Easy math?

A concept which is closely related to Bayes' theorem, and may be a somewhat easier way of understanding the relevant qualitative issues, is absolute risk vs relative risk. As you know if you are a faithful reader, the culture in the United Kingdom is much more favorable than ours to both the rational allocation of medical resources, and to promoting understanding of cost-effective care among the general public. So, fly across the pond with me for a good explanation.

In a nutshell, if I tell you that taking this test or swallowing a pill every day for the rest of your life will cut your risk of going tone deaf from Oppernockity's disease* in half, it might sound like a good idea to go for it. But if I told you that your chance right now is 1 in a million, and doing the test or the pill will make it 1 in 2 million, you might not be so inclined.

In fact it doesn't have to be some weird disease I made up that you never heard of. Your chance of getting some specific form of cancer, for example, is quite low. You may have heard otherwise -- that the chance of a woman developing breast cancer, for example, is 1 in 9. The risk of cancer rises with age, so if you live to 80 there may be a 1 in 9 chance of having a detectable lesion, but that doesn't mean it's going to kill you or make you seriously ill before something else gets you. Almost 100% of men develop prostate cancer but if we weren't aggressively looking for it the vast majority of them would never know it.

So public health specialists generally like to put risks inside of time frames -- what is the chance of this happening to you within 10 years, might be a typical question. The reason is that a lot can happen in that time. You could die of something else, or have bigger problems to worry about; or a miracle cure could be developed, or a better and cheaper and safer preventive.

As the linked article explains, a useful metric is the Number Needed to Treat. If the prior risk is 4/100, and a treatment reduces the risk to 3/100, that's a 25% risk reduction, which sounds pretty good, but you'd have to treat 100 people to prevent one instance of disease. That means there is a 1% chance it would benefit you. That's what you have to weigh against side effects, cost, and hassle. Put it that way, and lots of interventions and tests that are commonly done don't really seem worth it after all.


* He only tunes once.

Math is hard!

I have a problem, which is rooted in a very discouraging observation. I have the task of explaining Bayes' theorem to some regular folks who aren't necessarily mathematically minded. I tried to explain it to readers here once a while back, and I thought I'd done okay at the time but maybe not?

It turns out that a very large proportion of the people really don't get math at all. Bayes' theorem isn't actually very sophisticated mathematics -- all you need is high school algebra. There are no exponents, just multiplication, division and addition. But people tell me my explanation is just incomprehensible gobbledygook. I can't for the life of me imagine why -- it's straightforward, perfectly simple, and crystal clear as far as I'm concerned. The problem is that it has numbers in it, and an equation, and that seems to be enough to make people run screaming for the exits.

We really need to do something about this. I think that the shrieking mobs (metaphorically) who attacked the new mammography screening recommendations were largely a function of innumeracy, as is the paranoia about health care "rationing" and death panels. If people could just get into their heads the basic ideas about probability and absolute and relative risk, and the magnitude of risks and their consequences, we could have much more fruitful conversations about public health and health care policy. But it seems they just can't.

I did a mini probability and statistics course a while back. I can re-run it and try to improve it if that seems like a good idea. (Any advice will be appreciated.) And if anyone cares to check out the post on Bayes' theorem and tell me why it's absolutely impossible to understand, I'll take that too.

Since most people don't know . . .

what is in the Romneycare legislation the president signed last week, our hospital CEO has provided us with a pretty good summary. It's still a bit long for this blog, so I'm going to give you a summary of the summary with a comment or two from YT. Almost all of the outrage about this is either fake (in the case of Republican politicians such as the author of the legislation, Mitt Romney) or else comes from people who believe all kinds of stuff that isn't true. Maybe this will help you talk to them (though I doubt it). (Credit to my employer's staff for much of this, but they didn't say it was proprietary.) My comments in italics.

Expanding health insurance coverage

o 95% of legal residents will now have health insurance coverage. Emphasis mine. This is not really a true fact, it's a prediction. We'll see.

o Expanded coverage will be delivered through health exchanges in each state offering health insurance plans, similar to the Massachusetts Connector, which serves as a health insurance marketplace. Providers’ rates would be negotiated by the health plans and the providers. This exchange scenario should provide more consumer choice and competition among insurance companies.

o To be clear, this bill does not contain a government run public health insurance option as a means of providing more people with access to health insurance.



