Apo-calypso

I believe we're supposed to look back and look forward today, but instead I'm going to look at those people who look forward a certain distance and see a blank wall, at least in ethical terms.

I don't know if it's peculiar to the U.S., particularly, but we certainly are well endowed with eschatological movements. Eschatology and "end times" don't have to mean the end of time -- the dictionary says the terms can also refer to beliefs about radical transition from one age to another. Obviously such transitions have happened, whether we're talking about the universe, the planet, or humanity. We Homo sapiens are undoubtedly in one right now, and we're dragging the planet along with us.

But I'm talking about believers in change so radical that we owe no obligation to the future. Christian millenialists generally fit this definition. God is going to end history, Jesus and the Beast are going to battle it out, supernatural forces will bring about a future which, according to various interpretations, may or may not include the earth in some form but in any case, what we do to it today doesn't matter. Believing in the right mumbo jumbo might influence our personal fate, but that's all we have to worry about. Ronald Reagan's Secretary of the Interior, James G. Watt, was of this opinion, and used it to justify unrestrained exploitation of natural resources. What did it matter? The world would end soon anyway.

But it takes many other forms. I remember back in college a guy telling me I was foolish to worry about what to do with my life because the planets were going to align on March 10, 1982 and wipe out civilization. A couple of wacko charlatans named Mark L. Prophet and Elizabeth Clare Prophet told their followers in the Church Universal and Triumphant that World War III would occur on April 23, 1990. The people disposed of their possessions and moved to the Church's ranch in the Grand Tetons to wait it out in fallout shelters. You won't be surprised to learn that the CUT (weird acronym, huh?) has sailed on just fine ever since, despite the perfectly ordinary day that passed.

Then of course civilization was going to end on January 1, 2000, either because of Jesus or because the computers would all freak out. As it turned out, the state of Maine erroneously issued some antique license plates. We could go on but much of this is familiar.

What inspires me to write today, however, is a conversation I recently had with a friend that I found a bit disconcerting. He's a pretty well-known writer and he's very insightful. His new idea is that predictions of global climate change are a modern form of eschatology, and he very much wanted me to concede that we are living in the end times. I must say that I find that locution inaccurate, and unhelpful as metaphor.

I agree that it is too late to prevent profound change, and that times of great strife and woe lie ahead. However, we are not running up against a blank wall. The perils we face do not mean that there is just nothing on the other side. That would abolish all responsibility, which as I said at the top (tell 'em what you're gonna say, say it, tell 'em what you said) is characteristic of what we generally mean by eschatological thought. The crisis we face is very different from end times prophecies in many ways.

First of all, it is protracted and gradual. My friend agrees with that. Just as important, and I'm not sure everyone who should be is on board with this, it is highly uncertain. Many people make all sorts of exact predictions but in fact we can only speak in terms of probabilities of various direct effects on the climate system and indirect effects on humanity and the ecology. We don't really know exactly how matters will play out meteorologically, oceanographically, ecologically, demographically, or socially.

Most important of all, we do not face the end of civilization or the extermination of humanity. I can see no remotely probable scenario in which our species disappears in the foreseeable future. We are just too adaptable. What's going to happen is that the weather is going to change, some coastal areas will be inundated, and biological productivity may become somewhat less. Some number of people will figure out ways to keep going.

That will likely mean fewer of us, and a different way of life, but that has happened before. Europe not only survived the Black Death, but emerged into a great flowering of science and culture. One key difference today is that those of us who are willing to see have a basic understanding of what is happening and can plan and act to protect the future as best we can. The planet will still be here and so will its currently cancerous Homo sapiens. With luck our uncontrolled replication and rapacious metastasis will be cured, and we can carry on with the next age of history.

That's hard times, but it's not the end times.

The Visionary

Salviati: ... it is necessary that we declare ourselves as to whether or not you and I have the same concept of this center. Therefore tell me what and where this center is and what you mean.

Simplicio: I mean by "center" that of the universe, of the world; that of the stellar sphere, that of the heavens.

Salviati: I might reasonably dispute whether there is in nature such a center, seeing that neither you nor anyone else has so far proved whether the universe is finite and has a shape, or whether it is infinite and unbounded.

(From the third day of the Dialogue)

Galileo's project, ultimately, was not merely to demonstrate that the earth goes around the sun. That was just one instance of a much larger vision, which was fundamentally epistemological. By throwing off the shackles of received wisdom, and setting out to discover the universe as it revealed itself, he freed his imagination to conceive of a universe far grander and more wonderful than the church fathers could encompass. In this respect, it was in fact the one we know today -- unbounded and with no center. His telescope could not resolve the nebulae into galaxies, but he had an idea that the stars were suns, and the sun a star.

It is astonishing that nearly 400 years later, the implications of this insight are still so threatening to most Americans that they do not accept it. We are, after all, nothing special. We are not the principal interest of the almighty lord of creation, and the fate of our planet is of no consequence to the universe. It matters only to us and to the creatures with which we share it. If we could just abandon the delusions of religion, we might have a better shot at not screwing it up.

Priorities -- and this time it's personal

Mark Fischetti in Scientific American provides a picture of federal spending on scientific research and development. In 2009, the Department of Health and Human Services got about $29 billion. The Department of Defense got $56 billion. Other money is scattered here and there, some of it for social benefit, such as $343 million for the Department of Education (that's with an M, not a B, in other words less than 1/100th of what DoD gets), and $3.6 billion (back to a B again) for the National Nuclear Security Administration.

Republicans are vowing to cut all non-defense research spending, as you may have heard. They can do it, too, because appropriations require affirmative action by the House of Representatives. The Senate and President can't do anything to produce appropriations the House doesn't generate.

My work is funded mostly funded by NIH, the biggest component of HHS R&D spending at $28.5 billion. I'm dependent on a very small part of that, however. The U.S. supported only about $1.1 billion in social science research in 2009. Right now, many investigators are waiting on grants that haven't come through because the federal government is operating on a continuing resolution that level funds all the agencies, and the NIH institutes and centers are reluctant to commit to new projects since they don't know what's going to happen in March when it runs out.

We'll all keep trying, of course. NIH isn't going to go away. But the current level of funding has created a community of investigators of a certain size. If it falls, some number of post-docs will never get faculty appointments and some number of research faculty will get squeezed out. The pace of discovery and translation to better medical care will slow down. The hope you may have for better treatment or prevention for MS or Alzheimer's or pancreatic cancer or HIV will be delayed; the work I do to improve the delivery and effectiveness of medical services will slow down too, in case anyone cares.

On the other hand, we will, if the Republicans have their way, continue to invest more and more in better and more effective ways to kill and maim people. It is, after all, the Christian thing to do.

Mobility

I didn't post yesterday because I had to deal with snow removal in two places, with a substantial travel ordeal in between -- including following a rolling roadblock of snowplows down the interstate at 20 miles an hour. Whenever we have a big weather event like this, it makes me think about the curses and the blessings of modernity.

The big news -- which is still dominating all the networks 24 hours after the storm pulled away -- is all the unfortunates stuck in airports. That is truly unpleasant. On the other hand, air travel wasn't a routine habit of the ordinarily affluent until 50 years ago, at the most. Either you stayed close to Waga Waga where you grew up, or you just said goodbye to your parents and sent them Christmas cards. If you did go to see them once every few years, it took several days anyway.

Streetcars made suburbs possible, but they were a different kind of suburbs than the ones we know today, spawned by the automobile. Streetcar suburbs -- which to a large extent have been incorporated into their parent cities -- were organized around town centers where the people could walk to stores and church and taverns. Automobile suburbs are monocultures of houses on landscaped quarter acres from which people drive to shopping centers and soccer practice.

There are environmental consequences, which are obvious, but the social consequences are just as profound although we think about them less. Most of the friends I have made in the course of my life are hundreds or thousands of miles away. That's basically normal. Growing old nowadays often means becoming alone, but lots of younger people are pretty isolated as well.

When we adopt new technologies we are entirely short-sighted. We see what they do for us immediately, but have little thought of how they will change the fabric of life. Truly, we probably could not predict that anyway.

Many people think and write about these issues but they aren't much a part of popular consciousness or political discourse. We have a bedrock assumption that innovation equals progress. On balance, perhaps, it seems true to most people so far. Deaths in automobile crashes are more than balanced out by children not dying of infectious diseases. Routine tourism to exotic lands is fun, although perhaps not as enlightening in most cases as we would like to think. Global trade fills our world with stuff, even if it leaves a lot of workers behind. But it's worth thinking about the balance sheet much more carefully than we ordinarily do, and having more concern about how all these bargains will look in a few years.

Knowing

Simplicio: From the oldest records we have it that formerly, at the Straits of Gibraltar, Abila and Calpe were joined together with some lesser mountains which held the ocean in check; but these mountains being separated by some cause, the opening admitted the sea, which flooded in so as to form the Mediterranean. When we consider the immensity of this, and the difference in appearance which must have been made in the water and land seen from afar, there is no doubt that such a change could easily have been seen by anyone then on the moon.

