead with the surgery. "The Iraqibacter pretty much sealed the fate for my amputation," he says.

The bacterium nicknamed the Iraqibacter is an increasingly multi-drug-resistant supergerm that is plaguing wounded soldiers who served in Iraq. The Infectious Diseases Society of America (IDSA) has put it on a short list of six dangerous, top-priority, drug-resistant microbes. Doctors are running out of ammunition to fight it. The Iraqibacter joins on that list a better-known and more common supergerm, methicillin-resistant staphylococcus aureus (MRSA). Though less virulent than MRSA, acinetobacter baumannii is more drug-resistant. Not only does it possess a number of resistant genes itself, it also accepts resistant genes from other bacteria.

And I had another message from, of all people, the American Meat Institute. (Hey bub, do you have any idea who you're e-mailing?) Anyway, they very much want me to tell you that the so-called "swine flu" has nothing to do with swine and it is "not caused or spread by pig production nor is the virus transmitted to humans by eating pork." Okay, Janet M. Riley, Senior Vice President, Public Affairs, you're right about that. However . . .

According to the Alliance for the Prudent Use of Antibiotics:

* Use of antimicrobials in food animals contributes to the growing problem of antimicrobial resistance in human infections. Transfer of bacteria from food animals to humans is a common occurrence.
* The amount of antimicrobials administered to animals is comparable to that used in humans. Unlike use in humans, however, much of the antimicrobial administration to food animals is to large groups at low doses, for non-therapeutic purposes such as growth promotion and disease prevention.
* The elimination of non-therapeutic use of antimicrobials in food animals and agriculture will lower the burden of antimicrobial resistance in the environment with consequent benefits to human and animal health.

Selected Recommendations
Based on its assessment of the scientific evidence, the Scientific Advisory Panel strongly urges implementation of policy reforms in a timely fashion. Specific changes called for are:

* Antimicrobial agents should not be used in agriculture in the absence of disease.
* Use of antimicrobials in food animal production should be limited to therapy for diseased animals or prevention of disease when it has been documented in a herd or flock.
* Use of antimicrobials for economic purposes such as growth promotion or to enhance feed efficiency should be discontinued (with the exception of ionophores and coccidiostats, because current evidence indicates that use of these antimicrobials does not affect resistance in human pathogens).
* Because of their critical importance to treat human disease, fluoroquinolones and third generation (or higher) cephalosporins should not be used in agriculture except to treat refractory infections in individual animals.
* Antimicrobials should be administered to animals only when prescribed by a veterinarian.
* In many cases, legislation by Congress or direct changes in policy by the US Food and Drug Administration, US Department of Agriculture, US Environmental Protection Agency, or other government agencies will be necessary to implement the recommendations of the Panel. The ecology of antibiotic resistance should be considered by regulatory agencies in assessing human health risk associated with antibiotic use in agriculture.

Unfortunately, Janet M. Riley has successfully blocked any such legislation. Therefore, she is making us sick and even killing people.

Unnecessary prescribing of antibiotics by doctors is another big reason why we have a growing problem of antibiotic resistance. APUA will give you the whole story. This is yet one more reason why physicians need to have government bureaucrats come between them and their patients, by establishing clear practice guidelines that will get them to stop handing out antibiotics for common upper respiratory tract infections.

And while we're on that subject, UK doctor Des Spence writes:

I wandered through the museum at Scapa Flow in Orkney, meeting the gaze of servicemen and women in fading black and white photos, a generation who gave their lives defending the values of democracy and fighting totalitarianism. We have never forgotten the generosity of the United States, which helped our nation in its darkest hours. Since then, we two nations have become married together—through sickness and health. Through right and wrong, we continue to battle together to defend commonly held values of democracy and freedom.

Therefore the US should appreciate the real pain and anger that recent attacks on the NHS by US politicians have caused. These comments have been so wantonly ill informed as to be downright stupid. The NHS was founded after the second world war, a horror beyond comprehension. The NHS was forged not of socialism but of patriotic service—put simply, our people deserved better.

But, according to U.S. politicians, our own people don't deserve better.

Go learn, play, participate

I should have mentioned this before but the New England Journal of Medicine has set up an open-access web site with a ton of information and debate about health care reform. There are even ways to participate, and you don't have to be a physician. NEJM has offered a range of perspectives on the issues, but as far as I'm concerned they have not shown any of the bias toward the financial interests of specialist physicians that contaminate a lot of professional medical association perspectives.

You'll find our old friends Steffie and David there, the excellent reporter John Iglehart, and analyses from top academic health care economists, policy analysts, and political scientists, written for public consumption.

There's even a poll for you to crash: "Do you believe that a public insurance option should be developed to compete with private insurance plans?"

Go there.

Now this is just too weird to be true

Public Policy Polling decides to get into the heads of the birthers. And you thought Oily Taint was a nutty as it gets.

62% of Americans think Obama was born here, while 24% think he was not and 14% are unsure.

10% of the country thinks that he was born in Indonesia, 7% think he was born in Kenya, and 1% think he was born in the Philippines.

That leaves 20%, which includes at least some people who correctly believe that Obama was born in Hawaii, but who don't consider Hawaii to be part of the United States. You read that right- 6% of poll respondents think that Hawaii is not part of the country and 4% are unsure.

It's hard to say what the rest of that 20% thinks. We did ask them if they thought Obama was born in France and while less than half a percent of respondents did, two thirds of that remaining 20% said they 'weren't sure' whether Obama was a Frenchman.

How is it that more people think he was born in Indonesia than think he was born in Kenya? I've never even heard of anyone making that claim. Maybe they reverse engineered it from the claim that he attended a radical Islamist school there, but if that's the case, they haven't even been listening to Rush Limbaugh and Lou Dobbs, they just arrived at it independently.

It is true, however, that Hawaii is not part of the United States.

Obscenity

Tip o' the hat to Dr. Rick, this web site gives the compensation of health insurance CEOs. A small sample:

CIGNA CEO
Edward Hanway
Five-Year Compensation, as of April 30, 2008 (Forbes)
$120.51 million
Total Value of Unexercised Stock Options (Forbes)
$28,881,000
Value of New Jersey Beach Home (Cape May County Assessor)
$13,607,400
Articles:
The family of a 17-year-old girl who died hours after CIGNA reversed a decision and said it would pay for a liver transplant plans to sue the company, their attorney said Friday.
Hundreds of entertainment industry workers in California and New Jersey who buy health insurance as a group are being hit with a rate increase that will raise some family-plan premiums to more than $44,000 a year.