Expanding access by providing government subsidies

o The health reform bill provides federal subsidies for health insurance to individuals and families with incomes up to 400% of the federal poverty level (FPL) ($43,320/individual and $88,200/family of four). Massachusetts only provides subsidies to individuals and families with incomes up to 300% of FPL, so increasing subsidies from 300% of poverty to 400% of poverty could cover about 75,000 more people in Massachusetts. These Massachusetts residents are already required to have insurance or pay a penalty; so "cover" more people means give more people subsidies, not give more people insurance.

o Tax credits will be provided to small employers that provide health insurance, and have fewer than 25 employees with average annual incomes of less than $40,000. The tax credits are available for up to 35 percent of their contribution toward the employee’s health insurance premium.

Paying for expanded coverage

o The bill is slated to cost $940 billion over ten years.

o Much of reform package is paid for in cuts to Medicare reimbursements to providers, new taxes and industry fees. Congress and the administration held true to their provision that all players must “put some skin in the game” as we see in the rate cuts and fees or taxes levied on all of the major stakeholders. That includes providers, employers and consumers, pharmaceutical companies and medical device manufacturers. And most importantly, Government has a responsibility to pay its fair share. Note: these are not, repeat not cuts in Medicare benefits; they are reductions in reimbursements to providers. While providers complain that they can barely get by on Medicare as it is, these reductions are targeted so as to encourage efficiencies, not drive providers to the poorhouse. Our CEO is worried about this but not despairing, writing "Further cuts to Medicare fees will require that we become increasingly efficient and prudent about how we use our limited resources." This is not the best way to start to contain costs but it's the only way forward with the wingnuts screaming about death panels.

Individual Mandate beginning in 2014

o The bill imposes penalties on individuals and families if they do not purchase health insurance.

o An income tax penalty will be applied to hose without coverage ranging from $695 (single) per year up to a maximum of $2,085 (per family) or 2.5% of household income, whichever is higher, by 2016. Unfortunately, this is considerably less than the cost of insurance and some people will undoubtedly choose to pay the penalty. Then they'll be hit by a bus or get cancer and, since medical underwriting will be banned, they will still be able to buy insurance and make the rest of us pay for their irresponsibility.


Employer Mandate

o The reform package requires employers to provide a minimum level of benefits to employees and imposes a penalty on employers if they do not.

o Firms with more than 50 employees will pay an uncovered worker fee of $750 per uncovered person per year by 2016. Again, much less than the cost of insurance, obviously, but a small revenue stream to help pay for the subsidies.

o The reform law does not contain a fee assessment for new hires in a waiting period for their insurance, but limits waiting periods to 90 days beginning in 2014.


Other taxes and fees levied to pay for expanding access

o A 3.8% Medicare tax on investment income of high-income households. An increased Medicare tax on high-income households by 0.9 percent. High income is defined as more than$200,000 for singles, more than $250,000 for married couples filing jointly. Good! The Medicare tax as it stands now is regressive. This will help keep Medicare solvent, although it's only a start. They should do the same thing with Social Security, BTW.

o An excise tax on premium plans, so-called “Cadillac health plans”, will raise $32 billion. Cadillac plans are those with low deductibles, low co-pays and rich benefits. I don't particularly like this -- everybody should have comprehensive insurance with low cost-sharing, it's in society's best interest. On the other hand, if ways can be found to keep prices down while still providing good benefits, thereby avoiding the tax, okay.

o An excise tax on tanning. Sounds kind of stupid but it's a public health issue. Tanning is dangerous, causes melanoma, and should be discouraged.



o Taxes on the pharmaceutical industry totaling $28 billion over 10 years. The industry benefits enormously from publicly sponsored biomedical research. They owe us this money.



o An excise tax on the medical device manufacturing sector to raise $20 billion over 10 years. Ditto.



o An excise tax on insurance companies to raise over $57 billion over 10 years. This is kind of stupid -- it's a perpetual motion scam.



Cuts to Medicare and Medicaid

§ Reductions in Medicare and Medicaid Disproportionate Share Payments (payments made to states for treating a disproportionate number of Medicaid and Medicare patients). Ideally, this would become an anachronism anyway, but right now it isn't; Medicaid rates in particular are too low and some hospitals have a hard time making ends meet.