(From the Dialogue Concerning the Two Chief World Systems)

By giving these words to Simplicio, Galileo clearly is not trying to argue for this conclusion. But as neither Salviati nor Sagredo object, it also seems that this opinion was generally held among the educated Venetians in 1632 and that Galileo either did not doubt it, or did not care to contest it.


What is most surprising is that geologists today believe this to be true. The event, called the Zanclean Deluge, happened more than 5.3 million years ago. Therefore it seems impossible that the people of Galileo's time could have known it based on any good evidence.

It seems to have been a lucky guess by Pliny the Elder, hence the principal relevance to our present interest. The Dialogue does not reference the Bible at all, and barely glances at religion. The debate is between the theoretical insights of Copernicus and empirical observations of Galileo, on the one hand; and the authorities of classical antiquity on the other. I'm sure that Galileo could not have directly challenged the Bible and expected to avoid being tortured to death. Nevertheless, while I am not an expert on his time, it does seem clear that Old Testament literalism was not the prevailing intellectual fashion, but rather fealty to Aristotle and the classical philosophers.

Indeed, Galileo had presumed he could convert the church authorities to his cosmology, and had actively sought them out to make his presentations. He was very unpleasantly surprised by the reaction he got. I'm sure the authority of the Bible was salient in his hearings before the Inquisition, but I do not think it was Biblical literalism the church was concerned to defend so much as the metaphysical implications for the relationship between God and humanity of moving the earth from the center of the universe.

And they were right to be afraid of this. Galileo, in fact, did not put the sun at the center of the universe either, as he states in one of the most astounding passages in the Dialogue, to be considered anon.

Quote of the Millenium

Salviati: In the long run my observations have convinced me that some men, reasoning preposterously, first establish some conclusion in their minds which, either because of its being their own or because of their having received it from some person who has their entire confidence, impresses them so deeply that one finds it impossible to get it out of their heads. Such arguments in support of their fixed idea as they hit upon themselves or hear set forth by others, no matter how simple and stupid these may be, gain their instant acceptance and applause. On the other hand, whatever is brought forward against it, however ingenious and conclusive, the receive with disdain or with hot rage -- if indeed it does not make them ill. Beside themselves with passion, some of them would not be backward even about scheming to suppress and silence their adversaries. I have had some experience of this myself.

Sagredo: I know; such men do not deduce their conclusions from its premises or establish it by reason, but they accommodate (I should have said discommode and distort) the premises and reasons to a conclusion which for them is already established and nailed down. . . .

-- Galileo Galilei, Dialogue Concerning the Two Chief World Systems, translated by Stillman Drake.

I will have a good deal more to say about this astonishing, and lately insufficiently appreciated document, in coming weeks. Salviati is Galileo's alter ego; Sagredo is his friend who stands for the open-minded interlocutor.

For more wonkery on the same subject . . .

I recommend William Pewen's blog at Health Affairs. Basic points, all true:

1) The individual mandate, in spite of the compelling practical arguments in its favor, does create potential problems when it interacts with legal sophistry. Justices could easily decide either way as to its constitutionality and construct sufficient arguments to not look ridiculous, but you and I both know that their ultimate motivations will be political. And hey, it's 5 to 4.

2) Without the mandate, the PPACA won't work. This is because of basic features of the market for health insurance, which by the way don't resemble anything they teach you in freshman economics. (Sorry to be a broken record on that one.) If insurers have to issue insurance to everybody, at more or less the same price, people who think they are unlikely to need it won't buy it, which will make it more expensive for people who are likely to need it, which will drive out the somewhat likely, making it even more expensive for the highly likely -- in other words, The Death Spiral, and the insurance market has been destroyed.

3) There was a much simpler and better way to do this all along: Medicare for everyone. Universal, comprehensive, single payer national health care. No constitutional problem whatsoever. Congress has unequivocal power to raise taxes to promote the general welfare. QED. The reason we didn't do this is because conservatives wanted to protect the private insurance industry, which was shoveling money at them. And now they are trying to get the very creature they birthed declared unconstitutional. And they might just succeed.

So let's say it again:

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

Owned! (I think I was supposed to type Pwn3d or something)

I presume, although maybe I should not, that the New York Times tries to publish a representative sample of letters in response to any given news story or op-ed column. If that is correct, it appears that Jason Mazzone's recent argument that the health care reform act is unconstitutional did not, shall we say, persuade a high proportion of readers.

After the bill passed, as conservative state attorneys general began to file lawsuits, most knowledgeable commentators dismissed these as stunts intended to appease the inhabitants of wingnutistan and predicted that they had no prospect of advancing. They did not reckon with the judicial activism of the right, however, and I am now far from sanguine. Now that they have found a federal judge to agree that the law is unconstitutional, the case will inevitably make it to the Supreme Court no matter what, and the same justices who produced Bush v. Gore are sitting there licking their chops as they wait for it.

The basic argument, defended by Mazzone, is that the Commerce Clause does not give Congress the power to force people to engage in economic activity. As the letter writers point out, this is basically nonsensical. I can even make a few points of my own. Paying taxes is economic activity, and so is buying a stamp to mail your tax return. So is paying whatever the additional cost may be for all regulated goods and services. In order to carry out any public purpose, under the Commerce Clause, Congress reallocates costs and income in one way or another.

The fact is, if your appendix bursts, or you are shot using an unregulated hand gun, or you ride your motorcycle without a helmet and end up getting scraped off the asphalt, all of us will engage in economic activity by paying for your medical treatment. If making you buy health insurance, along with various measures to make sure you can afford it, is unconstitutional, so is requiring doctors and hospitals to treat people in emergencies. Which the federal government already does, and with good reason. Your supposed "liberty" not to buy health insurance infringes my liberty to hold onto my own money. Which is just one more reason why libertarianism is fundamentally nonsensical.

Yet somehow, utter nonsense dominates our political discourse.

A miracle

A conversation I had today got me thinking about the times I've lived through. I worked my way through graduate school doing consulting work for community based organizations. My friend Wayne Wright, who died of AIDS in 1995, was Executive Director of the Multicultural AIDS coalition, and he connected me with many community based AIDS service organizations, for which I did program planning, proposal writing, strategic planning and other work.

Wayne had really bad luck. Effective treatment for HIV became available just after he died, with the approval of indinavir in 1996. Up until then all we seemed to do was death watches and memorial services. If you weren't in a big city and didn't have any relationship with heavily affected communities it was just something happening to other people, and specifically other people who you probably didn't like very much. (That's "you" in the generic sense, not referring to my own readers.) I'm not gay but there I was in the middle of it, one friend or respected colleague after another, young men mostly, energetic and passionate and committed to good works dying horrifically. It wasn't just the individual losses that kept piling up, it was the devastated communities, whole swaths of life smashed and the pieces scattered to the winds.

This must be what it is like to be in the midst of war. I'm sure great disasters like Hurricane Katrina or the southeast Asian Tsunami felt similar. But for most of us, such plagues belong to history. They're just stories in books we haven't read.

And then the miracle happened. One of the most important AIDS-related institutions in Boston was the Hospice at Mission Hill, where the lucky went to die. In 1996, they started rising from their death beds, emaciated bodies filling out with muscle and fat, people who had figured out how to die suddenly having to figure out once again how to live. The latter problem was sometimes harder. Nowadays the biggest challenges people with HIV usually have are the challenges of growing older, living with a burden to be sure but not necessarily a very large one. It was astonishing. I do not have words for this event.

And so there must be special circle deep in hell reserved for the lunatics who continue to deny that HIV causes AIDS and that antiretroviral drugs keep people with HIV healthy. Some of them, such as Mathias Rath, are psychopaths whose evident motive is greed. Others, such as Peter Duesberg, are evidently afflicted with profound psychological problems. You can read about a whole bunch of them here. Sadly, they still manage to convince people not to take the pills, and the result is that those horrible deaths still happen when they really don't have to.

Now, people in Africa still can't get access to treatment, and we're falling farther and farther behind. More people are infected each year than are enrolled in treatment programs. And that's even starting to happen in the U.S., where the states are broke and are putting people on waiting lists for antiretrovirals -- including right here in Rhode Island, which isn't exactly Mississippi. In the richest country in history, we're telling people to go drop dead. Hey, at least the rich people don't have to pay two percent more in taxes on the portion of their income they can't shelter completely.

A brief primer on drug regulation wonkery

I realize there is a lot of potential for confusion when we talk about the drug approval process and exactly how consumer protection and drug company economic interests interact. I'm not actually a major expert on these issues myself but I think I can at least give you a handle on some basic concepts that will help clarify matters.

First, drug manufacturers, like every enterprise engaged in research and development, can file for patents on new compounds. These generally last for 20 years. As long as a company holds a patent on a compound, no other company can sell it, unless they come to an agreement with the patent holder and (ordinarily) pay royalties.

However, you can't legally sell a drug and make health claims for it without FDA approval -- called a drug license. (Not to be confused with a license sold by a patent holder to another company to make the drug.) Before getting a license to market a drug, a company first gets an investigational license that allows them to test it in clinical trials. By the time this process is completed and a company is licensed to market a drug, much (if not all) of the 20 years of patent protection has expired. So Congress has sweetened the incentive to develop new drugs by also allowing the FDA to grant additional marketing exclusivity periods, typically of 5 years.