These are the people the benighted souls who show up at town hall meetings shrieking about "socialism" (or "fascism," not that they know the difference) are protecting. They perform no socially useful function at all. They are parasites. Tapeworms.

Pulling the Plug on Grandma

Physicians for a National Health Program wants me to hip you to this report about for-profit vs. non-profit nursing homes. It's what's called a meta-analysis. That means the authors took data from a whole lot of studies and combined it to develop one big picture. The method evens out the variations that happen due to chance and various features of study design, and gives a pretty convincing overall conclusion about what is going on.

You will be interested to know, by the way, that in Canada, even though it's a totalitarian socialist dungeon, more than half of nursing home beds are owned by for-profit companies. Most of the studies covered in the meta-analysis were done in the U.S., but Canadian and Taiwanese studies were also included.

The miraculous virtues of the invisible hand are plainly visible.

Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17).

According to the PNHP press release, quoting the senior author:

"The reason patients' quality of care is inferior in for-profit nursing homes is that administrators must spend 10 percent to 15 percent of revenues satisfying shareholders and paying taxes," said Guyatt. "For-profit providers cut corners to ensure shareholders achieve their expected return on investment."

Well duhh. As long-time readers know, my father spent his last years in a nursing home, one which was originally non-profit but was acquired by a huge for-profit chain. It was in the process of transformation from what had been a mission of caring to a mission of making money, and my family observed that first hand. The very compassionate and skillful long-time nursing director suddenly disappeared, and it was pretty clear why: she raised the issue of Medicare fraud, which was going on quite blatantly. Staffing diminished and as I have told you earlier, they tried zonking my father out with drugs so they wouldn't have to look after him, until my mother caught them at it and insisted that it stop.

Since his problem was dementia and he didn't have major physical problems, they were able to get him out of bed every day until close to the end, so he wasn't at risk for bedsores. But those are no joke. It's not a minor issue at all. They result when people are left unattended in bed and not repositioned for long periods. This is done to the most vulnerable among us in order to make money. Then the people who pocket the money contribute it to politicians to try to stop enforcement of standards of care or reimbursement policies that will cut into their profits.

That's evil.

plus ça change, plus c'est la même chose

The Preacher and the Slave, by Joe Hill

Long-haired preachers come out every night,
Try to tell you what's wrong and what's right,
But when asked about something to eat,
They will answer in voices so sweet:

Chorus:

You will eat bye and bye,
In that glorious land above the sky.
Work and pray, (work and pray),
Live on hay, (live on hay),
You'll get Pie in the Sky,
When you die, (that's a lie!)

And the starvation army they play,
They sing and they dance and they pray,
Till they get all your coin on the drum,
Then they tell you when you're on the bum:

CHORUS

If you fight hard for the good things in life,
They will tell you to stop all the strife,
Be a sheep for the bosses they say
Or to hell you are surely on the way!

CHORUS

Workingfolk of all countries unite;
Side by side we for freedom will fight
When the world and its wealth we have gained,
To the grafters we will sing this refrain:

Last Chorus:

You will eat, bye and bye,
When you've learned how to cook and to fry;
Chop some wood, 'twill do you good
And you'll eat in the sweet bye and bye.
(That's no lie!)

AND: What Johann Hari says:

Indeed, if you spend any time with American right-wingers -- as I have, reporting undercover on events like the National Review cruise and the Christian Coalition Solidarity Tour of Israel -- you soon find that your arguments don't center on philosophy. You have to concentrate on correcting basic factual errors about the real world.

They insist Europe has fallen to Islam, since Muslims immigrants are becoming a majority and are imposing sharia law. In reality, Muslims make up 3 percent of the population of Europe, and most of them oppose sharia law. They insist Franklin Roosevelt caused the Great Depression, and should have cut government spending. In reality, whenever he did cut spending -- as he tried periodically throughout the 1930s -- the economy began to tank. But explain this patiently -- with a thousand sources -- and they simply shriek that you are lying, and they know "in their heart" what is true. They insist gay marriage would cause the institution of the family to collapse. In reality, where it has already been introduced in Europe, heterosexual families continue just as before. On the list goes: evolution is a lie, a blastocyst is akin to a baby, torture produces actionable intelligence...

How do they train themselves to be so impervious to reality? It begins, I suspect, with religion. They are taught from a young age that it is good to have "faith" -- which is, by definition, a belief without any evidence to back it up. You don't have "faith" Australia exists, or fire burns: you have evidence. You only need "faith" to believe the untrue or unprovable. Indeed, they are taught that faith is the highest aspiration and most noble cause. Is it any surprise this then percolates into their political views? Faith-based thinking spreads and contaminates the rational.

Strong words

Many of you, like me, have had personal experiences with end of life decisions about loved ones. We are all justly outraged by the truly evil lies of Republican opponents of the current health care reform legislation, including prominent United States Senators as well as the usual gang of gibbering gasbags on the radio and TV, who have succeeded in persuading a substantial portion of the electorate that the provision to have Medicare pay for advance care planning is a plot to murder the elderly and disabled. Robert Creamer thinks it will backfire on them, but I'm not so sure of that. He writes:

In their attempt to enflame the powerful emotions surrounding the deaths of loved ones by spreading intentional lies, the Republicans have stooped to a new low. The Terry Schiavo case should have taught the Republicans that some emotions are too precious to be exploited for partisan political advantage. Apparently it did not.

But when Americans begin to discover just how far the Republicans have been willing to go to stop health insurance reform, they may receive a new lesson. Republicans will learn that combining those powerful emotions with deceit can create an explosive mixture that they will find impossible to forget.

The basic problem, I think, is that the "Christian" "culture of life" is not really about life at all. On the question of the beginning of life, the anti-choice movement is not fundamentally about the supposed sanctity of human life at all, it is about sexual repression and the subjugation of women. I have made that argument here many times and I won't recycle it. What I will concentrate on here is the end of life. Just as they deny human sexuality, these "Christians" try to deny death.