§ Medicare Advantage Rates Frozen in 2011 until 2012. Government payments to Medicare Advantage plan (for seniors) cut $132 billion over 10 yearsGood. M.A. is an insurance industry scam on the public.


§ Tighter restrictions on payment for readmissions to hospitals. This is a bit arcane but basically, it's a way of encouraging higher quality, better coordinated care. It's a good idea.

Insurance reforms

o Healthcare reform creates significant changes to the way insurance companies do business. The overall impact to payers is that they will see many more new customers; new market opportunities through state health exchanges and new regulations and oversight. You'll notice their stock prices jumped.

o There will be temporary mechanisms to provide coverage to individuals with pre-existing conditions and for non-Medicare eligible retirees over age 55. This will happen within 90 days of enactment of the bill. Still won't be affordable though -- few will benefit, I think.



o Insurers will be prohibited from setting annual and lifetime limits, dropping coverage (except in cases of clear fraud), and excluding coverage to children based on a pre-existing condition. This will take effect within six months of enactment of the bill. First steps toward eliminating medical underwriting. Bravo!

o Parents will be able to include dependent children up to age 26 on their health insurance plans. A stopgap, half-assed measure intended to give people a lollipop right away, for political reasons. A good idea on that basis.

o Health insurers would be prohibited from excluding coverage based on pre-existing conditions for adults, beginning in 2014. She also doesn't mention that rate discrimination can be on the basis of age only. This will largely end medical underwriting although the bad news is people in their 50s and early 60s may have real affordability problems even with the subsidies.



Other provisions

o Primary Care Physicians: Requires states to increase Medicaid payment rates to primary care providers in 2013 and 2014 only to Medicare levels, and provides 100 percent federal funding for the incremental costs to states.

o 340B Program: Extends eligibility for the 340B drug discount outpatient program to children’s, cancer and critical access hospitals, as well as certain sole community hospitals and rural referral centers. It does not expand the program for existing 340B hospitals (of which we are one) to cover inpatient drugs. This is a significant disappointment, as it would have resulted in large savings and administrative simplification, but was clearly an area where pharma lobbying won out.

o Graduate Medical Education: Contains no reductions in IME (indirect medical education) payments. This is a critical piece as it shows government’s understanding of the importance of protecting the pipeline of new physicians – for which there will be increased demand across the country. This will not happen fast enough. We'll need new efforts to create more Nurse Practitioners and Physician's Assistants to meet the need for primary care.


She forgot to mention the death panels, and the government takeover of 1/6th of the economy. I guess those are in the secret codicil.
o Resident Slots: Redistributes 65 percent of unused residency training positions for qualified hospitals who would be able to request up to 75 new slots.



o Malpractice Reform: Creates grant programs for states to enter into pilot programs to begin examining malpractice reforms. This measure is not as strong as many of us in the industry had hoped it would be, however we will continue our fight on the state level for greater malpractice reform measures.



o Medicare Part D gap: Starts closing Medicare Part D gap; expansion begins with $250 rebates for enrollees entering donut hole in 2010. Closing Medicare Part D ‘donut hole’ would increase pharma volume from seniors, so pharmaceutical companies will receive significant benefit from the healthcare reform changes.



o Flexible Spending Account : Increases contribution limits for flexible spending accounts to $2,500 per year and then grows by the annual Cost of Living Adjustment.



o Demonstrations and Pilots: Creates and encourages many pilot and demonstration projects on funding mechanisms and care delivery, such as ACOs and bundled payments.



o Physician Self-Referral: Bans physician self-referral to physician owned hospitals.

What seest thou else . . .

in the dark backward and abysm of time?

This news about research using the Hubble Space Telescope to study the structure of "dark matter" in the universe may or may not interest you, but contemplate this if you will:

Thanks to an improved algorithm to analyze the images, Schrabback's team could study in great detail the shapes of over 446,000 galaxies in a 1.64 square degree patch of sky.

Half a billion galaxies of one hundred billion stars each in one 50 thousandth of the sky. And oh yeah, God wants Josef Ratzinger to tell what's wrong and what's right.

Update: BTW, I should have offered this link in the first place. The Hubble space telescope has its own web site, and it is kick ass. You think you have a photo album?