If a drug is licensed, then physicians can prescribe it (or it can be sold over the counter if it has that kind of license). However, the drug companies are additionally restricted by the FDA in the specific claims they can make when they market the drug. That won't necessarily stop doctors for prescribing it "off label," for unapproved indications, but the companies are not legally allowed to encourage them to do so. This is a major problem area. Enforcement has been lax, and drug companies have found all sorts of ways of getting around these restrictions.

Once both the patent and marketing exclusivity periods have expired, other companies can apply to manufacture the drug. But they have to satisfy the FDA that their formulations are biologically equivalent to the original. The original license holders can intervene and contest these claims.

Once generic versions of a drug are available, the price typically goes way down, because now there is competition. The unit cost of manufacturing a pharmaceutical is usually trivial. Drugs are expensive because of marketing exclusivity which allows manufacturers to charge whatever they think they can get.

The final layer in this casserole is insurance reimbursement policy. Medicare is pretty much required to pay for drugs prescribed for any approved indication, but private insurers can set their own policies and they often have tiered co-payment systems that encourage use of medications which are cheaper for them. They can also refuse to pay for certain treatments if they choose. This is an endless source of confusion to physicians who have to deal with patients whose insurers use different "formularies," or lists of approved drugs at various levels of copays.

Drug manufacturers try to extend their marketing exclusivity by coming up with just slightly different versions of old drugs that they hope they can persuade consumers and physicians are better and hence worth paying brand name prices for. This is called "evergreening." The whole COX-2 inhibitor fiasco can be understood as essentially an effort to evergreen aspirin. They can also keep advertising the brand name drug and hope to persuade people it is better than the generic, viz. Lipitor. (There is absolutely no reason that I can see for anyone to pay for Lipitor with very cheap generics available that are biologically equivalent. But remember, I'm not a real doctor.)

Here's some information about all this on the FDA's web site.

So, to clarify a recent flapdoodle, the FDA had given conditional approval to market Avastin for metastatic breast cancer on condition the manufacturer conduct additional trials to demonstrate that it really works. It turns out it doesn't, so approval for those specific claims has been withdrawn. However, Avastin is still licensed and approved for other indications, so doctors can still prescribe it to women with metastatic breast cancer if they want to. The question is whether insurers will pay for it. Presumably, once the appeal period is over, and if it is unsuccessful, Medicare will not.

That's why Genentech is unhappy. But it's a) still licensed and b) still under marketing exclusivity.

Then there's the whole question of so-called "supplements," which we'll get to another time. . .

They'll keep spouting this nonsense . . .

. . .until somebody stops them. The FDA has decided to withdraw approval of Avastin for metastatic breast cancer. Their reasoning, which I know is unspeakably cruel and atrocious, is that it doesn't work. Women who are given the drug for that purpose live not one day longer, and often suffer unpleasant side effects. This means that once the decision is final (Genentech can appeal) Medicare, and most likely private insurers, won't pay for it. Which is a good thing for the rest of us, because it's all of our money, and it could be going to safe and effective treatments instead. You can already guess what the Republicans are saying, those champions of fiscal responsibility, implacable foes of wasteful government spending, and defenders of freedom.

Reporting by NYT's Andrew Pollack:.

The F.D.A.’s decision also drew political criticism, with some Republicans contending that withdrawing this treatment for breast cancer was akin to rationing under the new health care law.

“It is troubling that women in Germany and France will soon have access to a life-saving drug, while women in the U.S. will not,” Representative Kay Granger, a Texas Republican, said in a separate statement.

When will the corporate media, and the people, catch on that these people don't actually believe a single word they say. They don't give a moldy fig about the federal deficit, wasteful spending, or for that matter Medicare or your health. They only care about their corporate masters. This is not a life saving drug, that's the whole point. It is, however, a money making drug for Genentech. That's the only thing that matters to Kay Granger.

First Principles

Apologies. I missed yesterday because my life was just too hectic. Right now I'm living in two different places and working (mostly) in a third, gradually disentangling myself from one home and trying to get established in another, finding my way in a new work environment and taking on new projects, and commuting more than 1 hour every day, which I have never done before and don't care to continue. Meanwhile, just getting the normal stuff done -- from auto maintenance to doctor appointments (yeah, I get doctored) to shopping -- is complicated and requires advance planning about where I am going to be and how I am going to get there. Add to that several recent Mondays in Baltimore and it's very draining.

I'm not complaining, not at all. All this is in service of an opportunity I chose to accept, and it will all get sorted out and settle down in due course. But it leads me to reflect a bit on what health really means and how it is produced. We have some conventional measures of population health which are awfully crude -- infant mortality rate, life expectancy.

We can look at age adjusted rates of specific illnesses, if they happen to be available for a given society, although these are generally very much distorted by what we call ascertainment bias. You don't have diabetes unless you've been diagnosed. So one population might have a higher rate of diabetes than another because the people are more likely to have insulin resistance and hyperglyecmia; or because they are more likely to have doctors who do tests and end up telling them that they have diabetes.

The simplest thing to do is ask people how healthy they think they are. The simple question, "Compared to other people your own age, would you say your health is excellent, very good, good, fair or poor" is actually strongly predictive of life expectancy among older people. But why do people answer as they do?

Many people do not take pills their physicians prescribe, even inexpensive ones with few or no discernible side effects, even though the doctor has told them, and they may well believe, that they're likely to live longer if they take them. Maybe it's just not worth the hassle, or they'd rather spend the $15 a month copay on something else, or life is better if you just don't worry about too much stuff.

One of the strongest determinants of population health, as conventionally measured, is social inequality. Egalitarian societies are healthier, even if the average level of wealth is lower, within a pretty wide range of total affluence. And, up to a point, richer people also say they are happier, on average -- although plenty of not so rich people also claim to be happy and lots of rich people aren't.

My affluence is slightly above average, and I don't have any diagnoses of major diseases. I have a bit of osteoarthritis as most of us do as we grow older, but it really doesn't stop me from doing anything except maybe running marathons. My life is satisfying in some respects but not others. What's missing is actually important, but it can't be fixed by doctors.

I am really unhappy, though, because of what I see happening around me. I'm in a reasonably good position to weather the storms ahead but most people are not and we may well be headed for very unpleasant times. This disturbs me greatly. So am I healthy? I could go to a psychiatrist or psychotherapist and discuss my angst. I don't think I would get a disease label but you never know. In any case, what would be the best investment in my health and that of the people around me? Should it focus on the services of physicians and the goods they purvey? If not, what should be a higher priority use? If we spend less on medicine, what should we spend more on?

Those are probably more important questions than the ones I usually discuss here.

The Truth is Out There

I've been re-reading The Bias of Science by Brian Martin, published in 1979, which figured in my master's thesis. (Which, by the way, was titled Which Way is Up? Social Welfare and the Ideology of Progress.) I find that some of Martin's monograph holds up okay, some of it not so well. But it strikes me that overall, there's been a fairly radical reversal in the zeitgeist in just 30 years.

Martin builds a political and social critique of the scientific enterprise around a dispute which is nearly forgotten: whether it was wise to operate a large fleet of supersonic transports (SSTs). Proposals for SSTs were promoted in the 1970s in the U.S., Britain, France and the Soviet Union. They were controversial mostly on environmental grounds -- opponents were worried about sonic booms (unquestionably real) and the possibility that emissions of oxides of nitrogen from jet engines in the stratosphere would deplete the earth's protective ozone shield. Martin closely analyzes two scientific papers, one supporting the danger of ozone depletion and the other minimizing it, and finds them both tendentious in various ways.

One key point of Martin's critique is that a debate framed almost entirely as environmental directed attention away from economic issues. It scarcely seemed remarkable at the time that a large public investment was needed for the SST even to be possible, and it is interesting that he doesn't even seem to notice this. It would surely be noticed today. But regardless of where the money was coming from, did it make sense to put what would in today's terms be many of billions of dollars of R&D and production costs into a means for rich people to save a couple of hours on a transatlantic flight?

As it turns out, the economic question took care of itself. In the end, only 20 Concordes were every built and they were retired in 2003 because there weren't enough rich people willing to do that after all. The U.S. program never happened, and the Soviet program was a failure that never operated commercially.

I hope to discuss Martin's work in some detail eventually, but for now I want to notice One Big Thing. Back in the ancient world of the 1970s, there was a substantial critical movement both within and outside of science that viewed the scientific enterprise as largely a creature of corporate and elite power. This was partly based from within a broad acceptance of the philosophy of science, but attentive to the selection of scientific problems, and the way in which findings were promoted, suppressed, and interpreted to serve privileged interests. It was also partly based in more radical "post modernist" critiques which contended in essence that all interpretations of reality are at least to some degree arbitrary and which even seemed to deny the existence of objective reality. Martin mostly wants to be in the first place, but he at least sets foot in the second.