There have been numerous studies that find that people who are more religious, and who use religion to cope with terminal disease, are more likely to favor aggressive measures to prolong life such as feeding tubes and mechanical ventilation. Unfortunately, most of this research is in subscription only medical journals. (Much of this research has been framed in ethnic terms, as the citations below show; but that is really beside the point, it is religiosity which is the focus of these studies.) Quoting Andrea Phelps, et al in JAMA (March 18, 2009)

In a survey of 1006 members of the general public, 68.3% of individuals stated that their religious beliefs would guide their medical decisions if critically injured, and 57.4% believed that God could heal a patient even if physicians had pronounced further medical efforts to be futile.9 Religiousness and religious coping have been associated with increased preference for cardiopulmonary resuscitation, mechanical ventilation, hospitalization near death,10 and heroic end-of-life measures.1 It has been suggested that lower rates of advance care planning among minority patients may arise partly from spiritual appraisals of illness and healing (eg, belief that only God knows one's time to die).11-13

9. Jacobs LM, Burns K, Bennett Jacobs B. Trauma death: views of the public and trauma professionals on death and dying from injuries. Arch Surg. 2008;143(8):730-735.
10. True G, Phipps EJ, Braitman LE, Harralson T, Harris D, Tester W. Treatment preferences and advance care planning at end of life: the role of ethnicity and spiritual coping in cancer patients. Ann Behav Med. 2005;30(2):174-179.
11. Bullock K. Promoting advance directives among African Americans: a faith-based model. J Palliat Med. 2006;9(1):183-195.
12. Crawley L, Payne R, Bolden J, Payne T, Washington P, Williams S, Initiative to Improve Palliative and End-of-Life Care in the African American Community. Palliative and end-of-life care in the African American community. JAMA. 2000;284(19):2518-2521.
13. Johnson KS, Elbert-Avila KI, Tulsky JA. The influence of spiritual beliefs and practices on the treatment preferences of African Americans: a review of the literature. J Am Geriatr Soc. 2005;53(4):711-719.

This may seem odd: one of the most essential beliefs of devout Christians is that death is an illusion and they will be rewarded after death with a blissful eternity. It would seem to make little sense, then, that believers would insist on doing everything possible to delay death, even at the cost of great suffering. But perhaps that's because we're reversing cause and effect: people fervently believe in the afterlife because they cannot accept the reality of death. It's a last resort coping mechanism.

Well, sex and death are yin and yang, after all, and I'm not talking Freudian mysticism. Evolution has programmed us for death because that's the only way to make new generations possible and enable species to adapt. Until taxes came along, these were life's two great inevitabilities. Although we are built to desire sex and fear death there are downsides to both these instincts, obviously. Cultures suppress sexual behavior because it can lead to conflict and damage the social fabric if it doesn't flow in the right channels. And the fear of death is useful only so long as death can, in fact, be avoided. Then it becomes our greatest curse.

The best we can do, then, is acceptance. We have to accept the reality of sexuality and celebrate its expression as long as it doesn't infringe on the rights of others, endanger people, or violate promises. (And don't make 'em if you can't keep 'em.) And we have to accept the reality of death while doing what we can to keep it in its proper time and place. But Christian fundamentalism is, fundamentally, an exercise in denial. It's for people who can't accept things as they are. There is no reason to expect the Christian right to get angry when their preachers lie. That's what preachers are supposed to do.

A few worthwhile links

I hope to have time to get back to the Comparative Effectiveness Analysis tomorrow. Meanwhile, you can bone up on some of the issues with the help of your corporate media.

My hometown fishwrapper discusses CEA with a big picture of Peter Neumann, who runs the Tufts center for study of same. This article is not extremely enlightening -- it's written by incompetent hack reporter Michael Kranish, who does his usual job of mangling the issues and mistaking "balance" for analysis -- but it will give you something to think about and some introduction to the issues.

Meantime, two op-eds in the NYT are more worth your while. Richard Dooling names the truth that shall not be named:

IN the 1980s, I worked as a respiratory therapist in intensive-care units in the Midwest, taking care of elderly, dying patients on ventilators. . . . When the insurance ran out, or Medicare stopped paying, patients and their families gave the hospital liens on their homes to pay for this care. Families spent their entire savings so Grandma could make yet another trip to the surgical suite on the slim-to-none chance that bypass surgery, a thoracotomy, an endoscopy or kidney dialysis might get her off the ventilator and out of the hospital in time for her 88th birthday. . . .With so much evidence of wasteful and even harmful treatment, shouldn’t we instantly cut some of the money spent on exorbitant intensive-care medicine for dying, elderly people and redirect it to pediatricians and obstetricians offering preventive care for children and mothers?

Note that today, I am not venturing and answer to the question. I am just observing that some has asked it, in public. No doubt a howling mob will show up outside his house, and pelt him to death with teabags.

As usual, Krugperson explains it in terms even a Republican ought to be able to understand, but probably can't.

So I'll pick up on all this shortly and give you my own arrogant, scientific take.

Meanwhile, please oh please oh please: Michelle Bachmann will run for president if God calls her. Okay big guy in the sky, make that call.

And one more: Idiotic statement of the day department: "'The microbes have hopes, dreams and aspirations just like human beings. In their case, it's to infect other people,' said Dr. Howard Markel, a pediatrician and medical historian at the University of Michigan." Give that man a seroquel.

The two chief world systems

We go about our daily lives understanding almost nothing of the world. We give little thought to the machinery that generates the sunlight that makes life possible, to the gravity that glues us to an Earth that would otherwise send us spinning off into space, or to the atoms of which we are made and on whose stability we ultimately depend. . . . In our society it is still customary for parents and teachers to answer most of these questions with a shrug, or with an appeal to vaguely recalled religious precepts. . . .

Hawking embarks on a quest to answer Einstein's famous question about whether God had any choice in creating the universe. Hawking is attempting, as he explicitly states, to understand the mind of God. And this makes all the more unexpected the conclusion of the effort, at least so far: a universe with no edge in space, no beginning or end in time, and nothing for a creator to do.

-- Carl Sagan

Stephen W. Hawking, having heroically survived the efforts of Her Majesty's government to murder him as part of the UK's ongoing eugenics program, still holds the professorial chair at Cambridge University once occupied by Isaac Newton. He published A Brief History of Time in 1988. The above quotation is from Carl Sagan's foreword. One of our readers disputes the basic scientific picture of our universe and accuses scientists of "arrogance" because they do not accept the possibility that the biblical account of the cosmos and of history is correct.

This strikes me as a highly tendentious accusation because, obviously, preachers absolutely believe that they are correct and that people who disagree with them are not only wrong, but condemned to eternal damnation. That seems quite a bit more arrogant to me, especially when you recognize that scientists do not, in fact, hold absolute or unchallengeable beliefs, except for a commitment to a way of thinking.

