A totally unnecessary observation

If some guy I don't know personally, who has no public responsibilities and no position of trust, wants to get in his Escalade at 2:30 am and crash into a fire hydrant, I do not give a FFOARD. Not my problem, not my business, none of yours either.

Blowing Smoke

For reasons I will not elucidate, I've been engaged in a thought experiment. Suppose that instead of writing a blog that a few people read when they are home sick and there's nothing on TV -- i.e., whenever they are home sick -- I had the opportunity, the privilege, and the responsibility of being the main conduit of information about public health and health care for a large community of politically active people. It would be my choices of subject matter and my interpretive slant that defined public health and the politics of public health for a million or more engaged readers.

How would I interpret my responsibility? How would I apportion the subject matter of my posts? What essential issues and ways of thinking about issues would I guide my readers to consider? There is no specific right answer to this challenge, but I consider it ethically compelling and I would think hard about doing the job in a way that served the common interest.

My answers are still developing, but here's what strikes me initially.

First, I would take a global perspective. In the scenario I am writing principally for a U.S. audience with a foremost interest in U.S. policy and politics, so I would emphasize issues of particular concern in the U.S. more than the 5% of the world's population we represent. But I would nevertheless work very hard to put our problems in context and to make time for problems that don't affect us in a direct and obvious way as well. That's both because my ethical perspective is that of a citizen of the world, a human first and an American second; and also because we are in fact interdependent and what happens everywhere does ultimately affect our own well being.

Second, I would organize all of my around the social determinants of health. The usual way to think about the determinants of health is to consider the social and economic environment, the physical environment, and people's individual characteristics and behaviors. But it is essential to recognize that these interact. People who are socially and economically disadvantaged generally experience less healthful physical environments, and have less healthful personal behaviors, not because they are irresponsible but because our behavioral options and choices are powerfully shaped by external influences. Health is strongly determined by social status and the health of whole societies is damaged by inequality. Public health is fundamentally about equity and justice: the most powerful way to improve the health status and life expectancy of populations is to reduce inequality and improve the circumstances of the disadvantaged.

So what diseases and risk factors would I tend to discuss the most? It depends partly on contingencies, of course, but you would, first of all, see a fair amount about the great infectious scourges of humanity -- HIV, TB, malaria, diarrheal diseases of children (mostly from unsafe water), pneumonia (strongly associated with the compromised immune systems of undernourished and chronically ill children). And there are numerous less prevalent but still very important infectious and parasitic diseases that place a huge burden on many populations such as leishmaniasis, river blindness, guinea worm, etc. So I would discuss those.

These are of considerably less direct importance in the U.S., however, so I would also emphasize our challenges at home. Tobacco control is still very high on the list, but obesity, physical inactivity and diet are right up there. If we don't act with a real sense of urgency, diabetes is going to overwhelm our health care system, and quite imminently. By the way, there is a strong social class component to both of these problems; and they are also very much driven by corporate greed and irresponsibility.

Other major issues for the U.S. include unintentional injury -- much of it motor vehicle related, but we still have important areas of occupational safety and health, and household safety, to address. Again, these are problems with a strong political component. Violence is also a huge problem, again with a class and caste differential but also with a gender dimension. Most violence in our society is hidden within families.

If you are particularly worried about children, remember that diabetes begins in childhood, tobacco addiction begins in adolescence, that millions of children in this country are victims or violence or witnesses to violence, and that the most likely way for a young person to die is in a car crash.

Universal access to affordable, quality health care is important, so of course I would discuss that, in its proper place and context. Health care is not in fact the most important determinant of population health, but it is more important than it used to be and anyway, this is a fundamental issue of justice. But it comes after truly basic needs -- safe and healthy housing, adequate and healthy diet, nurturing family and community, educational opportunity and the opportunity for meaningful and remunerative employment. By the way a rational drug control policy and emptying our prisons of non-violent drug offenders is part of that.

Global and local physical environments, free of dangerous human caused pollution and pathogens would be in my mix. Oh yeah, antibiotic resistance. Food safety. All sorts of smaller or highly specific issues that might come along. I'd try to mix it up, but keep it all within the framework of social justice, because that's where the politics of public health are rooted.

I think if I could pull that off I would have honored my privilege, opportunity and responsibility.

To the Uttermost West

As is common on these special occasions, I now depart for a primitive realm, isolated from the All Knowing Web. For the next three days, my knowledge of the outside world will be limited to what I can discern from the marks Bill Keller allows to be made on sheets of mashed up wood. I will be unable to experience DemFromCt's 645th consecutive post on the swine flu apocalypse and the post-civilization world into which it will soon plunge us all. I will return no doubt changed, my mind devolved to the more primitive state of human consciousness of the late 20th Century.

I will try to enjoy it. Probably back on Sunday.

Sorry to be a downer . . .

but in case you haven't noticed, this global climate change thang just keeps looking worse and worse. Here's the link to the "Copenhagen Diagnosis" report you've likely heard about, in which some of the world's leading climate scientists try to update policy makers on what we have learned since the Intergovernmental Panel on Climate Change (IPCC) Fourth Assessment Report was written three years ago. It has become clear that AR4, as it is affectionately known, was far too cautious. Ice sheets are melting faster than predicted, sea ice is diminishing faster than predicted, sea level is rising faster than predicted . . .

The bottom line is that even if anthropogenic greenhouse gas emissions were to completely stabilize at current levels right now and then be completely eliminated after 2030, warming would likely continue to above the 2 degrees centigrade generally considered to be barely tolerable. In fact, greenhouse gas emissions are continuing to grow, despite the global recession, and will undoubtedly rise even faster as India and China continue to industrialize. Not only that, but the prospects for positive feedbacks from lowered albedo as ice continues to melt, carbon emissions from thawing permafrost and drought-killed vegetation, and the reduced capacity of the ocean to absorb CO2, among other factors, means that we could well hit tipping points in which the planet shifts to a higher temperature regime which reduced anthropogenic emissions cannot reverse.