Nowadays, however, there is something wrong with this picture. Nobody can claim that science, on balance, is a tool of corporate interests, when the corporate party in the United States is an implacable enemy of a large swath of scientific understanding. Corporate power never managed to recruit more than a small minority of scientists, mostly people whose careers had failed to develop within mainstream scientific institutions, to its well-funded campaigns to deny the health effects of tobacco, or lead pollution; the environmental effects of acid rain, mercury, and fine particle pollution; or more currently, anthropogenic global climate change.

To be sure, the corporate media were seduced by these campaigns for a while, and still are by global climate change denialism, but ultimately the scientific consensus won out in the earlier cases, as it surely will in the latest. We have seen that in an important applied area of science, evaluation of new drugs and medical devices, corporations have succeeded in suppressing findings unfavorable to their products and manipulating and cherry picking data that favor them. But it turns out that there was enough countervailing pressure from university and even government experts that they are finding this more and more difficult to do. (It doesn't hurt that they keep getting successfully sued either.)

It turns out that for all that it proceeds by fits and starts, goes down blind alleys and stumbles over falsities, over time science does converge on ineluctable truths. The world really is a certain way, it really does make certain kinds of sense, and if you keep hacking away at it you will find that out. It is what it is. And if that happens to be uncongenial to the Koch brothers, all of their billions cannot change it.

Unlike Glenn Beck and Sarah Palin . . .

I'm not a scholar of constitutional law. However, I can have an opinion about the practical, common sense implications of policies. The "individual mandate" to purchase health insurance has been the main focus of lawsuits by teabagging state attorneys general claiming that the Patient Protection and Affordable Care Act is unconstitutional. Now that the co-owner of a right wing consulting firm that made money in the past year by opposing the act, who also happens to be a federal judge (who would have thought that was permitted?) has ruled the individual mandate violates the constitution, there is much rejoicing to starboard. Most experts think the ruling is insupportable, and several judges have already dismissed similar lawsuits, but given the makeup of the Supreme Court, we would be very unwise to depend on what most lawyers understand to be the law.

That said, the only reason we have the individual mandate, instead of tax funded insurance, is because of the prevailing ideology. The difference is essentially semantic -- we have all sorts of federally required individual mandates. For example, I am required to pay for pieces of missiles and agribusiness profits. If I were required to mail checks to Raytheon and Dole, it might feel more offensive, but except for the price of the stamps it would pretty much amount to the same thing.

So we got the individual mandate, which requires us to mail checks to Aetna and WellPoint, because that seemed less "socialistic" than single payer national health care. The wingnuts don't like it anyway, so they're suing. But there would be absolutely no constitutional question whatsoever about raising taxes to pay for health care, which after all the federal government already does, just not universally.

The individual mandate is a much worse alternative for all of us, because a chunk of our money goes to the socially useless, parasitic insurance industry; it is much more difficult to create a properly progressive financing regime; and it is much more difficult to promote efficient and effective use of resources and stop the relentless suctioning of our national wealth into the pockets of drug companies, medical device makers, and overpaid medical specialists, among others.

I don't know about you but personally, I'm not giving up. With a Democratic House and Senate in 2013, we can fix this mess very easily by introducing a public option. Between now and November of 2012, we need to keep working to reframe the terms of this debate and purge the bullshit.

It can be done.

The slipperiness of truth

For much of the 20th Century, as scientific discovery and technological innovation were the dominant drivers of social change and major intellectual preoccupations, the generally accepted philosophy of science was positivism. I'm not going to go into any detail on that here (but you can read some of my past discussion here and in the links therein embedded). I just want to make a simple point: the central idea of the verifiability of scientific assertions runs into trouble when you get to probabilistic statements -- which, as it turns out, probably most scientific assertions happen to be.

Scientific inquiry relies heavily on statistics, notably so in epidemiological and clinical research. But think about it. When the weatherbot on your local teevee says "There is a 50% chance of rain tomorrow," how do you decide whether that assertion is true? Whether or not it rains tomorrow is no help, obviously.

Even if you follow the weather forecasts and the actual weather for a long time, you can't quite tell at what point you start to believe that the forecasters are making accurate predictions. If it rains 52% of the time they say there's a 50% chance, they haven't been exactly right but maybe that's just bad luck and it will even out the next few times.

The squishiness of probability creates a big fat opening for bias -- unconscious or deliberate -- in the presentation of clinical trial data. For the story I am about to summarize I rely heavily on Melanie Newman in the Dec. 11 BMJ, which sadly I cannot link to as it is behind the subscription wall, but here are the first few paragraphs.

The key question is a debate over the circumstances under which published research should be officially "retracted," which means in essence that the journal declares the paper no longer to exist as peer reviewed science, and it centers on a single paper published in 2001 in the Journal of the American Academy of Child and Adolescent Psychiatry, reporting a clinical trial sponsored by the company which is today Glaxo Smith-Kline of its anti-depressant paroxetine. The paper claimed the drug was effective for treating depression in adolescents.

The problem is that based on the 8 outcomes specified in advance, it was not more effective than placebo. These included 2 so-called "primary outcomes," which were the change in the average score on a questionnaire called the Hamilton Rating Scale, and the proportion of subjects who met a threshold for improvement after 8 weeks. So what did the investigators do?

They cooked up 19 new secondary outcomes, and found a positive response on four of them, one of which they then proclaimed, ex post facto, to be "primary." The manuscript was actually drafted by a company contractor, after an internal memo declared that it would be "commercially unacceptable to include a statement that efficacy had not been demonstrated."

Although all this is now publicly known, the journal refuses to retract the article because they claim it does not include any false results. Whether this assertion is itself true is essentially imponderable. Yes, all the numbers shown in the tables are accurate, and so are the p values based on the calculations that were actually done. But to say that the p values are accurate is to fundamentally misunderstand the concept of statistical significance.

It is supposed to represent the probability that an observed difference could have arisen purely by chance, without representing a real association in the total population. But that only works if I make a single comparison (assuming I don't have any information about prior probability -- which gets us to Bayes theorem, which is really where we always ought to begin anyway, instead of with p values. But I digress.) If I make 21 comparisons, as in this case, chances are I'll hit on some ostensibly "significant" p values (which is an arbitrary standard to begin with) purely by chance. The values aren't really significant after all.

So the numbers in the paper may be true in some sense; but the conclusions are false. Their meaning has been fundamentally misrepresented. I don't know if that means the paper should be retracted, however -- if we start going down that road we're going to have a massive bonfire.

Mission Accepted

You may have seen a link to this posting by M.S. on The Economist blog, which has drawn some blogospheric attention. Only 6% of scientists identify themselves as Republicans, compared to 55% who identify as Democrats. M.S. wonders why:

I can think of three testable hypotheses they might look into. The first is that scientists are hostile towards Republicans, which scares young Republicans away from careers in science. The second is that Republicans are hostile towards science, and don't want to go into careers in science. The third is that young people who go into the sciences tend to end up becoming Democrats, due to factors inherent in the practice of science or to peer-group identification with other scientists. In the absence of data, I leave it to you to decide which you find most plausible. But by all means, social scientists should look into this.

Hey, I'm a social scientist! But I don't have to look into it, I already know the answer, and it's None of the Above.

Scientists study reality, carefully applying rigorous methods of data collection and rules of inference. They think from evidence to conclusions. I don't need to tell you that reality has a well-known liberal bias. That's why conservatives don't go near it. They reason from a priori principles to decide that reality must be whatever they need it to be in order to believe what they already believe, which isn't actually true. So they can't be scientists.

Reap This Righteous Rant

Michael Millenson, on the Health Affairs blog, opens a can of whoop ass on the medical industry for apathy about patient safety. Since the much ballyhooed Institute of Medicine Study To Err is Human, issued in 1999, we have made essentially no progress on reducing the estimated million preventable patient injuries, and close to 100,000 deaths, in hospitals every year. (People don't even seem to think about outpatient iatrogenic injuries and deaths. I'll get to that in due course.)

Millenson's basic point is, we know how to enormously improve safety and reduce errors that harm patients, but people just don't bother to do it. Hospitals eschew opportunities to join programs to enhance safety, because their administrators think they're already just so fabulous, or they are worried that by trying to do better it will look like they are admitting they have a problem, or . ..

They actually make money by harming patients. That's right: when people suffer avoidable complications, such as catheter associated infections, the hospital gets paid more to take care of them. Of course if the patient dies they might earn less due to the shortened stay, but that's usually a risk worth taking. Millenson doesn't mention that Medicare is trying to change reimbursement policy to eliminate this perverse incentive in certain readily definable and obvious cases, but in general, it's still true. (It was true in my own case, BTW, when surgeons erroneously removed my ascending colon and then fed me while my bowels were still paralyzed, and oh yeah I got nosocomial C. difficile. Then they sent me a bill for $25,000. I told them to fold it until it had as many corners as humanly achievable entonces metelo donde el sol no brilla. But they tried. But I digress.)

The way to fix this, of course, is the way civilized countries fix it: put hospitals on a global budget to take care of the population of their catchment area. Everybody gets a salary, and nobody makes a profit, but people can get bonuses for doing good stuff. That way, the incentives are to deliver care as efficiently and effectively as possible. And oh yeah, they have to meet the standards of the single payer, whether they like it or not.