Unlike religion, science is not a body of belief. It is a program of exploration. Religion forbids exploration. You are told what to think as a small child and from thenceforward, not the slightest deviation is permitted. Unfortunately, many people obey these oppressive ideologies and proudly proclaim that their minds are closed forever. I would urge anyone in that state to reflect anew.

While science always allows for the possibility that conclusions will change if new evidence is discovered, as we continue to explore the universe some findings become so convincing that it would be inefficient, indeed quite silly, to question them. For example, the moon certainly revolves around the earth, and the earth-moon system and all the planets certainly revolve around the sun. No sane person can doubt this because we have actually flown people to the moon and sent robots to explore all of the planets, and they arrived on schedule based on the assumptions about the mechanics of the solar system which guided their paths.

Yet this is contrary to the Bible. We know that the stars are objects like our own sun, and that they are not fixed in a crystal sphere or a firmament but scattered through a vast 3-dimensional space because we have telescopes powerful enough to resolve the nature of the nearby stars, and we have carefully measured the apparent change in position of nearby stars against more distant ones as the earth moves in its orbit. This is also contrary to the Bible.

I won't take the time here to explain how it is we know the earth is approximately 4.5 billion years old, but there is a simple way in which we know it is much, much older than the chronology in the Bible. This is because each year, in places such as Antarctica where the temperature never rises above freezing, the snow that is deposited each year is compressed by new snow that falls on top of it and eventually compacted into ice. Annual layers can be easily discerned in the ice because of seasonal changes in snowfall, temperature and subtler changes in the air which is trapped in the snow. That these layers truly are annual can be proved by correlating their contents with known historical events, particularly dust from volcanoes. At Vostok Station in Antarctica, Soviet and then Russian scientists have drilled an ice core which contains a continuous record going back 420,000 years. They stopped at that point for fear of contaminating a vast lake under the ice called Lake Vostok. If you don't trust Russians, U.S. and European scientists have drilled cores elsewhere in Antarctica and in Greenland.

Now, if you wish to dispute the conclusions of science, the first thing you have to do is to study science. You don't need to go to graduate school and get a Ph.D. A great deal of literature exists which explains the reasoning behind our understanding of cosmology and biology in terms which lay people can understand, although it may take a bit of work and concentration. For example, you can read Stephen Hawking's book. You can also read Darwin.

Unlike the vast majority of Christians, I have actually read the Bible, from cover to cover, more than once, in two complete translations and parts of others. Most Christians, were they to actually read the Bible, would be quite disconcerted, I am sure. It is filled with internal contradictions, moral depravity, and manifest nonsense, as well as a great deal which is just tedious and silly. Much of what it contains, I assure you, is radically opposed to contemporary Christian belief. (Marriage is between one man and one woman? Not according to the Bible! Abortion is murder? Not according to the Bible! Try reading it.)

Anyway, it is feckless to try to attack science by asking questions to which you do not know the answer on the assumption that scientists must not know either. For example, there is the old chestnut, "If people evolved from monkeys, why are there still monkeys?" Wrong on two counts, obviously. Scientists do not believe that people are descended from monkeys, but even if they did, that would not mean there could not still be monkeys. That is like asking, "If you are descended from your father, why is your father still alive?" Scientists do in fact believe that people are descended from fish (though not specifically any fish which are still extant), and obviously there are still fish. That may seem even more improbable to you than the idea that people are descended from monkeys, but if you study evolution and in particular try to appreciate the time scales over which it occurred it will become easier to accept.

Similarly, if I tell you that the solar system condensed from a disk of dust around the young sun, it is silly to challenge me by asking, "Where did the dust come from?" because I happen to know the answer. Hawking's book will tell you, but I will briefly explain that nuclear fusion reactions in the first generation of stars after the so-called Big Bang created complex nuclei such as the silicon, iron, oxygen etc. that make up our planet. Some of these stars exploded as supernovae, spewing these elements out into the galaxy where they became part of the mix that condensed into later generations of stars and star systems.

All of this understanding is very hard won. It is much easier simply to believe the stories that people made up in ancient times, when they didn't know very much. Also, when people make up stories, the stories are shaped, consciously or unconsciously, to seem intuitively persuasive and to provide us with comfort or to flatter our pretensions about ourselves. The truth has no such built-in appeal. It is what it is, like it or not, and so naturally some people resist it. But whether a story feels good or seems culturally or emotionally useful has no bearing on whether it is true.

That is the cold fact about the world. It is not here for our benefit, we just happen to be in it. It's up to us to make the most of it.

A repost

This is one of my greatest hits from a almost exactly three years ago. I'm reposting it now and then I'll have something to say about it before I get back to Cost Effectiveness Analysis. - C

In ancient times, people looked up at the sky and it appeared that the sun, moon and stars were revolving about them. The ancient Greeks studied the heavens more closely and noticed that, along with the sun and moon which wandered among the apparently fixed stars, there were a few stars that also wandered. Based on the geocentric assumption, Ptolemy devised a mechanical model of the universe in which the heavenly bodies were embedded in crystal spheres, rotating about the center of the earth. (By the way, the Greeks were well aware that the earth was spherical, and even produced a very accurate estimate of its diameter.) Obviously, something must keep the heavenly bodies from falling to the earth as everything does, but that something must be invisible, so crystalline spheres seemed to do the trick.

Over the ensuing centuries, closer observations of the planets challenged Ptolemy's model. They would acclerate and decelerate, even briefly reverse direction. The solution was to make the centers of their spheres themselves rotate about other centers, rather than being fixed. Even these solutions failed upon more exact measurements, and so the epicycles needed epi-epi-cycles of their own.

In 1514 the Polish mathematician Nicolas Copernicus gave a handwritten book to a few of his friends. In it he declared seven of what he called "axioms," though they are in fact deductions:

1. There is no one centre in the universe.



2. The Earth's centre is not the centre of the universe.<./li>
   
   
3. The centre of the universe [i.e., solar system] is near the sun.



4. The distance from the Earth to the sun is imperceptible compared with the distance to the stars.



5. The rotation of the Earth accounts for the apparent daily rotation of the stars.



6. The apparent annual cycle of movements of the sun is caused by the Earth revolving round it.



7. The apparent retrograde motion of the planets is caused by the motion of the Earth from which one observes.

In 1543, shortly before his death, he published the full elucidation of his theory under the title "On the Revolutions of the Heavenly Bodies." He had deduced a much simpler explanation of astronomical observations than Ptolemy's.