Allianz, a huge capitalist insurance company that employs not a single DFH, as far as I know, has teamed with the World Wildlife Fund to lay out some of the likely costs. They tell us:

The focus of climate change mitigation policy to date has been on "preventing dangerous anthropogenic interference with Earth's climate system". There is no global agreement or scientific consensus for delineating ‘dangerous’ from ‘acceptable’ climate change but limiting global average temperature rise to 2 °C above pre-industrial levels has emerged as a focus for international and national policymakers.

The origin and selection of this 2 °C policy threshold is not entirely clear but its determination has been largely informed by assessments of impacts at different levels of temperature increase such as those of the UNFCCC Assessment Report 4 (AR4). With few exceptions, such assessments tend to present a gradual and smooth increase in scale and severity of impacts with increasing temperature. The reality, however, is that climate change is unlikely to be a smooth transition into the future and that there are a number of thresholds along the way that are likely to result in significant step changes in the level of impacts once triggered. The
existence of such thresholds or ‘tipping points’ is currently not well reflected in mitigation or adaptation policy and this oversight has profound implications for people and the environment.

To say the least. The tipping points are related to the arctic sea ice, West Antarctic ice sheet, Greenland ice sheet, die back of the boreal forest, thawing permafrost, destruction of the Amazon rain forest, and changes in the climate system including the El Niño/Southern Oscillation phenomenon, and the West African and Southeast Asian monsoons.

I, for example, live in Boston. The rise in sea level here is likely to be more than half a meter by 2050, and even higher in the western North Atlantic. Seriously. According to the report, that will mean more than $25 trillion in property exposed to destructive floods, including $462 billion worth in Boston. That's tough -- we'll have to abandon a lot of property, some of our most expensive real estate will in fact be underwater. But it's going to be a lot tougher on poor people in the southern hemisphere and central Asia. The western United States may see major cities turned into ghost towns due to lack of water. (The URL appears to be mistyped, but the link should lead to the correct document.)

But you know what is going to happen at the climate summit in Copenhagen, right? Nothing. President Obama is unwilling to lead on this issue -- as seems to be the case for most of the urgent issues confronting us -- and his caution and reticence guarantee that nothing good will be done.

Catastrophic climate change will happen. It will not be stopped. We will just have to deal with it.

It isn't influenza, so who cares?

But I'm still going to link to this new and disturbing information about the growing prevalence of community-acquired MRSA.

Extending the Cure, a project of Resources for the Future, works to make sure we still have antibiotics that work. Yes, they are somewhat redundant and repetitive with my friends at Alliance for the Prudent Use of Antibiotics, but their writ is a bit broader than APUA's since they also focus on policies to make developing new antibiotics more attractive to drug companies. Antibiotics are not big profit centers because they are given in short courses of a week or ten days, so the drug companies would rather focus on pills you have to take for a long time, preferably the rest of your life. Of course, without antibiotics, a lot of us wouldn't have any rest of our lives. But I digress.

MRSA is, of course, methicillin resistant Staphylococcus aureus, a common pathogen that has acquired resistance to a major class of antibiotics called beta lactams, which includes penicillin-like drugs. For a long time, it has been a major cause of nosocomial (hospital-acquired) infections, but more and more it is found in people coming to the hospital, who picked it up out here in the real world. Not only is it antibiotic resistant, it seems to be more virulent than non-resistant strains and can lead to severe necrotizing infections (that destroy tissue) or septicemia and death. Ugh.

To quote the press release from Resources for the Future:

Over the length of the study, researchers found that the proportion of MRSA increased more than 90 percent among outpatients with staph and now accounts for more than 50 percent of all Staphylococcus aureus infections. The findings suggest that this was due almost entirely to an increase in community-associated strains, which jumped from 3.6 percent of all MRSA infections to 28.2 percent—a seven-fold jump from 1999 to 2006. Similar increases in inpatients suggest that these strains are spreading rapidly into hospitals as well.

MRSA kills an estimated 20,000 people in the United States each year. The superbug, which is resistant to most common antibiotics, can attack wounds and trigger potentially lethal blood stream infections. Community-associated strains, while generally less virulent and susceptible to more antibiotics, can still cause significant morbidity and mortality.

Unlike flu, this isn't going to blow over in a month or two. It's going to keep getting gradually worse and worse. It is appropriate that we pay attention on the anniversary of the publication of On the Origin of Species (yup, that was November 24, 1859) because this is an example of Darwinian evolution. Believe.

Grasping the Third Rail

I'm pretty sure I don't have to tell anybody how I feel about the explosion of idiocy occasioned by the new recommendations on screening mammography from the Preventive Services Task Force. Said idiocy extended across the full political spectrum and included many people -- from Dick Durbin to Debbie Wasserman Schultz -- who really, really ought to know better. Is it really smart politics to endorse Sarah Palin's depraved rantings? Because that's what they're doing.

This just proves how deeply embedded in our culture is the faith that more medical services must be better. Detecting "cancer" -- and by the way applying that label to many of the lesions found using screening mammography is debatable -- and treating it is equal to "saving lives," in the collective consciousness, so passing up a chance to do it means killing people. That someone could look at reality -- you know, the actual true world out there that we inhabit -- and do calculations, in good faith, that demonstrate that you do more harm than good by one or another form of medical test or intervention, and make a reasonable recommendation not to do so, is just inconceivable to people.

Norton Hadler's first rule of rationing is pretty simple: "If some medical or surgical act does not advantage me or my family or my patients, it shouldn't be done. I don't care how well it is done, how cheaply it is done, how efficiently it is done; if it doesn't work, don't do it." Yet we can't even accept that seemingly obvious advice. Comparative effectiveness research, which only aims to answer the question of whether an intervention does any good at all, or is better than alternatives, is equated by a large segment of the political class with Nazi eugenics, a position with which the corporate media does not, generally, take issue.