But no, that would be socialism. So don't even think about it. Just shut up and die.

Anecdotal evidence

I can't answer Daniel's question about what percentage of medical spending in the U.S. is for stuff that we just shouldn't do in the first place, but this story in Health Affairs illustrates the problem. A 90 year old man with dementia, heart disease, and diabetes, goes through hospitalization, surgery, multiple tests that cause serious complications, in and out of a rehabilitation facility, all of it costing more than $200,000, and none of it doing him a damn bit of good. He dies six weeks later.

There isn't any corruption, and not even any significant misaligned financial incentives behind this debacle. It's largely a function of our medical culture -- shared by physicians and the public, in this case as represented by the patient's daughter -- which just assumes that doing more is better and leaving well enough alone is irresponsible. And oh yeah, that we must never just accept death.

Listen up buster. Death is unconquerable, at least as of 2010. So is getting older. Get used to it.

Cheap, completely understood, and it works

That would be aspirin. I wrote about it a long time ago, the message being that drug companies invested a lot of money in (as it turns out bogus) research and marketing in order "evergreen" aspirin. Since the patent on aspirin was gone before I was born, it sells for bupkis and anybody can make it. Ergo, Pfizer and Merck couldn't make any money off of it. Hence we got the debacle with the Cox 2 inhibitors, which were supposed to do all the good of aspiring with less risk of gastrointestinal side effects.

Sadly, no, as it turns out, because aspirin reduces the risk of heart disease and ischemic strokes, whereas the Cox 2 inhibitors increase it. I'd rather have an upset, or even bleeding stomach (generally reversible if you just stop taking the aspirin) than drop dead. And I have always felt that the side effects were overblown as a result of the drug companies hyping them in order to justify their much more expensive products. I'm not a real doctor, so don't rely on that judgment -- and for sure, not everybody can take aspirin. But at low doses, it's unlikely to cause problems.

There's no money to be made from aspirin, so it's hard to fund studies. As you may have heard, these docs in the land of the brolly and bowler hat did a secondary analysis of data from trials originally intended to determine the cardiac benefits of aspirin. Turns out it is also fairly effective at preventing many cancers. Not dramatically -- about a 20% reduction in risk of death from cancer over 20 years, and only if you keep at it for all that time. 75 mg a day will do it, more is not better!

Yes, there can be side effects but it's one more thumb on the scale in favor of more people considering this. (As always, ask your doctor, and I don't mean Dr. Ruth.) By the way, although salicylic acid is famous for being found in willow bark, it and similar compounds are found in many vegetables, which may help account for the overall goodness you get from eating lots of them. Just a speculation on my part, but it looks good.

The real lesson here is that aspirin was a miracle drug 100 years ago, but we haven't studied it nearly enough because there was no money to be made from it. If the drug companies had invested in understanding more about aspirin, instead of trying desperately to find something patentable, we would have gotten this news a long time ago. But of course they never will, because the Free Market™ doesn't allocate sufficient resources to basic research that can benefit humanity. Only government can do that, because knowledge is a public good.

It's Ecomomics 101 time again . . .

From the NY Times, a disgusting story about a cardiologist who was implanting stents, by the hundreds and thousands, in people for whom they were not indicated. As you may recall, these devices don't actually reduce your risk of heart attack or death. At best, they relieve the chest pains which can be a symptom of cardiovascular disease. In our last episode, we learned that many patients who receive them have the impression that they do in fact reduce the risk of heart attacks and extend lives. Did they just misunderstand their doctors?

Or did their doctors lie to them? From the Times article:

Edward Chaid, 68, a semiretired general contractor from Timonium, Md., is among those who have sued. Five years ago, Mr. Chaid decided to get his first physical examination in decades. Just to be safe, his doctor sent him for a cardiac stress test at MidAtlantic, which revealed a small “squiggle” of concern, Mr. Chaid said. He was sent to Dr. Midei to get his arteries X-rayed, and he emerged from the procedure with two stents.

“Dr. Midei said: ‘You sure are lucky. You had 90 percent blockage.’ And the nurse said, ‘Oh yeah, you were blocked in your widow-maker.’ And I said: ‘Thank God. I guess I’m really lucky you got it when you did,’ ” Mr. Chaid said in an interview.

Actually Mr. Chaid didn't even have a severe blockage, but even if he had, if he didn't have chest pain, there would be no reason to implant the stent.

I'll leave it to interested persons to read the Times article for all the gory details of this story, which also involve Abbot Labs and the hospital as unindicted co-conspirators. But for our purposes the point of this story is that once again, it proves that neoliberal economics is completely disconnected from reality.

Libertarians and their allies in the Theology Economics departments of our major universities envision buying and selling transactions as necessarily benefiting both parties. The problem of externalities, which we have often discussed, does not enter into this. We're talking about the internalities, as it were. According to standard economic theory with which college freshmen are indoctrinated, the money gained in the transaction must be worth more to the seller than the goods and services rendered; and they must in turn be worth more to the buyer than the money. Otherwise the transaction would not take place. So everybody wins. Not only that, but consumers are sovereign: they create the demand which calls for the productive potential of the economy. If people didn't want stents, not so many of them would be made, and not so many hospitals and cardiologists would share the $10,000 a pop they get for implanting them.

The problem, obviously, is that you and I don't have the slightest idea whether we would benefit by more than $10,000 from a stent. Let's even leave aside the issue of third-party payment. If somebody told me I needed it to save my life, I'd come up with the ten grand somehow on my own, if I possibly could. How was I supposed to know the guy was a greedy psychopath who was lying to me so he could pocket the fee?

This is obviously an extreme case. The medical industry could not function at all if physicians didn't have a code and a culture of ethics that we know we can rely on. We have to trust our doctors and most of the time, they are basically trustworthy. Still, if there is money to be made, they are likely to be swayed unconsciously in the direction of doing more. And the culture of their specialty will, again without conscious bias or awareness of pecuniary motives, tend to lean toward valuing what they do highly. No surprise, if you are diagnosed with prostate cancer, surgeons will think you need surgery, radiologists will think you need radiation, and oncologists will think you need chemotherapy; but maybe what you really need is nothing.

This is why it is ridiculous for conservatives to try to scare us with the specter of government bureaucrats coming between us and our doctors. We and our doctors need the best possible information about what treatments are indicated and cost effective under what circumstances, and they need some guidelines to keep everybody at least in the ballpark of doing the right thing. Without that, we don't just waste money, we get physically assaulted and maybe seriously harmed, if we happen to stumble on an amoral greedhead. Free Markets™ and liberty have nothing to do with it.

A doctor of the wrong philosophy

Benjamin R. Barber, Walt Whitman Professor Emeritus at Rutgers, writes in the November 29 Nation (subscription only) on "America's Knowledge Deficit." He hits the spot with me on his main point, that an "epistemological deficit . . . is putting Democracy at risk." He writes that

[F]ar too many Americans, including not just many of the new Tea Party politicians but established leaders like former president George W. Bush, honestly think the difference between, say, evolution and creationism is merely a matter of opinion: you think man is descended from apes; I think he is a creature made by God. Tolerance, to Bush, means we respect both views and acknowledge their common creditability, because, after all, we both feel deeply about the matter -- which means, in turn,we teach both views in our schools.

Well yes, except that man [sic] is not descended from apes. Prof. Barber needs to brush up on his evolutionary biology. Humans and apes have a common ancestor, which was not quite ape and not quite human. It is most accurate, probably, to say that we are apes. But this is a common misconception, which I will forgive.

However, Barber goes more seriously wrong:

There are, of course, many issues that cannot be judged by empirical evidence or objective truth. The existence of God is one of them. These are normative rather than empirical claims. . . . When as an evolutionist I claim man is descended from apes . . .I am claiming something that can be corroborated or falsified by reference to fossil records, genetic affinities, geology and other kinds of empirical data and testable hypotheses. When I claim God created man and then woman from the rib of man, there is no way to confirm or falsify this claim, no "evidence" that can counter what is subjective belief.

Err, no. The claim that God made "woman from the rib of man" is as false, and as falsifiable, as the claim that "man" is descended from apes. Religious beliefs about the nature of reality and the history of the world are completely falsifiable, and almost always false, because they derive from faulty epistemology. Barber has adopted the unfortunate attitude of many people who want to adopt the stance of reason but don't want to offend religious people by pointing out that there beliefs are, quite obviously, false. For some reason we just can't say that, so we need to put them in a separate category where "truth" means something different than it does in, well, reality.

This is just silly. God did not make a woman from the rib of a man, there wasn't any Noah's ark, and Jesus was not born of a virgin and did not walk around accosting people after he was dead. These assertions are objectively false and can be disproved by resort to our senses and reason, just like every other objectively false assertion. And believing in falsehood is bad for you.

Site news: I have indeed established a new blog, called Windham County. There isn't much there yet, but I'll be posting material there that doesn't really belong here, to keep Stayin' Alive clean and on topic, at least somewhat. Let me know if people want to exchange links. (The Dharma Bums get a freebie.)