Galileo then used a new invention, the telescope, to make observations which conclusively proved the theories of Copernicus. For example, he observed the phases of Venus, which demonstrated that it revolves around the sun. He also discovered moons of Jupiter, which would have smashed its crystalline sphere, although neither he nor Copernicus had any way of explaining what else held the heavenly bodies aloft.

As we know, the Pope and his lieutenants refused to look through the telescope. They threatened to torture Galileo to death, in the name of Christ, if he continued to defend the Copernican system, and he relented. But the truth could not be denied. Kepler improved on Copernicus by determining that orbits were not circles, but ellipses. Newton developed a mathematical theory of gravitation which, among other achievements, finally demolished the conception of any "center" of the universe (a conclusion which Copernicus had somehow intuited, but not pursued). By the late 19th Century, improved telescopes and observational and analytic methods had made it possible to prove that the stars are trillions of kilometers from the earth, and are objects similar to the sun. By the 1920s, astronomers had determined that the stars occupy a volume a few hundred thousand light years across, the Milky Way galaxy, which they believed constituted the entire cosmos.

Then Edwin Hubble discovered that most of the objects known as nebulae are not, in fact, clouds of gas, but other galaxies beyond our own, millions of light years away. Then he discovered that distant galaxies are moving away from our own at substantial fractions of the speed of light -- that the universe is expanding. From this astonishing revelation, scientists were able to begin to deduce the history of the universe, and to speculate on its ultimate fate.

Our universe -- everything we can observe, that is, although quite possibly not everything that is or has been or may be -- is about 13 1/2 billion years old. The earth came along much later, about 4 1/2 billion years ago. The universe is so vast that there is no referent to human experience in the distance to even the closest star, while that distance is but a hundred thousandth of the width of the galaxy. The nearest galaxy (other than two small satellites of the Milky Way), Andromeda, is almost 3 million light years away.

Here is a portion of an image called the Hubble Deep Field, looking out in space and back in time nearly 12 billion years. This is a tiny piece of the sky, smaller than the end of a pencil held at arms length:














Each of the galaxies in the image -- and the tiny red dots are very distant galaxies -- contains on the order of 200 billion stars (as does our own).


These discoveries have smashed completely, and forever, the biblical cosmos. If there is a sentient creator of the universe, the purpose of the creation cannot have had anything to do with us. The universe is indifferent to our existence. A million galaxies like our own could vanish in an instant, and the universe would go on, not recognizably changed. This is the cosmos that we have discovered with our senses, and our reason, and our wondrous tools. But it is very difficult for most people to accept, and most people do not accept it. Two hundred thousand years of cultural development, of attitudes about the world, of explanation, of belief; the bedrock of the social order in religious authority, the answer to the terror of death and the futility of bereavement, the anchor of purpose; all swept away in a few hundred years, in a devastating avalanche of nearly incomprehensible truth.

It is no wonder that we are experiencing a turning away from reason, and truth, a flight into comforting darkness. Perhaps we have elevated such a limited, willfully ignorant man [i.e., George W. Bush] to our highest office precisely because his limitations are comforting. But the dark ages must be over now. If we are going to survive the challenges ahead of us, we must step out into the light, no matter how painful, and never turn back.

There is still a source of hope, of meaning, and purpose, and social order. That is, or course, humanity -- our astonishing selves. We are on our own, but that does not mean that we cannot find our own meanings, our own purposes, and succeed.

August, 2006

Credit where it's due department

I complained about them yesterday, but Rutenberg and Calmes have now written the story they should have written in the first place, in which they call the death panel assertions "false" and trace their provenance without fear or favor. They call it a "rumor," which isn't accurate, this isn't spreading by word of mouth or e-mail forwarding, it's being loudly asserted by prominent Republican politicians and media gasbags, but I will let them off the hook for that. I'm not sure I want to let them off the hook for giving a wackjob the last word, which seems to be obligatory in this sort of exposé, but at least we're making progress.

Nonetheless, if we are lucky enough to get some meaningful restructuring of our health care non-system past the screaming mob of liars, we are still going to have to confront the need for practice guidelines, and soon, if we want the reform to succeed. Sufficient unto the day is the evil thereof, and all we can do right now is say no, that isn't in the bill and hope for the best. But if you think this has been hard, it's just going to get harder. So let me try to prepare the ground by making some distinctions clear. I know, I know -- the conservative movement depends on confusing people by conflation among its extensive arsenal of dishonest tactics, and maintaining these distinctions in the face of journalistic corruption and laziness will not be easy. But let me make them anyway.

Number one, more efficient, less costly health care is not synonymous letting people die or go without treatment that might benefit them in some way. Sometimes we run into those difficult moral choices, but that's only a subset of the problem. There are lots of opportunities to get doctors to make choices that save money and benefit patients at the same time.

Here's a simple example, the Ottawa ankle rules. These are simple guidelines that a doctor in the ER can follow to determine if somebody with an ankle injury needs an X-ray. The only reason to take an X-ray is to find out if the person has a bone fracture. Otherwise you've got a sprain and you don't need a cast. X-rays don't just cost money, they're bad for you, creating a small but real additional risk of cancer. Unfortunately, these rules are not followed consistently, even though they are well known and well-validated. There are innumerable similar situations in which we can encourage more conservative approaches to treatment, reduce use of diagnostic procedures, and save patients time, spare them possible pain or risk, save money, and still get optimal results.

Of course, when we save money, that means somebody isn't getting paid, and that person isn't going to like it. So much of the opposition to "rationing" -- which is a good thing, it means allocating resources rationally -- comes from specialty physicians and medical device and drug companies. They're happy to use scare tactics about euthanasia and "bureaucrats" interfering in the sacred doctor-patient relationship if that's going to keep the gravy train running, but let's have no illusions as to what this is all about.

Second, as I wrote yesterday, there is a distinction -- a big one -- between Comparative Effectiveness Research (CER) and Cost Effectiveness Analysis (CEA). The president has encouraged the former, but he has been silent about the latter. CER does not consider cost, it just compares one treatment to another to see which one works better. It's hard to see how anybody can oppose that but they do. See the preceding paragraph. CER in fact does not necessarily result in any cost saving -- in principle, it can just as easily favor the more expensive treatment.