There is the occasional exception, I am happy to say. You may have seen or read about the pretty good 60 Minutes story last night on end of life care. They actually tell the tale of a dying woman who was given a pap smear. Well, it's the standard of care, right?

The basic moral proposition that death is the greatest enemy of humanity, that death can and should be conquered, and that we can and must spend unlimited resources to conquer death in the case of any given identifiable individual, no matter how desperate the straits, is the essential basis of political opposition to any form of health care reform. Even if this made sense, of course, it would not be a logically defensible reason to oppose any current legislation, but we don't even get that far with many people because their judgment is obliterated by the specter of somebody "rationing" life. How very odd that this delusional and anti-humanist position is associated most strongly with people who believe that death is an illusion and they are all going to eternal paradise.

I don't get it.

Update: Regarding the screening mammography issue, Kathy's story in the comments is actually a good illustration of an underappreciated reason for the growing caution among experts about screening. The most dangerous, aggressive cancers are unlikely to be detected early by screening because they grow too fast, in other words you're likely to have a negative mammogram and then come down with a palpable tumor a few months later. Most of the tumors detected by screening are of unclear importance: they might some day cause life threatening disease, they might just sit there and do nothing, they might in fact disappear. But when we find them we have to treat them, for better or for worse. Therefore finding more of them earlier is not necessarily a good thing. Now, the day may come when we have ways of distinguishing among lesions that will and will not become dangerous; or very quick and easy ways of eliminating early stage tumors without side effects or risks. When that day comes, early and often screening will make more sense. But that day isn't here. Medicine isn't miraculous, it's just a lot of stuff that we know and a lot more that we don't know. Sometimes, it's best to leave well enough alone.

Health Equity is Health, Period

I believe I may have mentioned here at one time or another that the amount of inequality in society is related to health status and longevity, regardless of the absolute level of material wealth. In other words, unequal societies are less healthy not only because they have more poor people, but just because they are unequal. Poor people in the United States have far more in the way of material resources than poor people in poor countries, but their health is still impaired.

Although I have long found the evidence for this conclusion convincing, it has remained controversial among those who are not such know-it-alls as I. But now some folks in Japan and Boston have pretty much nailed it down. (BMJ makes its peer reviewed research open access, but not the editorials, commentaries, and news reports which are usually more interesting to general readership. Annoying.)

The article is a bit technical, but in a nutshell, it's what's called a meta-analysis. That means they pooled data from many studies and analyzed it together. What they find is that an increase of .05 in an index called the Gini coefficient of income inequality is associated with an 8% increased mortality risk, but that there is a threshold -- the effect appears when the Gini coefficient is above .3.

The Gini coefficient is actually not very difficult to understand -- here's the Wikipedia article. Essentially, if income were exactly equal, then a graph plotting percent of national income against percent of population would be a perfectly straight, 45 degree line. With inequality, the line is curved, starting out nearly horizontal and becoming more vertical as you move right into the higher income part of the population. The Gini coefficient is simply the area between the curved line and the 45 degree straight line.

You won't be surprised, I'm sure, to learn that the United States has a fairly high Gini coefficient among the OECD countries. Half of them are under .3 and so have no excess deaths due to inequality per se, according to this analysis. (Examples include the Scandinavian countries Switzerland, Germany and France. You know, those socialist dungeons.) Canada, Ireland and Australia are barely above .3 and so their population attributable deaths are barely noticeable. The U.S., however, has a Gini coefficient of .357 and these authors attribute nearly 884,000 premature annual deaths in this country to inequality.

Here's a ranking of the planet's countries by Gini coefficient. It uses a different source, the UN, which gives our Gini as .4 (multiplied by 100 in this listing and reported as 40). That's more unequal than, for example, Trinidad and Tobago, Yemen, Uzbekistan, and Kazakhstan, not to mention Laos, Indonesia, and Guinea. It's identical to Ghana. And of course, it's getting worse.

Of course, we're still the greatest country on earth.

Yes, I am worried

The most dismal exponent of the dismal science, Nouriel Roubini, remains in full gloom mode. The gist:

[I]ncome and wealth inequality is rising again. Poorer households are at greater risk of unemployment, falling wages or reductions in hours worked, all leading to lower labour income, whereas on Wall Street, outrageous bonuses have returned with a vengeance. With the stock market rising and home prices still falling, the wealthy are becoming richer, while the middle class and the poor – whose main wealth is a house rather than equities – are becoming poorer and being saddled with an unsustainable debt burden.

So, while the United States may technically be close to the end of a severe recession, most of America is facing a near-depression. Little wonder, then, that few Americans believe that what walks like a duck and quacks like a duck is actually the phoenix of recovery.

Roubini fears that the U.S. working class will never recover from its losses in the Great Recession. And he makes a strong case. The suffering in this country is palpable. Hunger and want are growing in the land. The Hoovervilles -- shantytowns -- of the 1930s are appearing again. And it's just going to keep getting worse.

Astonishingly, the Obama administration and the Democrats in congress seem utterly unaware of what is happening in this country. They don't talk about it, they don't seem to want to do anything about it, while the political opposition right now is extremist, bellicose, and irrational. Does it remind you of a period in German history in the past century? If the sane party doesn't wake up right now, we risk a political debacle more ruinous than our present economic disaster.

I don't know if any of this is any good . ..

I don't have time to check it out, but I got an e-mail about a set of links to Open Courseware classes in public health and health care-related subjects. I do know this is legitimate because the Epi and Biostats course was created here and the listed faculty are real people who I know. They present all this as being a way to learn about health care reform but it is far broader than that.

If anybody cares to try any of it, please let us all know what you find.

The FDA works in mysterious ways

No, I don't quite understand this myself. The FDA has long recommended that you dispose of left-over medications by mixing them with something disgusting, e.g. used kitty litter, putting them in a zip-lock bag, and tossing them in the household trash. This may not be the absolutely ideal thing to do but it seems practical. They'll end up in a landfill and pretty much just sit there till the last ding dong of doom, is the idea.