Stuff

This is more of a personal note than I usually write here, but I want people to know what's going on with me. As I have at least hinted, I'm in the process of gradually moving out of my home of more than 20 years, taking stuff one pickup truckload at a time to my country place in Connecticut. As soon as I can sell the property in Boston, I'll get a pied a terre of some kind near my new workplace in Providence. It's obviously done with mixed feelings. My underlying reluctance is making it go more slowly than it needs to.

But there's also something healthy about it. I'm finding out what I have -- a lot of old junk and paper that has existed in my space for years or decades for no particular reason, it turns out. I'm throwing away more than I expected, although it's often a close call. On the other hand, it's just as often the case that I have no idea why I kept something in the first place. For some reason, I had several newspapers and magazines from what, as far as I can tell, were unremarkable days in 1999. A lot will be recycled but a lot will also go to the landfill. At least it's mostly non-toxic, except maybe for all the toner cartridges from an old photo printer that doesn't work any more. (And how the hell do you ethically dispose of electronic equipment, anyway?)

But I'm also discovering things I'd forgotten about, that are worth keeping, and that also remind me of past thoughts, plans, ideas -- some of which, who knows, might be reborn one day. I'm keeping some material that's just autobiographical evidence -- reminders of past events, people I knew, observations of the day.

Anyway, I'll end up not only traveling through life a little bit lighter, at least until the accumulation returns to its present level; and also a little more in touch with myself, a little bit better organized, and if I don't lose momentum, a lot tidier. Still, it's kind of sad.

It's Economics 101! (The Continuing Series)

Government regulation stifles economic growth and innovation. Lift the dead weight of government from the backs of our entrepreneurial class and we'll all be more prosperous and free. And oh yeah -- I'm actually Brad Pitt.

Commissioner Margaret Hamburg reviews the history of the FDA in the new NEJM, which, quaking before the mighty power of Stayin' Alive, makes her essay available to you, the undoctorated. As Hamburg tells us, before the FDA came along, heroin was marketed as a remedy for coughs and asthma. It does actually work, unlike most of the crap that was sold as medicine in those days.

At first though, the FDA couldn't require proof of safety before medications were marketed. In 1937, a company sold sulfanilamide (an antibiotic) in a solution of diethylene glycol, otherwise known as antifreeze, which as you probably know is not good for you. In fact it killed more than 100 people. So Congress passed the Food, Drug and Cosmetic Act to require prior evidence of safety. The FDCA, by the way, spared the United States from the Thalidomide disaster which resulted in thousands of babies born with severe birth defects in Europe.

It wasn't until 1962, however, that the FDA could require good evidence of effectiveness before approving drugs and approving marketing claims. One third of drugs then in common use ended up being withdrawn from the market because they just didn't work.

It was regulation that spurred the immense explosion of pharmaceutical innovation since that time. Only when they were required to develop good scientific evidence of safety and effectiveness did drug companies actually start spending the money to get it -- big investments that have had big payoffs for human health.

We still have a long way to go -- publication bias, me too drugs, and aggressive marketing of drugs that are no better or even worse than their cheaper competitors still plague us. We need better, stronger regulation. But it's the regulation we do have that has spurred scientific knowledge, technological development, and the wealth generated by the pharmaceutical industry. Without it, we'd still be swallowing snake oil.

BTW, the specific flaw in the totally bogus theory of the Free Market™ in this case is the requirement of perfect information. Consumers don't have information about whether drugs are safe and effective unless the government requires it. That's why we need government intervention in the market to give us drugs that help, rather than hurt us. There's no other way.

Minority Report

I've just gotten done participating in a proposal review process. I'm not allowed to say anything specific about it, and I know that specificity is the essence of good story telling, so this will just have to be a badly told tale. Still.

I really didn't like the proposal, but everybody else did. The basic reason was that I couldn't see any good reason to do undertake the experiments the investigators proposed, whereas the other reviewers do the same sort of thing themselves so naturally they weren't very open to the idea that it's all basically pointless.

To get slightly more specific, this has to do with the existence of some new high tech toys that allow people to make observations that sound like they ought to be really cool and might even be like really wild cool stuff that you read about in science fiction -- to be even more specific, reading people's minds.

That's about as specific as I can get but here's the bottom line. We know that stimuli get registered in the brain, and that the brain creates experience, such as specifically pain. So if people are in pain certain parts of the brain are more active, and if they are in less pain those places are less active. On the other hand we don't know what pieces of that, if any, have to do with the conscious experience of pain, because most of what goes on in our brains does not impinge on our consciousness. And just looking at the pictures will never, ever tell us. And for that matter, even if it could, what would it mean other than, these are the part of the brain that are active when we are in pain, and these are the parts that are associated with our conscious experience of pain. If I do something that results in people reporting less pain, I would expect the images of their brains to be like the images of brains of people who report less pain. So what?

Apparently so something, even though they couldn't really explain it to me. So this will probably get funded. Oh well.

Good science isn't about fancy toys and stuff that only a few people know about. It starts with asking the right questions. And that's not just a matter for scientists -- it ought to be a right of the people.

Bo-o-o-o-o-o-o-o-o-gus!

People who ought to know better are apparently unaware of the basic laws of inference. Here's a headline: Study: Drugs Linked to 1 in 5 Fatal Car Crashes. "Of the 21,798 drivers were killed on the road in the United States in 2009, about 18 percent of them had drugs in their system at the time of death, the National Highway Traffic Safety Administration says in a new report released Tuesday."

"Drugs" includes illicit and legally prescribed drugs and over-the-counter medicines.

What question did they fail to ask? (Jeopardy! music plays . . . )

What percentage of all drivers has one or more of these drugs in their system at any given time? Could it be as high as 18%? Wouldn't surprise me one bit.

Where was I?

Sorry for the no post yesterday, I had to get up at the crack of dawn to fly to Baltimore for a three hour meeting, and fly back that afternoon. Yeah yeah, bloggers who do that sort of thing usually blog from the airport but I just wasn't up for it. Apologies for the carbon emissions as well but it wasn't up to me.

Anyway, I don't subscribe or regularly read The Economist, but it is a good way to kill 3 hours so I often buy it at the airport. As I presume most readers know, this is a British magazine which is not particularly written by or for economists. It's a comprehensive review of global affairs, somewhat comparable to Time or Newsweek but far smarter and more comprehensive. It is generally considered conservative in outlook and I suppose it is, by UK standards, but by current U.S. standards it's not that far from the Daily Worker. It could be the Bernie Sanders campaign manual. That's how warped we have become.

Here's their latest page on the U.S., where they endorse the Fed's "quantitative easing" while pointing out that it's an inferior option which is only necessary because we have provided insufficient fiscal stimulus; endorse not only the DREAM act but comprehensive immigration reform while slapping Republican demagoguery about "amnesty"; and also slap the Republicans around over blocking ratification of the new START treaty, among other positions.

Every issue has a theme section and this week, it was anthropogenic global warming, which they portray as an urgent problem which we ought to be addressing by reducing carbon emissions but, since that apparently isn't going to happen, they focus on possible responses.

The Economist is also entirely free of the pervasive American trait of narcissism -- it opens up to the world and tries to free itself of a British centered perspective. Its dispatches from darn near everywhere -- Sri Lanka to Kenya to Brazil as well as the more obvious major powers and hot spots -- take the local perspective and dispassionately portray local culture and politics.

If we had conservatives like that, we would not be idiots. But we don't, and we are.

A speciation event?

Now that I'm a part-time country boy fer sher, it's a major new experience for me and I'm going to be tempted to write a lot about my observations of the nature of nature and the idiocy or wisdom of rural life and all that. For example, today I spent the morning in my neighbor's woods harvesting firewood from the tops where he had a lot cleared and some sustainable logging done. Heating with wood is normal here, and chainsaws in the distance are background music this time of year.

Wood cut in the fall is no good till next winter, but it will be perfect then, and this is a good time to cut it. The understory has died so it's easier to see what's going on and make your way in the woods, and the leaves are off the trees so it's easier to clean up your fire logs. Loggers, in fact, prefer to work in the winter, even with snow on the ground. This time of year, it's not so cold that I didn't sweat a bit working hard, but it does feel cold when you stop. With the sun so low, it feels like it's late in the day, all day.

So, firewood forces you to be very forward looking, storing up not for this winter, but for next. Rural forms of Self-sufficiency in general tend to be like that, very obviously. What I do this fall will have a lot to do with what I can produce from the garden next summer, and from fruit trees in three or four years. I suppose that's true of any career or business one tries to build, but in these particular matters the link between current effort and future prosperity holds little mystery.

Anyway, what I'm thinking of doing is starting a new blog, to be called Windham County, where I can post all this sort of idiocy, and keep Stayin' Alive more or less on topic. Not that I'm always great about that but I'd like to keep it within limits. Let me know if you have any thoughts.

Ah-ooooooooo!

Now that I'm spending more time in the country I'm getting to know where I live. Last night as I was drifting off to sleep a coyote got to whooping and hollering, seemingly just outside my window. It gave a complicated performance consisting of rhythmic yelps and howls that broke upward in the middle by a diminished fifth. (The Devil's interval, banned by the medieval church.) The concert lasted two or three minutes, with the pattern of yelps and howls varying throughout. Later, after midnight, presumably a different individual, or at least it was a different song, somewhat farther away, gave a brief, simple performance consisting of four howls with slight downward inflection.