I don't have any empirical data on this, but I suspect that over time, the reality will be that CER does tend to constrain costs, and the reason is that without it, the system has a built-in bias toward excessive spending -- again, because that's how people make money. For example, last week's New England Journal of Medicine published two separate studies finding that a commonly used procedure called vertebroplasty has no beneficial effect. This is when surgeons inject cement into the spine of people with osteoporosis and micro-fractures. Sounds logical, but it turns out that all of the observed effect was a placebo effect. Obviously back surgeons don't like this result, but the fact is that a large proportion of what physicians currently do routinely isn't based on evidence, and we'd probably all be better off if they just did less stuff overall. Less is more.

Only now, after we've already worked through a lot of issues that are going to make drug companies and left kneecap surgeons scream and yell, do we come to actual difficult ethical problems. Cost Effectiveness Analysis, CEA, is where the excrement hits the ventilator. The basic set up for Treatment A vs Treatment B is like this:

Costs more, works worse | Costs more, works better
_____________________________________________________________

Costs less, works worse | Costs less, works better


Obviously, the treatment in the upper left-hand corner should not be used. The treatment in the lower right-hand corner, on the other hand, wins. It's the upper-right, lower-left diagonal that presents the problem. (These are equivalent, obviously, just exchanging Treatment A and Treatment B.) Here's where we need to ask how much more spending is worth it.

Honestly folks, nobody is even starting to talk about this problem in this country outside of wonks like my colleagues at the Tufts CEA Registry. You can find lots of info there. I will take this on in my next post.

The wonkish truth behind the death panels

It is a plain fact that there is absolutely nothing in any of the health care reform proposals currently moving in either chamber of Congress which in any way addresses limiting the use of approved drugs or procedures or forcing doctors and patients to choose one over another. Although as we have noted Jim Rutenberg of the New York Times considers charges that the legislation would impose rationing and euthanization to be "questionable," these assertions are in fact false. Of course reporters are not allowed to say that Republicans are lying. They can only say that about Al Gore.

Nevertheless, everybody who studies health care seriously knows full well that we do, in fact, need to have rational controls over the use of medical resources, because if we don't, the irrationality of the way resources are allocated will just continue to grow worse and worse. The problem is that the public is simply unable to confront reality in this area, and meaningful action has become politically impossible. There are four basic concepts that I think people need to understand in order to make sense of the problem. These are the fact of scarcity; the rule of rescue; comparative effectiveness; and cost effectiveness.

Uwe Reinhardt, the eminent health economist, writes:

The . . . opponents of cost-effectiveness analysis [include] individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

Reinhardt is invoking the fact of scarcity. The fact is that none of the people who are howling about euthanasia at the town hall meetings actually believes that life is "priceless." They think they believe that, but they don't. There are thousands of children dying every day whose lives they could save for five dollars apiece. Alright, they aren't thinking about those kids because they mostly have dark skins and live in faraway places, so let's talk about what they are thinking.

The Rule of Rescue is a moral intuition that most people have, which essentially says that no effort should be spared to save people in dire circumstances. We are emotionally drawn to these situations -- the miners trapped underground, the earthquake victims trapped in the rubble. But if you stop to think about it, the resources which are actually allocated to these situations are limited. If life were infinitely precious, nobody would ever go down in a mine in the first place. Certainly if they did, far more would be spent on safety than is spent in reality, and the drilling equipment needed to rescue them in the event of a collapse would be pre-positioned. That we accept peril in exchange for saving money is a commonplace of everyday life.

Let us suppose you got a survey in the mail and one of the questions was whether you agree or disagree with the statement that "Every patient should have access to effective treatments regardless of the cost." I think most people would agree. Then suppose you were given a specific case to think about. There's a cancer patient, and there's a treatment that costs $200,000. Do you think the person should be given that treatment if it will extend his or her life by 1 day? How about 1 week? 4 months? A year? I don't know what amount of additional life span you think justifies spending $200,000, but I do know that hardly anyone thinks it is worth it for 1 day. If I bumped the money up to $1 million, obviously, people would tend to need longer added life to make it seem worthwhile -- especially since we're presumably talking about somebody who is very sick with cancer and probably has a very poor quality of life to begin with. So there you have it -- you do put a monetary value on life.

And if you say you don't, then why are you drinking that double tall latte? You could be donating that money to save somebody's life.

Obviously insurance companies can't charge an infinite amount for premiums, they have to keep their product cheap enough that employers and the occasional individual will buy it. We know all the bad things they do -- kick off people with pre-existing conditions, drop people when they get sick. But they also limit what they will pay for, short of dropping you entirely. People don't want to pay infinite taxes for Medicare and Medicaid either. And guess what? If we did pay everything we have to keep very sick people alive for as long as possible, we would have a lot more sick people because we wouldn't have adequate food, clothing and shelter.

So we have no choice but to decide that when it comes to health care, enough is enough. Life may be priceless in some sense, but not in the financial sense. We can only do so much.

The president has talked about Comparative Effectiveness Research, and as a matter of fact he's gotten congress to pay for it through the stimulus legislation. But Comparative Effectiveness Research does not consider cost. It just compares one treatment to another to see which one works better. Drug and medical device manufacturers, and some medical specialists, don't like this because it makes it harder for them to sell stuff that doesn't work very well, but why hordes of screaming right wing Christians are opposed to it is very hard to understand.

Cost effectiveness analysis, on the other hand, which does consider costs, has not even been mentioned by the president nor is it incorporated in any legislation, although it is used in the United Kingdom and Canada routinely. They manage to live longer than we do even though they don't consider human life to be priceless. The reason is precisely because they put a price on it, which enables them to make rational decisions -- yes, to ration -- to use the resources they do have as effectively as possible.

Note, however, that they do not consider people's current state of health or disability. Steven Hawking, in spite of having ALS, gets health care. Rather, the consideration is the value added by the treatment. Since Trig Palin is a baby, presumably giving him medical care should he say, get cancer, will add decades to his life. Therefore, cost effectiveness analysis says we should spend a whole lot on him. That he has Down Syndrome is irrelevant. The issue is not the person, but the treatment and what is gained by it, regardless of who is treated.

But it is politically impossible to talk about this in the United States. As a result, we'll just keeping dying sooner than we have to, because we console ourselves with the illusion that we aren't rationing health care.

Public health roundup from today's JAMA

. . .with influenza in appropriate perspective. Some of it is open access, some of it is subscription only, as usual, but at least I can do a service by telling you uncredentialed rabble what's in it.

I have not neglected to tell you that the prevalence of dementia is almost 14% among people 70 and older in the U.S., and that means as the population continues to age we'll have more and more of it. It's a huge problem, not only because of the destruction of quality of life in what ought to be the harvest years, and the distress and burden on loved ones, but also because of the enormous expense, much of which is ultimately borne by Medicaid after life's savings are wiped out.