But now they have decided that there are some drugs which are just so horrifically dangerous that you should introduce them into your septic tank or municipal sewer system via the ceramic throne. All but three of the drugs on this list are opioids. For some reason the most commonly prescribed opioid, hydrocodone (commonly sold in combination with acetaminophen as Vicodin) is not on the list.

One of the other three is methylphenidate (Ritalin) which as you probably know is widely prescribed to children who don't like to sit quietly for hours on end concentrating on boring tasks. Its mechanism of action is similar to that of cocaine.

The other two items are kind of peculiar, and rarely prescribed. Diastat is diazepam (Valium) in the form of a suppository, which is prescribed for people with a rare pattern of seizures. Xyrem is gamma-hydroxybutyric acid, also known in some circles as GHB, liquid ecstasy, or the date rape drug. It is prescribed to people with narcolepsy.

The FDA doesn't really explain why you should flush these particular drugs and no others. They say something about them being especially dangerous to have around the house, but why that means you should flush them instead of doing the kitty litter thing -- well, it doesn't seem to follow. And if Ritalin is so dangerous to have in a household with children that it requires urgent disposal, uhh, well, it's normally prescribed to children and they normally carry it around with them. Hmm.

A more plausible theory is that your kids might take these drugs with them to a party, or sell them in the schoolyard, but the FDA doesn't want to say that out loud. Somebody might just be tempted to pick them out of the kitty litter for those purposes, hence the flushing. The exception would seem to me to be the Valium suppository, which I can't see having a great deal of recreational appeal but maybe I'm just unimaginative. But then we would have to ask why the more common Valium pills aren't included.

Personally, unless there is something more the FDA isn't telling us, I think this is basically nuts. I don't suppose we'll ever get high enough concentrations in the water to zonk out the fish, but I don't think we really know what the environmental effects might be. Meanwhile, assuming my guess about their real motivations is correct, this does point to an underrecognized problem. We have an epidemic of prescription drug abuse among young people in this country, fueled in part by pilfering from the medicine cabinet. Unfortunately, some kids get hooked. The street price of these drugs is high, so many of them end up turning to heroin, which is very cheap since the U.S. invaded Afghanistan and the country resumed exporting its number one cash crop.

Interesting bit of Kremlinology here, that's all I can say.

That old holism/reductionism thing . . .

My friend Dena Rifkin, who recently completed a fellowship at Our Glorious Institution before moving to San Diego (I guess she wanted to go to Sea World, I dunno) has an essay in the NYT that I commend to your attention.

There has been a multifaceted movement underway for some time now to have doctors, practices, hospitals and whatever kind of institution or subset thereof document adherence to practice guidelines, process of care indicators, and/or outcomes. These efforts may be framed in terms of patient safety, evidence based medicine, realignment of incentives from volume to performance, or some mashup of the above. As I have noted here, or at least I meant to at some point, these sorts of schemes are essential if we're going to have meaningful payment reform that reins in wasteful and even harmful overtreatment, while making cost-effective and preventive care happen when it's supposed to, and gets us all something closer to our money's worth for our health care dollar.

In my own words, Dena's caveat is analogous to the much-decried problem of teaching to the test in education. Teachers who concentrate on maximizing students' ability to check the right boxes on a standardized test, because that's how their own performance of that of their school are assessed, may not be teaching critical thinking, appreciation of the arts and humanities, or promoting emotional intelligence and the diverse talents and interests of their individual students. Doctors who focus on the checklist may end up failing to treat patients as people, failing to listen and respond humanely, and might even make diagnostic errors because they don't take an adequate history or appreciate people's social context.

Some of my physician colleagues here complain about a lesser but still noteworthy problem, that having to document process of care indicators forces them to go through some ridiculous ceremonies that probably don't really harm patients, but aren't the best use of anybody's time. And then there are people with serious co-morbidities that make some process indicators simply absurd. Should you really get docked for failing to meet the cholesterol control target of somebody with terminal cancer? The way these things work now, you just might.

These are genuine concerns. It is important to have a standard metric, for both educational and medical excellence. We need to have accountability and comparability in both fields. But both fields also combine art and science, and deal with the extremely complex entities call human beings who cannot possibly be properly served by focusing on a one-page list of prescriptions and targets. Somehow we need to find an approach compatible with both the reductionist and holistic goals of the enterprise. I don't have a magical answer, but I do honor both sides.

Waste, fraud and abuse

Ronald Reagan used to blame government spending on poor people, who were supposedly ripping off Medicare, Medicaid and welfare programs. There is indeed a lot of ripping off of the government going on, but it's not the beneficiaries, it's doctors and nursing homes and medical device manufacturers.

The Obama administration is trying to make a more effective effort to detect and deter Medicare fraud, but I'll tell you right now it's going to be very difficult unless we have a major reform in how we reimburse for medical services. The kinds of frauds they can detect are only the tip of the iceberg. Once people go into nursing homes, the operators can bill for all sorts of unnecessary services, which they don't even have to actually provide, and all they need is a crooked physician to sign off on it and split the loot. I know this from personal experience. And the boundary between outright fraud and just questionable judgment is sufficiently difficult to establish that even if they got caught it would be hard to hang charges on some of these sleaze dogs.

As a matter of fact, private insurance is subject to a certain amount of similar gaming. This is anecdotal, but I'm sure it's pretty common. I had friends who took their child to a hospital for a procedure, and they found his pediatrician hanging out in the waiting room. The pediatrician chatted with them for a minute, and the next time they got an insurance statement, he'd billed $350 for a consultation. And no, he had nothing to do with the procedure, he was just vulturing on the opportunity.

This sort of thing will continue as long as we pay doctors to do stuff instead of paying them to take care of people. It's sad but true that physicians are human. They're just about all subject to unconscious pecuniary influences, and a certain percentage of them -- probably about the same percentage as people in other occupations -- are thieves. The problem is, we give them absolute authority to decide what is appropriate for particular patients. If they want to make money off of us first and heal us second, they can do that. In Canada and the UK, however, they can't, certainly not to nearly the same extent. (In the UK, they are on salary; in Canada, the single payer has access to 100% of the claims of all practicing physicians, and can detect strange patterns.)