They apparently do this to tell other males to stay out of their territory, and invite the females in if they are so inclined. (When I try it it doesn't seem to work.) But for a predator to announce its presence so assertively seems awfully sporting. As I say, the turkeys can fly up into the trees.

It's Economics 101!

Yet again. One very common conservative trope is that making people pay out of pocket for their health care will make them wise consumers and help control health care costs. This is not a finding, of course, it's an assumption, and it's an assumption based on a prior assumption that consumers have perfect information and behave "rationally" -- both of which are essential to the theory of the Free Market™.

Here is a very simple illustration of why this isn't true. When Blue Cross Blue Shield of North Carolina eliminated co-pays for generic medications, more people took their calcium channel blockers and other basic maintenance meds. These are very inexpensive medications that really do prevent strokes, heart attacks, and kidney failure, which are very expensive when they do happen.

A) People don't make a cost-benefit analysis that that tells them paying the 5 bucks for the pills is worth it, especially if they need the 5 bucks for something else; and
B) Even if they did know how to do the calculation, they might just say what the heck, I'll take the chance, it isn't really going to happen to me.

And for that matter, sometimes people don't have 5 bucks. But we still have to pay for their dialysis.

While we're on the subject, what's in that tea they're drinking anyway? The whole thing is supposed to be about cutting government spending, but the last thing in the world they will ever stand for is -- cutting government spending, specifically in this case spending on Medicare. The Patient Protection and Affordable Care Act created the Patient Centered Outcomes Research Institute, which will fund comparative effectiveness research, but the language specifically states that the institute "shall not develop or employ a dollars-per-quality- adjusted life year (or similar measure ...) as a threshold to establish what kind of health care is cost effective or recommended under Medicare." So we aren't allowed to save money because that would be "rationing." We have to cut spending, cut taxes, cut the deficit, and commit ourselves to infinite spending on Medicare. But we also can't guarantee health care for people under 65.

Makes perfect sense.

I am now headed for Windham County, which is positively infested with turkeys -- real ones, the kind the pilgrims ate, not the grotesque freaks farmers have bred with gigantic breasts and microscopic brains. Real turkeys can fly, quite well. And they're smart enough to thrive and multiply despite the harsh New England winters, and the foxes, coyotes and bob cats. If Ben Franklin had gotten his wish, and the turkey, rather than the eagle, had become our national symbol, would we be less inclined to go to war?

A slightly tough question

I guess. At least it seems to be to a lot of people. For reasons I cannot disclose, I've been thinking a bit lately about the placebo effect -- or possibly effects. Due to some combination of expecting to get better, and therapeutic attention, people who get treatments that have no specific biological effect tend to report that they feel better than people who get no treatment. This only works, obviously, with symptoms. There is a strong response to placebos in depression, and many people also respond who have chronic pain.

Now, this is philosophically a bit tricky to begin with. Pain and depression are more or less defined as particular ways that people feel. There could be "objectively" measurable correlates, such as range of motion in the case of pain or appetite in the case of depression, but if people say they feel better, then it seems pretty ridiculous to say the treatment wasn't really effective. Feeling better is what they want.

Accordingly, Brian Berman and colleagues raised quite a few hackles back in July when they argued in NEJM that physicians ought to refer people with idiopathic chronic low back pain (CLBP) to acupuncturists. CLBP is a real pain in the backside because most of the time, it doesn't correspond to any identifiable physical cause and it doesn't respond well to analgesics, physical therapy, or anything else. Surgeons used to do spinal fusion all the time, until it was shown that the surgery was actually a placebo. People responded just as well to fake surgery, in which they were opened and closed but nothing else was done, as they did to the real surgery.*

It turns out that people with CLBP also respond to acupuncture, even though it is well established that acupuncture is actually bogus. It doesn't matter where you insert the needles, or even whether you insert them at all. As long as people think they've had acupuncture, they often report feeling better. The same is true of homeopathy. Homeopathic 'remedies' are completely useless, but homeopathic consultations make people feel better.

So should doctors give people fake pills, or fake physical interventions such as pretending to stick needles in them? It only works, remember, if you tell the people that it will make them feel better. Actually, that's true, but it's only true because you're saying it. In other words, you're fooling them, sort of, but as long as they are fooled, it's not fooling . . . And this sentence is a lie.

Okay, here's what I think. There is no need to pay money to fake therapists for fake treatments. We can instead have real doctors who are engaged, empathetic, take time with their patients, and give them whatever treatments they can that have been shown to be more effective than placebo, along with encouragement and sound advice about coping. As Edzard Ernst writes (in the essay whose abstract is linked above):

Modern mainstream medicine seems to neglect the importance of medical core values such as empathy, sympathy, time, understanding and holism. This creates a situation where alternative practitioners tend to provide the non-specific and mainstream doctors the specific effects. Clearly this is wrong and may be one reason why patients consult alternative practitioners.

*Yes, this resulted in the famous defunding of the Agency for Health Care Policy and Research at the behest of spinal surgeons who cared more about money than they did about their patients.

Excavating my past

I don't recall whether I have mentioned it in this space, but I'm getting ready to move from my home in Boston, where I have lived for more than 20 years. I haven't sold the place yet, but I've started going through the mass quantities of paper and junk, moving what I can to my country place and deciding on what to landfill.

It turns out I have a lot of stuff I didn't know I had, and I did quite a few somewhat consequential things I hadn't thought about for a long time and had nearly forgotten. Back when I was in graduate school, for example, I paid for my crusts of bread with a consulting business. Among the projects I took on were a minority needs assessment study for the city of Fitchburg, Massachusetts; and strategic planning processes, including environmental assessments, for Boston Mobilization for Survival and Boston's Multicultural AIDS Coalition.

I found my files from these projects in a box in a spare bedroom I've been using for storage. This all happened in the early 1990s, and obviously there is no practical need to keep the papers. I ended up tossing them. But it got me to thinking about history. It consists of stories built around whatever evidence happens to have survived.

Ethnic relations in the post-industrial Merrimack Valley in the 1990s would be an interesting subject for a history dissertation. Fitchburg is a lot like Lawrence, where the famous Bread and Roses strike happened in 1912. It's a mill town where back then, immigrant workers were from Eastern and Central Europe, Ireland and French Canada. In 1994, those were the "indigenous" residents and the town was painfully absorbing a big influx of Latinos (lots of Uruguayans, for whatever reason), Hmong refugees who had been resettled there, and of course it had an African-American population from the great migration north of the Depression and war years. All of this with a scarcity of jobs, far from the big city.

The early days of the HIV epidemic, as a social, political and cultural phenomenon in African American, Latino and/or Haitian communities, would make another good dissertation; as would the remnants of the New Left as the counterculture 60s (which lasted from 1964 to 1975) faded away in the 1980s and 90s.

My files would have been a good resource for any of those: lots of pertinent interviews, survey data, and minutes of meetings where highly knowledgeable key activists were debating the state of affairs and what to do about in great depth. It's possible that the relevant organizations still have some of it in their archives but I doubt it. Leadership has moved on, the times have changed, I expect that at some point they did the same file purging I did. So all that is gone.

Why didn't I hold on to the files? Basically, I consider the probability vanishingly small that anyone with an interest in these little bits of history would ever track me down and connect with my yellowing pieces of paper. I've got enough stuff to schlep and organize, I just can't keep it all because someday, some way that I can't possibly predict somebody might be interested in it. And I don't think any university library is going to want to catalog and archive my papers when I'm gone either.

How much of what we think we know about the past is a function of what documents just happened to survive? I know historians worry about such questions all the time, but it was interesting to hold some pieces of the past, not entirely insignificant, in my hands, and realize that I am part of the age old process of selective memory.

Hang up and drive!

So sayeth Ray LaHood. And he's right. As an irredeemable pedestrian, I am tired of nearly getting killed 5 times a week by idiots sailing through stop signs while steering with their knees while yelling, "So she was like, 'No way!' and I was like 'Way' and she was like 'No way' and I was like, 'Whatevah'" into their phones.

World of Illusion

I'm reading Joseph Stiglitz's book Freefall: America, Free Markets, and the Sinking of the Global Economy. (WW Norton and Company, 2010)

This isn't a review, per se -- I haven't even finished it -- but some reflections. Stiglitz is a prominent economist -- indeed a winner of the phony "Nobel Prize" that economists give each other -- so it's comforting to see him agreeing with what I have maintained here all along.

Stiglitz says, quite directly, what I have also said, that economics, as taught, practiced and promulgated, is a form of theology, not a science. This is a specialized use of the word theology, by both of us. Economists don't talk about God, but they use the methodology of theologians. Theologians begin with received truths, purported facts written down in scripture or declared by priestly authorities, and construct edifices of thought on these assumptions. Some of their effort is devoted to spinning out consequences, whether descriptive, explanatory, or prescriptive (i.e. moral) from their assumptions. Some of their effort is devoted to vindicating the assumptions in spite of the manifest failure of observable reality to correspond to them. For example, the problem of theodicy - how can God be all powerful, just and compassionate, given that the world does not exhibit justice or goodness?