That's why it's so important that a study by Scarmeas et al finds that older people who stay physically active have a sharply lower risk for Alzheimer's disease. They found that this effect was additive with adherence to a so-called "Mediterranean" diet, with lots of olive oil and veggies and stuff, an effect which was not supported by a separate study by Féart et al, so the jury's out on that one, but the physical activity prescription looks pretty good.

That's why an essay by Michael Katz (sorry, you don't even get an abstract for this one) is so important. Katz points out that interventions focused on individuals to get them to do things like exercise more, eat right, not smoke, etc. are expensive and usually only mildly effective. However, so-called "structural interventions" can be very cost-effective. These are modifications of the social and built environment. Sewer systems and safe drinking water, for example, are responsible for much of the increase in longevity in the first part of the 20th Century. Today we can encourage physical activity by land use planning so that people live in neighborhoods where they can walk to shopping, school, and public transportation (a favorite cause of Atrios); safe parks; and even wider sidewalks. Other examples are workplace smoking bans, removing soda machines from schools, offering phys-ed in schools, designing schoolyards to encourage physical play, and so on. We already know these are ways of combating the obesity epidemic, diabetes and heart disease, but now we know they're good for combating dementia as well.

It turns out, as reporter Bridget Kuehn tells us, that stimulants given to kids to treat Attention Deficit disorder can kill them, specifically by causing sudden cardiac death. It's rare, but it happens. We already know they stunt growth and do other long-term damage. I think these drugs are grossly overprescribed and we really need to do something about it. But that's a longer story for another day.

Samet and Wipfli discuss "unfinished business in tobacco control." We've cut the prevalence of smoking in half in this country, but the goal needs to be to drive it to zero. Tobacco is still killing more Americans than any cause. Structural interventions have been the most effective here as well -- banning smoking on airplanes, in workplaces (especially restaurants and bars) and oh yeah, hospitals, actually encourages and helps people to quit. We've eliminated TV advertising and limited other forms of advertising and promotion. And we've raised tobacco taxes. But we haven't done all of that everywhere -- 39 states still don't mandate smoke-free restaurants. Insurance needs to pay for smoking cessation products, and we need to fund anti-tobacco advertising.

Oh yeah, influenza. Morens and Taubenberger review what is known of historical influenza epidemics and pandemics conclude that in fact, the widespread belief that there is a standard or typical pattern in which new strains of influenza first circulate in a mild form, then come back in a killer "second wave," is illusory. That has not been a pattern with most previous events, and it's not even clear that it really happened in the 1918 "Spanish flu" event which is the one that has people's knickers in a twist. They conclude:

Considering the long and confusing track record of pandemic influenza, it is difficult to predict the future course of the present H1N1 pandemic. The virus' modest transmission efficiency, the possibility of a degree of pre-existing population immunity due to prior cross-reactive viruses and vaccines, and its arrival in the Northern Hemisphere as summer approaches, all give reason to hope for a more indolent pandemic course and fewer deaths than in many past pandemics. . . . [P]andemic history suggests that changes neither in transmissibility nor in pathogenicity are inevitable.

Amen. This is no big deal folks. We have much bigger fish to fry in public health.

A theory disproved

I don't know how many of you are familiar with Peak Wingnut Theory, but essentially, as the likelihood of an Obama victory became clear, John Cole proposed that:

Sure, there is still lots going on- the Obama smears have been fast and furious, and there are lots of current attempts to mainstream nonsense (a solid example would be Jonah’s market analysis), but it all seems so yesterday. These days, there seem to be more than enough outlets to rebut the bullshit, the media is tired of being treated like morons, and the Democrats seem for once ready and itching for a fight. But most of all, the attempts just seem so feeble. In the past few days we have seen Red State put a front page post up about Obama’s birth certificate and NRO’s Andy McCarthy tried to convince us that William Ayers ghost wrote Obama’s books, but for the most part, they gained no traction and were laughed off by everyone.

Even then, there were doubters: "It pains me to disagree so strongly with both John and Glenn, but the idea that a crushing defeat will shame the fringe right into silence or even quiet them down a bit is simply crazy."

Well, we know who got that one right. We have yet even to sniff Peak Wingnut on the breeze from afar. No-one can even conceive of the limits of wingnuttery. Indeed, it seems increasingly plausible that wingnuttery is unbounded even by the cosmos, that it knows no limitations of time, space, or physical laws. If this is so, wingnuttery can expand forever, its ultimate extent is undefinable and even transcends countable infinity. Josh Marshall is training his Hubble Wingnut Telescope on the phenomenon and it is more awesome than The Great Attractor. E.g.

During a protest Monday outside the Anchorage office of Sen. Mark Begich (D-AK), demonstrators carried signs saying, "ObamaCare = Euthanasia" and "Kill the Bill or Kill the Seniors." "If we have ObamaCare, the older citizens will be euthanized," one protester said. When asked what part of the bill made her think that, she responded, "All of it."

"If they [senior citizens] need any health benefits, they will not be given the benefits because we're not productive anymore," another demonstrator said. The government will send a "representative," she said, "to let us know what we want to do in our last days, because we won't get any medicine, and medical help at all." She said she'd read the bill -- or at least "parts of it." "I read it online," she said.

Recall that John Cole thought that "the media is tired of being treated like morons." (Media is plural, BTW, but I'm just an insufferable pedant.) But we get this in the NYT -- today no less:

The White House on Monday started a new Web site to fight questionable but potentially damaging charges that President Obama’s proposed overhaul of the nation’s health care system would inevitably lead to “socialized medicine,” “rationed care” and even forced euthanasia for the elderly.

Uh, yeah, it's, err, questionable. You see, the problem is not that the media are treated like morons, the problem is that they are in fact morons. And as long as the loudest shouter, the most outrageous liar, and the most delusional psychotic get Fair and Balanced coverage, their screaming outrageous nightmare visions will sweep away the truth like a tidal wave.

And that's the way it is.

The Grim Reapublicker

The "Christian" right denies a whole lot about reality, including evolution, cosmology, the unsustainability of our current form of industrial civilization, the intrinsic nature and variety of human sexuality, and you can no doubt think of more examples. But for me, their weirdest denialism is denial of death.