Just one more reason why we need universal, comprehensive, single payer national health care.

There will always be an England

A commentary by Tony Delamothe in the new BMJ led me to an interesting editorial from earlier this year in the Journal of Psychopharmacology, by DJ Nutt. Alas, this is all closed access, which annoys me no end. Anyway, Nutt is concerned with the relative harms of various drugs of abuse. He writes:

The dangers of equasy were revealed to me as a result of a recent clinical referral of a woman in her early 30’s who had suffered permanent brain damage as a result of equasy-induced brain damage. She had undergone severe personality change that made her more irritable and impulsive, with anxiety and loss of the ability to experience pleasure. There was also a degree of hypofrontality and behavioural disinhibition that had lead to many bad decisions in relationships with poor choice of partners and an unwanted pregnancy. She is unable to work and is unlikely ever to do so again, so the social costs of her brain damage are also very high.

So what was her addiction – what is equasy? It is an addiction that produces the release of adrenaline and endorphins and which is used by many millions of people in the UK including children and young people. The harmful consequences are well
established – about 10 people a year die of it and many more suffer permanent neurological damage as had my patient. It has been estimated that there is a serious adverse event every 350 exposures and these are unpredictable, though more likely in
experienced users who take more risks with equasy. It is also associated with over 100 road traffic accidents per year – often with deaths. Equasy leads to gatherings of users that often are associated with these groups engaging in violent conduct. Dependence, as defined by the need to continue to use, has been accepted by the courts in divorce settlements. Based on these harms, it seems likely that the ACMD would recommend control under the MDAct perhaps as a class A drug given it appears more harmful than ecstasy.

Equasy is, a you may already have guessed, the practice of riding horses. Ecstasy (MDMA) is associated with acute adverse events in 1 out of 10,000 exposures, in other words horseback riding is almost 30 times more dangerous.

Professor Nutt, unfortunately, made a serious mistake. While his analysis is factually correct, it turned out to be politically incorrect. He was summarily dismissed as Chair of the British government's Advisory Council on the Misuse of Drugs, as the Home Secretary was "profoundly disappointed" by the editorial. Nutt responded that "Politicians believe that if they think something, it is true." You can read about the brouhaha here.

The fact is, we just cannot have a rational debate about "drug" policy, either here or in the UK, because ideology consistently trumps truth in this field. Our jails are bursting with people, mostly poor African American and Hispanic men, who are non-violent drug offenders. White people use "drugs" at higher rates, but don't go to jail for it. And believe me, a whole lot of perfectly legal activities are considerably more harmful than use of most illicit drugs. It makes absolutely no sense, in fact it is eroding the fabric of our society.

Science for Sale

This has gotten a bit of coverage in the corporate media, but they don't do a particularly good job of explaining, so I'll take a shot. Abstract only for the common folk, I'm afraid, but Dr. Vedula and colleagues, taking advantage of discovery in lawsuits against Pfizer and Parke Davis got documents pertaining to studies they had sponsored on the drug gabapentin (brand name Neurontin). They have been naughty indeed.

As regular readers know, once a drug has FDA approval there is nothing to stop doctors prescribing it for purposes other than the ones for which it is approved. However, drug companies are prohibited from marketing drugs for "off label" purposes. However again, there's nothing to stop them from doing studies of the drug for off-label purposes and getting those studies published, without bothering to go through the more rigorous requirements of actually getting approval for said purposes. However yet again, there are plenty of ways to get studies published in order to create an impression that a drug is useful for some purpose whereas you haven't actually proven any such thing. But you can make money if you make doctors think your drug is useful for all these off-label indications and prescribe it, even though you're just bamboozling them. But who cares about the health and well being of patients when you can make money off of them, right?

So here's the basic technical concept behind cheating. If you do an experiment in which half the people get the drug and half get the placebo, there will be differences between the two groups just because of random chance. So-called statistical significance is a calculation, based on the size of the two groups and the size of an observed difference, of the probability that the difference is due to chance -- a number called p. If it's less than 5%, by convention, we accept that there's a real difference. Yes, that's arbitrary, and there are better ways to assess whether a drug is really useful, but that's the basic starting point.

This only works, however, if you specify exactly what effect you are looking for ahead of time. If you just go ahead after the fact and make a bunch of comparisons between the two groups, chances are something will be different, but the p value for that difference will be bogus. You were just fishing, you happened to find something that is probably purely coincidental, but you can always lie and say that's what you were looking for all along.

Well, that's what Pfizer and Parke Davis did. Actually they did even worse than that. Gabapentin is approved to prevent seizures, but that's not a big market, so the drug companies wanted to be able to sell it for more common problems, specifically migraines, bipolar disorder, neuropathic pain (pain from nerve damage), and nociceptive pain, i.e. what in the vernacular you might call "real" pain, from damaged tissue. So they did a bunch of studies. However, if the study did not find the drug was effective for the primary, pre-specified endpoint, they tried to find a difference in the positive direction for some other end-point. If they succeeded, they lied and said that was what they were looking for all along, and published the study. If they couldn't come up with something, they just didn't publish the study at all.

That way, they hoped to bamboozle doctors into prescribing the drug to people for whom it probably wouldn't work. They have had to pay fines because they were caught doing off-label marketing in this case, but those fines are just a cost of doing business. As Dr. Vedula et al tell us, this stuff undoubtedly goes on all the time but we're just lucky enough to have caught them at it in this one case. Since they aren't trying to get FDA approval, they don't have to register their trials in advance, make any raw data available, or make unpublished studies public. So they can cheat all they want. And they do.

Scum of the earth.

Treasure your endosymbionts

I don't mean to cause any identity crises, but you aren't an organism, you're a whole biome of ecosystems. (You can get the abstract only of the original article here.)