Economists proceed in exactly the same manner. They make a large number of assumptions, all of which happen to be rather obviously false. They build an elaborate edifice of theory based on those assumptions. Then they forget that the assumptions are false and insist that reality corresponds to their theory, even though anyone can see that it does not. Many of the people who engage in this sort of exercise are among the most prominent academics. They receive salaries much higher than professors in other disciplines, they receive high level political appointments, and their absurd beliefs are central to much of the political and policy discourse in the United States and elsewhere in the world.

The prevailing central assertion of these theologians for many decades has been that an entity called the "Free Market" efficiently allocates resources and maximizes prosperity, is "self-correcting," i.e. it maintains itself in an "equilibrium state" from which goodness flows, and it works best when government intervenes the least. Taxes and regulations can only damage its mystic perfection.

To be sure, they admit that in exceptional circumstances, so-called "market failures" can occur. Here and there we may need to tweak things a bit. But these exceptions can best be understood in light of the prevailing truth of the God-like Free Market.

This is unalloyed, irredeemable nonsense. No such entity as this so-called "Free Market" exists, has ever existed, or ever could exist. Markets are social constructions, not forces of nature. In wealthy, technologically advanced and complex societies such as ours, markets are creatures of government, and they depend on continual, sustained and massive government action and intervention to exist and to function. They are not self-correcting, they do not allocate resources efficiently, they do not maximize prosperity, especially when regulation is minimal. The question is not whether they are regulated, but rather how -- for whose benefit.

I will say more about this in coming days. For now, I will leave us with this. We are trapped in a discourse that takes the word of these charlatans -- and I mean you, Alan Greenspan, and Greg Mankiw -- as genius. In fact, the technical term for it is bullshit. A couple of basic points. Lower taxes are not associated with higher economic growth. Reduced regulation is not associated with higher economic growth. Cutting taxes and regulation does not cause there to be more jobs or more national income. These assertions are indeed, as George W. Bush said, "Economics 101," and they are also false.

Buddy, have you got the wrong blogger

One of the interesting perks of blogging is that I get all sorts of pitches from publicists. It's surprising how many academic physicians are paying flacks to promote their breakthrough research, that the Nobel committee has somehow overlooked. Medical device manufacturers, drug pushers and even outpatient surgery centers think I might just throw them a mention here.

Not to be.

Even weirder, I would say, or maybe not, are the woo-meisters, the purveyors of the mystic arts and the miracle cures that "They" don't want you to know about. I consider these pitches weirder because, while I'm likely to ignore the former category, I'm likely to trash the latter. As I shall now proceed to do.

The first comes from a "manufacturer and marketer of leading natural supplements that promote optimal joint health." Well, no they don't. There was a flurry of interest a few years back in glucosamine and chondroitin, constituents of cartilage, as possible treatments for osteoarthritis. Later, more rigorous trials have been largely negative -- i.e., it doesn't work -- though perhaps equivocal in allowing some modest benefit for some people with moderate to severe joint pain. While no benefit of these supplements has been demonstrated, they probably won't hurt you, but they aren't likely to do you much good either.

So okay, selling this stuff isn't the worst scam out there. However, what is definitely a scam is the pitch this company uses. Their press release is headlined "Patients fire doctors over trust issues; PATIENTS GROWING WEARY OF DOCTOR/DRUG COMPANY RELATIONSHIPS SEEK ALTERNATIVES; More People Trust Own Instincts Rather than Endure Misleading Consultations." They cite a report in the Archives of Internal Medicine to the effect that most physicians accept items of value from drug companies. They exaggerate -- mostly we're talking the triangular plastic pen and the Post-it pad, but they go on about trips to exotic locations, speaking fees, and fancy dinners. Only a small minority of physicians nowadays get major gifts from drug companies, but it does still happen, it is corrupt, and I'm agin' it.

Nevertheless, it does not follow that you should stop consulting physicians, abandon their prescriptions, and depend on your own "instincts" to treat yourself from the snake oil aisle. In case you didn't notice, this company is itself making money by selling the stuff. So why should you trust them? Your doctor might have gotten a free pizza during his residency, but he isn't getting kickbacks from the drug companies. Probably. And he does at least have treatments available for which there is good evidence.

Worse is an "Ayurvedic M.D. and Naturopathic Physician," who is co-founder of a company that markets "ayurvedic herbs." He wants me to practice breathing exercises appropriate to my "dosha," or "natural constitution." I was once told that I'm a Pitta, meaning I "tend to run warm, get easily irritated and impatient and experience heated digestion." Fortunately I'm not a Vatta, or I would be "be anxious and absentminded and experience flatulence and constipation." As a Pitta, I'm supposed to:

1. Open your mouth to form an “O” shape. With your mouth in this position, form a funnel with your tongue and place it between your lips*

3. Slowly inhale through your tongue and feel the breath reach your heart

4. Relax the tongue and mouth, and then exhale through your mouth

5. Repeat this exercise 16 times, twice a day

* If you cannot form a funnel, bring your teeth together and inhale through your teeth instead

While the joint supplements are dodgy, this is total bullshit that the guy pulled out of his orifice of flatulence and constipation, after first getting his head out of the way. He then reinserted it. The mystery is why anybody believes this garbage.

The medical profession needs to clean up its act in many ways, not least because the ethical lapses create an opening for con artists. I hope the top docs will take this to heart.

The Quality of Quality

As Kathy noted on my previous post, there can be a lot to process when you're doing focus groups or any form of qualitative social research. We often hear confidences from our friends and family, have to respond to trauma in our own lives and our loved ones' lives, and live through hard times. Health care and social service providers obviously have to interact with very sick, dying and bereaved people as part of their daily routine. But there is something particular and particularly challenging about hearing tragic stories as a researcher.

I have to do my best not to influence how people present themselves, or steer the data in any direction. Normally, when it's appropriate to offer sympathy or reassurance or advice, that's what sane people do. Sociologists, however, ordinarily have to be very careful not to become a part of the real life of the people who we're trying to understand. (There are exceptions, mostly from the anthropological tradition, where investigators enter life worlds. But that's not what I was doing yesterday.)

That doesn't mean we don't care, or they're just specimens. If people really need help right away, of course we'll try to get it for them, and in a real emergency we'll step out of our role if we have to. In fact, I really have to be in the moment, I really have to empathize and understand, so I can figure out what questions to ask and where the discussion needs to go. But I also have to stay in my role of an observer and data collector. It's very taxing. Fortunately, in the situation I just worked in, the people were supportive of each other -- which is an observation -- so I didn't have to feel so stressed about it.

With the development of cheap electronic digital computing, social science, which had once been a largely descriptive discipline, became much more quantitative, and obsessed with statistical analysis and mathematical models. Qualitative methods fell out of favor. They were widely seen as intellectually inferior, not really scientific, more akin to literary art.

Fortunately we're getting past that. Fancy math is worthless if you don't understand what it is you are counting. We got to the point where our reductionism was squeezing the juice out of life. Human social interaction is different from biological processes because it has a particular kind of meaning for us, that we don't have very compelling ways of collapsing into few and definite categories that have specific, quantifiable relationships.

Because it is easy to turn survey data into mathematical models, survey methods became extremely popular in the social sciences, but as the saying goes, garbage in, garbage out. The investigator decides how to phrase the questions, and what responses to offer. Whether it makes sense to you, or means very much to you, as a respondent, is not the researcher's problem -- and we all know how annoying it can be to respond to a survey that doesn't ask the right questions, or asks them the wrong way, or doesn't let us give the answer we want to give.

On the other hand, just because I talk with some people and I see particular meaning in what they say to me, or to each other, doesn't mean you necessarily have to believe that my insights are the right or most important ones, or that those people are like others. We need ways of cogently defining units of meaning in social interactions and people's social worlds, counting them, and testing their associations with each other. It's a slow process, working back and forth between qualitative induction and quantitative deduction, and the average lay person probably doesn't think we've really gotten anywhere. But we have. A lot of what we have learned, however, people don't want to believe. But that's a problem for another day.

So what the heck do I know?

I'm involved in various forms of research based on the premise that "patient centered communication" is like, you know, good. That means that doctors encourage patients to say what's on their minds, set shared agendas, engage in shared decision making, enter patients' life worlds and understand how their values and goals intersect with biomedical understanding to shape the right choices for them, yadda yadda yadda.

This is, of course, in contrast to the old idea of medical paternalism where the doctor tells us what to do and we follow orders.

So, as part of this whole program, I'm running focus groups with people with HIV to talk about their relationships and communication with their doctors about antiretroviral medication taking and other such issues of their own behavior. So what do they like? It turns out they like it when doctors scold and yell at the people who screw up. That proves the doctor really cares.

At least that's what they tend to say when I ask them. It does not follow that it works in real life, but still. The life of a social scientist is a continual carnival of surprise and wonder.

(I did two focus groups today, which is actually fairly grueling. I have to do two more tomorrow then fly back to Boston. And no, I don't get time and a half.)