You no doubt heard about Sen. Grassley claiming that under a universal health care plan, Sen. Kennedy would die. I've got news for you Chuck -- Sen. Kennedy will indeed die. And so will you, and so will I, and so will everything that lives, universal health care or no. According to Rep. Paul Brown of Georgia, countries that already have universal health care don't appreciate the value of human life, and they're busy "killing" old folks. (Of course, people in Canada and the UK actually live longer than people in the U.S. but since when did facts matter to these lunatics?)

This isn't anything new -- recall the Terry Schiavo circus. How very strange. These are people who believe their God voluntarily chose death at a young age, who are perennially enthusiastic about sending young men off to slaughter and be slaughtered in wars, and whose most essential belief is that death is illusory and will be followed, for them anyway, by eternal bliss. Nevertheless they see death as itself mortal, as an enemy that not only can be defeated, but must be fought tenaciously and relentlessly, with every resource society can muster, to the bitterest end; and that declining to do so is somehow profoundly evil.

This means that when people's brains have deteriorated to the point that they no longer swallow when you put food in their mouths, God almighty (who presumably brought them to that state) demands that you jam tubes down their throats and pump in a synthetic slurry of nutrients. If they stop breathing, you have to jam a tube into their windpipe and pump in air. If their body can no longer fight off infections, you have to stick a needle in their vein and pump in antibiotics. It matters not whether they are conscious, whether they can perceive or speak or know anything of the world around them. Their "life," their "human life," is sacred and of infinite value. Offering people the choice to decline such treatment is precisely equivalent to murdering them. Jesus said so. It's in the Bible, right?

Of course, that doesn't mean that the rest of us can be forced to pay for it. That would be socialism. But it needs to happen anyway. Somehow.

That's the "culture of life." That's the Christian belief. Weird, bizarre, and very very strange.

Update: There is no word in the language for stupidity so profound as this.

This time it's personal

Harold Pollack gives Sarah Palin more respect than she deserves by actually responding rationally to her claim that Barack Obama wants to murder her baby.

Of course we will face the same dilemmas over end of life care and how much is too much no matter whether we have a national health service, single payer national health care, the mixed up mess we have now, or the system Sarah Palin wants in which only rich people have any health insurance at all. What is unfortunate is that the problem of allocating health care resources is barely addressed in the current legislative proposals, not that it is addressed on the basis of eugenics. The issues have nothing to do with whether any individual's "productive potential" as Palin seems to think.

As long-time readers know, my father died early this year after a very long, slow, increasingly tortuous battle with dementia. My mother had to battle equally hard with the nursing home staff and the Medicare fraudsters they brought in to pretend to be physicians. Among other atrocities, against her specific instructions and contrary to a Black Box warning, they twice gave my father antipsychotics in order to knock him out so they wouldn't have to bother to look after him. She found him slumped in his chair and drooling both times.

Anyway, she had to come up with instructions as we knew the end was approaching and she didn't have anybody to talk with about it except me. Her own primary care physician was useless for that sort of thing. Fortunately, she happens to have a son who is a medical sociologist and who works in an academic medical center, which meant I could consult with my M.D. colleagues specifically about my father's as well as draw on my own training and extensive acquaintance with the relevant literature.

It turns out that the specific instructions she needed to give wouldn't be obvious to most lay people. No feeding tube we can probably all think of, but we wouldn't know whether we could be comfortable giving that instruction if we didn't know the science about what happens to people with advanced dementia when they stop eating. It's okay, really: they aren't hungry and if they don't drink, it's because they aren't thirsty. She also had to know, specifically, to request no intravenous antibiotics and no hospitalization. These were the right choices for my father, my mother, and all of us in the family, and they allowed my father to die peacefully when the time came.

Now if Sarah Palin or anybody else wants to make different choices, they may do so. She can have the feeding tube and respirator and the central line pumping in antibiotics while her cerebral cortex turns to dust if she thinks that will bring her closer to God. What she should not be allowed to do, however, is demand treatments that just don't work, for Trig or anybody else, and that the rest of us pay for them. But that's much too complicated for her to understand.

The two-party system

Modern democracies typically have parties organized around various interest groups and/or principles. Parliamentary systems tend to have more than two parties with substantial representation. Parliamentary electoral systems that explicitly provide for proportional representation may have a dozen or more. In the U.S., however, because of the winner-take-all presidency, we're pretty much doomed to have two major parties struggling to get the bigger half of the wishbone.

Because political interests and beliefs aren't organized along a single dimension, however, the major parties are generally coalitions. For example, the Democratic Party for much of the 20th Century was an awkward coalition that included northern labor unions, northern and Pacific coast urban constituencies including what we today call African Americans and white ethnic voters, "enlightened" capitalists who believed a secure working class provided the most fertile ground for profit, and southern white supremacists. That coalition obviously fell apart in the 60s when Lyndon Johnson endorsed the Civil Rights Act of 1964.

From there the Republicans -- formerly the party of less enlightened capitalists, the petite bourgeois, and their dupes -- happily offered a new home to southern racists, and soon became the chosen vessel for an ascendant Christian extremist political movement. The unenlightened capitalists and petite bourgeois were happy to have the company since their own numbers are obviously too small to be competitive electorally. They need one or more scams to get people to vote against their own economic interest, and they found some good ones in the cultural divides that emerged so sharply in the '60s.

But it has gotten to the point now that the fundamental division between the parties in this country is the nature of reality. The Republican Party is the party of delusion and lies. There are real interest groups that finance it, but the powers behind the Republican party don't encourage public discussion of their true objectives and political beliefs, for the obvious reason that it would cause most people to vote against them.

Instead they encourage the fantasies of religious fanatics (see the previous post), they incite racist passions, and they spew outrageous lies, "the true goal of health care reform legislation is to murder your grandmother" being a particularly droll example. The denial of anthropogenic global warming, basic scientific facts concerning biology and cosmology, and simple stuff such as the depletion of U.S. oil reserves are the very foundation of their system of delusion. Since it would obviously be counterproductive to allow a reasoned discussion based on these "principles," they send howling, violent mobs to civic events to prevent any rational discourse from taking place, among other tactics.

The Fair and Balanced corporate media treat this antidemocratic, anti-rational movement that is trying to lead the country into the 13th Century with profound deference and total seriousness. That is because the wealthy people who own the corporate media are among the small clique that is behind the whole scam in the first place. To be honest, I never would have believed such a stew of idiocy and madness could possibly become a threat to the democratic order, such as it has been in this country, but there it is. This is truly dangerous. What are we going to do about it?