Costello et al have mapped the 100 trillion or so microorganisms inhabiting the bodies of each of several volunteers. There are distinct communities in various places, from navel to knee to gut. And you are distinctive -- the composition of these communities varies from person to person as well, although each individual's various ecosystems tend to be fairly stable.

I hope you aren't paranoid about germs -- these little guys are your friends. They keep the bad guys from taking over. Take it from me, because I've had two separate bouts with opportunistic infections that resulted when antibiotics wiped out some of my own little buddies. Once I got candidiasis -- a thrush infection -- in my throat after I took a course of antibiotics for an ear infection. The other time was much worse, a bout with the horrific C. difficile (y es muy difícil, take it from me) when I was hospitalized after surgery and the powerful antibiotics they were continually pumping into my veins wiped out the symbiotic colony in what was left of my colon.

So this is one more example of why more is less in medicine. Sometimes antibiotics really do save lives or prevent serious consequences such as amputations or rheumatic fever. But taking them when you don't need them is double plus ungood. Avoid them if you possibly can (but not if you can't!). I once again commend to your attention my friends and colleagues at the Alliance for the Prudent Use of Antibiotics. By reserving antibiotic use for when it's really, really needed, you will not only be taking care of your endosymbionts and therefore your own good health, you'll be helping to preserve the usefulness of antibiotics for all of humanity.

Oh yeah, don't eat factory farmed meat either. Antibiotic abuse in factory farming is just one of many good reasons.

Dear Joe Lieberman: Educate Yourself

I could write a book about why competition among private insurers is bad for consumers, gives you less choice, worse health care, and costs you more money, but let me start with one simple example that everybody can grasp, which I think is very powerful.

My previous insurer, which happened to be Blue Cross/Blue Shield of Massachusetts, charges $250 for a colonoscopy in its standard plan. That's a pretty standard copay for what is classified as outpatient surgery. It is more than enough money, obviously, to discourage a lot of people from getting one. Every foregone colonoscopy saves them quite a bit of money, since the provider is probably charging them close to a grand. It means they can offer a lower premium compared to a hypothetical competitor that charged a more affordable co-pay, or none at all.

Now, Republicans like to argue that co-pays like that are good, because they make us think twice about getting health care services and will therefore combat overutilization and keep overall costs down.

Sadly, no. It is difficult to imagine that anyone would go out of his or her way to get a colonoscopy that wasn't medically indicated just because it was cheap. We would only consider undergoing such an onerous experience because our doctor told us it was in our own best interest. The $250 can only make us refuse.

Some readers may dispute this, but it is generally accepted by the people who study these matters that screening colonoscopy, starting at age 50 and then at intervals depending on what is found the first time, is highly cost-effective from a social standpoint. It can actually prevent cancer from occurring in the first place, because the doctor removes pre-cancerous lesions during the procedure. That puts it way ahead of a mammogram. And it can detect cancers at an early stage when they are highly curable, whereas colon cancer detected after it becomes symptomatic is very bad news indeed.

So why doesn't the insurance company want me to have a colonoscopy? Because they figure, by the time I get cancer, I won't be their problem any more. I'll probably be on Medicare, actually, but even if I'm not there is a very good chance I will have changed jobs and be on a different private plan. (As indeed turned out to be the case.)

So what is cost effective from the point of view of society as a whole is that there be no cost barrier to getting a colonoscopy; when it's indicated, people should do it, because the cost is well worth it and indeed, it might even save money in the long run. But that is not cost effective from the point of view of the insurance company, which doesn't want to pay for my colonoscopy on the pretty good bet that ultimately, they won't have to pay for my cancer.

Guess what makes that problem go away? Universal, comprehensive, single payer national health care.

lecture notes

I'm trying to put together a talk for next Monday evening in Connecticut about a subject that would actually be simple but is complicated only because there are some seriously false assumptions deeply embedded in our political culture. The outline is something like this:

1. All the stuff you already know about how we spend more on health care than anybody else, but have the worst health and life expectancy of any developed country (and worse than some fairly poor ones), the least satisfaction, highest out of pocket costs, most trouble getting an appointment, and alone among wealthy countries, leave 15% of the population with no coverage at all.

2. The discussion of this problem is seriously warped because people believe in the fictitious economic theory they are taught in college. None of the assumptions underlying the theory of the Glorious Free Market are true, there is no such thing as a Free Market and never will be, but in health care it's even more obvious.

2.1 BTW, health care is a mixed good -- it has (or at least can have) positive externalities that are at least as valuable as the benefits to the recipient. We spend too much, yet at the same time, we manage to underproduce.

3. Paradox is explained in large part by provider-induced demand combined with pernicious effects of the insurance market . . .

4. Competition among insurance companies is bad. It does not produce efficiency or choice or consumer sovereignty, but rather medical underwriting (charging more or not offering insurance at all to people of high risk, no coverage for "pre-existing" conditions, and rescission); annual and life-time caps on benefits; limited benefits (e.g. no dental and no mental); and high co-pays and deductibles intended to discourage utilization.

5. Even the bogus economic theory does not predict just outcomes, but health, and the need for health care, are obviously determined unjustly. Nevertheless, we all grow older and will need more as time goes on. That's one purpose of insurance -- to spread risk and cost and help fix the injustice of the universe.

6. That requires getting everybody into the same pool. Yes, young healthy people will have to pay more than they may be paying now, but they all hope to be older and less healthy some day. It also requires that everybody be required to participate (or those young healthy folks won't), and that low income people get subsidies. But this cannot happen without government intervention.

7. Controlling costs and achieving high quality, however, requires more than universal coverage and community rating -- it requires a radical reorganization of the health care institution and how we pay for health care. That's not in the bill, and it means big trouble down the road if we don't start working on it now.

8. There is no conflict here between justice and liberty, because if I exercise my liberty not to participate today, and only choose to participate when it suits me (presumably because I'm now older and/or sicker), it will cost everybody else money and reduce their liberty. We are only free when we have a modicum of justice.

Now, I have to open up all those points and prove them and knit them together. And I have to be entertaining in the process. We'll see what happens.

Drive-by blogging

Another busy day (I had a meeting all morning that went an hour over time, three papers to write, two students needing recommendations, another student needing a paper critiqued, two proposals to write -- you get the idea). Anyway, a couple of links to commend to your attention.

Sense about Science is one of those most excellent UK projects that the U.S. is just too good for. They do their best to make scientific issues of public interest and of relevance to public controversies accessible. For example, here's their backgrounder on population screening for cancer and other diseases. If you want a reasonably in-depth but also accessible primer on some of the issues I often discuss here, this is a great resource.

Then of course there is the U.S. health care system, "The Greatest In All The World," sayeth the GOP, and if you don't agree you must look French and wear treasonous Birckenstocks.

Why then, when the Commonwealth Fund (Commonwealth, eh? Sounds socialistic to me) surveys primary care physicians in 11 countries, the U.S. comes in last on:

* Electronic health information capacity (yep, we're the lowest tech around);
* After-hours access to care without going to the ER;
* Percentage of patients who have difficulty paying for medications;
* Amount of time doctors spend trying to get access to treatment because patients aren't covered for it.

The U.S. also ranks low, though not last, on performance incentives, use of patient-centered chronic care models, and other innovations to make medical care more efficient, effective, and better at meeting people's needs and preventing serious consequences of chronic disease. It's the same old story -- we're still spending the most, and getting the least. We're losers. We're the pits. And we seem to be proud of it.

Okay, people have been asking

Why don't you write more about your own research? So say the masses. Well, partly it's because of the weird rules about discussing stuff that hasn't been published yet. So, while this may not be the greatest thing since The Revolutions of the Heavenly Bodies, it has been published, and best of all, it's open access. (It's kind of hard to explain, but being listed last is a funny privilege I don't quite deserve in this case. The main thing you should know is that Doug and Tim started the project and I came in to deal with the Spanish language material and participate in the interpretation and writing.)

Most of the work I'm doing now is more wonky and quantitative than this, but I also do keep up with the qualitative work. The major takeaway from these focus groups, for me, is that there is a big difference in the way physicians and patients experience their shared interactions. Physicians, health care researchers, and the NIH that funds these studies mostly view communication as instrumental. They're worried about whether patients understand the facts, concepts, guidance and instructions they get from their doctors, and whether doctors are getting an accurate understanding of the history and symptoms patients relate to them. And indeed, studies have found that immediately after a medical visit, people do not remember or cannot accurately report half of what the doctor said to them.

But as patients, most people don't know what they don't know. (Donald Rumsfeld had a point there, although what he didn't know was everything, and he didn't know that.) If they hear doctors saying "Magamamagama anamanapuna" they'll just nod and say okay. They will tend to fill in the blanks of their understanding. They are much more likely to be annoyed by the way they are treated -- that they don't feel respected, listened to, cared about. They may well perceive that the doctor didn't bother to give them some important piece of information at all, or would not accept what they were saying. This may be true, or it may be that the doctor did say something that they just didn't absorb, or heard them but placed a different interpretation on the information that she or he did not clearly and respectfully negotiate with the patient. But as patients, people just don't disentangle instrumental aspects of communication from the total experience of health care.

People just aren't going to say, "I don't think I understood that," or "I hear you but I don't believe you," or "I'm not going to do what you advise for reasons that I'm not going to tell you because I don't think you want to hear them." They'll nod and say okay and then go home and get on with their lives, however they are going to do it. These interactions are much more likely to be successful instrumentally -- as effective exchange of information and motivation of health promoting behavior -- if they are successful as interpersonal relationships. For that to happen, we need to find ways of narrowing the gap of experience and culture between physicians and patients, and achieving a more symmetrical relationship that nevertheless honors professional boundaries and the differential expertise between the parties.

So that's what a lot of my work is about. I'll try to incorporate more of it here.

BTW: Unusual for me to miss yesterday. I often generate my Wednesday post by riffing on something in JAMA, but the entire issue was about %$^&* flu. Feh.

Why we really, really need to stop talking about the #&*!@ flu.

I have written quite a lot about how inappropriate and misleading is the massive media obsession with the "novel" (not really) H1N1 influenza strain that's going around. It's misleading because influenza, even if we are having a somewhat worse flu season than average, is just not a very important cause of morbidity and mortality in the United States; but it's even more misleading and damaging to the political discourse because it drives out discussion of what is really important in public health, which is inequality, poverty, and political power. Flu is largely apolitical, and the more we talk about it, the less we talk about issues that really matter.

Regarding morbidity and mortality, the vast majority of people who get the flu get over it in a few days and then they are perfectly fine. The National Center for Vital and Health Statistics attributes around 36,000 deaths each year to influenza, which is way down the list of causes; and that will be true even if the absolutely worst case predictions come true this year (which at this point it is clear they will not) and we have 3 times the usual number. And most of those attributions are questionable anyway. What's more this will be over in a few months, whereas our other problems are still with us.

Approximately 6,650 Americans die every day. More than 1,700 of those deaths are attributed to heart disease, the number one cause, with cancer not far behind. About 122,000 Americans die of unintentional injuries every year. But in fact the actual, underlying causes of these deaths are largely social determinants subject to political responses: tobacco marketing, poverty, environmental contaminants, social stress, inadequate mass transit, you name it.

For example, there is the epidemic of obesity, which is associated with all sorts of major chronic illness and disability including diabetes, heart disease, cancer, blindness, loss of limbs, and kidney failure. And yes, it's affecting children more and more. And it's a political issue. The average child in the United States sees 15 television food ads every day, that is 5,500 per year. Food companies also market their products in schools and on the Internet, and they place products in TV shows, movies, video games and music. More than 98% of TV food ads seen by children are for high-calorie, low nutrition foods -- full of fat and sugar. There is consistent, direct evidence that TV food advertising causes kids to eat the advertised foods. Our agricultural policy, that subsidizes corn and its sugar that find its way into most of that junk food, either directly or by fattening up chickens and cattle, makes toxic junk food cheap compared to fruits and vegetables. This is not a failure of personal responsibility or even a cultural failing. It is a political issue. It is a public health crisis caused by corporate greed.

In fact, social inequality is by far the leading cause of premature death and disability. If death rates were equalized between Black and white Americans, there would be almost 84,000 fewer deaths in the United States each year. That's far more than influenza will ever cause. And yes, these premature, preventable, politically and socially determined deaths include more deaths of children than influenza will ever cause -- children are far more likely to be murdered than they are to die of the novel H1N1 influenza.

And of course, taking a global perspective, it's even less important. While we have been obsessing about influenza, pneumonia unrelated to flu has been killing a little kid every fifteen seconds. The new issue of Health Affairs gives us lots of information about the real burden of infectious disease in the world -- and no, it doesn't even mention influenza. There's HIV (sorry, abstract only to non-subscribers) which today infects more than 30 million people, with 4.1 million new infections every year, and only 1.3 million more people getting treatment -- in other words, we're falling farther and farther behind. And there are innumerable infectious diseases you probably never heard of -- 50 million people get dengue fever every year, 12 million are currently living with Leishmaniasis, 128 million people have lymphatic filariasis, 807 million have ascariasis, 37 million people are infected with onchocerciasis and nearly a million are totally blind or visually impaired as a result. I could go on and on but you get the idea.

And these diseases are not limited to poor countries. They are right here in the U.S. The prevalence of HIV in the District of Columbia -- yes, the capital city of the United States, in the shadow of our greatest symbols of national power -- is more than 3% among adults -- comparable to Nigeria and Angola. And the prevalence in black men is more than 6%. Poor people -- Black and Latino and rural white -- in the United States, are infected with some of those diseases you never heard of. As many as 4 million people, mostly African Americans in the south, are infected with ascariasis, which causes stunted growth and cognitive impairment. Toxocariasis may infect as many as 2.8 million Americans, again mostly African Americans. Latinos are subject to Cysticercosis, Chagas disease, and Dengue fever.

So why do we hear about nothing but the flu? Because it can affect rich white people, that's why. Because it has nothing to do with justice, or inequality, or politics. Because it's a convenient diversion to stop anybody from talking or thinking or doing anything about issues that really matter.

Time for it to stop.

Update: Just for the heck of it:

[I]t can't be denied that in most cases, the infection has run an astonishingly mild course. And the question of whether the WHO overreacted will only become more pressing. Some experts expressed criticism early on, saying that before declaring phase six, the WHO quickly modified its own definition of a pandemic. The organization simply disregarded the criterion that stipulates a very high mortality rate must first be present, and changed passages accordingly in the pandemic definition on its Web site. If the virus turns out not to be nearly as new as first believed, that begs a further question -- what, then, actually makes swine flu a true pandemic?

Some virologists already had doubts when the WHO first announced the existence of a new flu in late April. Top health officials were indeed talking about a "new subtype" of the influenza virus, one feature required by the US Centers for Disease Control and Prevention to meet its definition of a pandemic. But "new subtype," it turns out, was an inaccurate description -- the pathogen behind swine flu is in truth only a new strain of an old subtype. And as influenza expert Hans-Dieter Klenk at Marburg University's Virology Institute explains, "such strains are more closely related to each other than subtypes are." . . .

No one knows how swine flu's course will run. But in the end, British molecular biologist Derek Gatherer may prove to have been right all along. Gatherer declared his suspicions back in the beginning of July, that humankind is facing only a "pseudo-pandemic," one that "may be insufficiently virulent ultimately to enter the annals of major pandemics."

Chicken Little, anyone?

The proper goals of health care reform . . .

I'm too busy for a decent post today, so I'm just going to blow some smoke.

It is now fairly clear that any health care reform legislation Mr. Obama signs this year will be, to use a technical term from political science, crappy. It won't get us anything that we need. But, just maybe it will provide raw material out of which something better can be made next year. Meanwhile, here's some of what's wrong with health care in the U.S., none of which we are even talking about fixing.

It costs far too much. We don't get what we pay for. Every dollar we waste on health care -- and the waste is something like 6% of GDP -- is a dollar we don't spend on making people's lives better and securing our future.

We overtreat and often do more harm than good. When people are systematically given information and decision aids so that they fully understand the potential harms from common procedures such as prostatectomy, joint replacement surgery, coronary artery bypass grafts, etc., the proportion of people wanting such surgery declines dramatically. But right now, doctors get paid for doing stuff, so stuff they do.

Half of the drugs on the market are either basically useless and dangerous, or no better than much less expensive alternatives. Drug research and utilization are driven by commerce and marketing, not by what makes people healthier and feel better.

The system is fragmented. People have to negotiate multiple specialists who don't know them, are thinking only about the organ or disease they specialize in and aren't interested in people's lives, and they get multiple and conflicting prescriptions, advice and treatments, much of which is counterproductive.

We aren't investing in public health and improving the social and physical environment. We spend hundreds of billions every year trying to fix problems we could have prevented for five cents on the dollar, and usually we can't really fix them.

People are dying horrible deaths in sterile cells hooked up to machines while their friends and family are tortured with false hopes and pointless choices.

Primary care -- the key to an effective and humane medical institution -- is underfunded and despised. Primary care doctors don't have enough time for their patients, don't have awareness and can't manage the overall care of their patients with complex medical problems, they are overworked and underpaid, and they don't get respect within the profession. That means that as patients we don't have a medical home and we don't have a personal connection with the system that can make it work for us.

Yes, we need to cover everybody, but not at the expense of making them pay money they don't have. Universal coverage is only a progressive step if it is linked to progressive financing and reorientation of medicine away from profit and sickness care to taking care of people and actually doing health care. Without that, it's just one more way of stealing from the poor and giving to the rich. And yes Sen. Lieberman, I'm talking to you, you schmuck.