Now this is just weird

If Calif. Legalizes Marijuana, Outlaw Growers Say It Will Drive Down the Price of Their Crop and Damage Economy. Apparently the good people of Humboldt County fear their time-hallowed way of life will come to an end if California voters legalize the Weed With Roots in Hell. This is an objection I frankly hadn't thought about. The economy of Humboldt County is so dependent on keeping la yerba illegal that they're against making honest hippies out of themselves.

Of course their interests are also allied with the psychopathic drug cartels that are destroying the fabric of Mexican society. Making the aging '60s refugees of the north coast compete with corporate growers seems a small price to pay for a measure that would eliminate a major social problem in one stroke -- substantially reduce the prison population, free the police to worry about actual crimes, stop ruining young people's lives for no good reason, put a whole of real and very vicious criminals out of business, end the persecution of a whole lot of people with serious illnesses, and generally make the world a better place.

Not that this has anything to do with me personally, mind you.

This is kinda NICE . . .

Kinda. We have monthly faculty presentations here. I always learn something, except when I present, and yesterday I learned a bit about Medicare's National Coverage Determination process. Doctors can't just order up any old licensed procedure or drug and bill for it -- CMS (the wacky abbreviation for the Centers for Medicare and Medicaid Services) decides what Medicare will pay for, and for whom. In other words, patients have to meet certain diagnostic criteria in order for Medicare to reimburse particular services; they won't pay for off-label prescribing.

By an amazing coincidence, in fact, they sent me an e-mail today announcing a new National Coverage Determination, and I think it's a good example. Antiretroviral medications for HIV, and specifically protease inhibitors, can have an unfortunate side effect, called lipodystrophy. They cause abnormal redistribution of subcutaneous fat, which can produce a so-called "buffalo hump" on the back, and leave the face looking gaunt. So, CMS will now pay for dermal injections to improve the facial appearance, but only in people with HIV who have lipodystrophy. You can't get CMS to pay for those Michelle Pfeiffer bee-stung lips. If you back up on the web site you can see all the National Coverage Decisions.

CMS is not allowed to take cost into account, but only medical necessity and "reasonableness." According to the analysis by my colleague, more cost effective interventions are more likely to be approved, presumably because if there's already something just as good or better, and cheaper, the new intervention isn't actually "necessary." So this isn't quite like the UK's NICE -- if there's no better alternative, basically even the most expensive treatments can be approved -- but it does provide a starting point for bringing order and reason to our health care spending. Of course, we don't have a single payer system either, but private insurers keep an eye on these decisions and they do help legitimate their own restrictions.

One consequence that people haven't talked about much of the legislation the president signed yesterday is that when the companies can no longer do medical underwriting, they will have to look for other ways of keeping costs down and competing on price. They won't improve their popularity by screwing people who legitimately need treatments, so they will now have much more incentive to look for reimbursement policies and ways of restructuring delivery that get us more for our money. In other words, even though there isn't much in the way of cost containment in the legislation, maybe we'll get some anyway, as a beneficial side effect.

We already have some basic infrastructure at CMS. Let's build on it.

The horror, the horror!

I'm reading Peter Conrad's chapter on the medicalization of baldness.* It turns out that, quoting Valerie Randall, "In our youth-oriented culture, the association of hair loss with increasing age has negative connotations and, since hair plays such an important role in human social and sexual communication, male pattern baldness often causes marked psychological distress and reduction in the quality of life. . . "

Oh shit. It gets worse. "Wells, Willmouth and Russell found that hair loss in men is associated with depression, low self-esteem, neuroticism, introversion, and feelings of unattractiveness." No wonder that "Emanuel Marrit, a hair restoration surgeon, sees this as his medical responsibility: 'That simple office procedure has, in reality, just handed me a life sentence of follicular responsibility. The weight of this awareness is not only humbling, it can be, at times, simply overwhelming."

As the enormity of the tragedy which has befallen me finally dawned upon me, I at first berated myself for my own obtuseness. How could I have lived so long in denial? How could I have been so willfully blind? A lesser man might have contemplated suicide. As if the low self-esteem, depression, unattractiveness and neuroticism to which I am doomed were not enough, my self-loathing can only be compounded by the blame I am owed for inflicting such an intolerable burden on the noble Dr. Marrit.

But as it turns out, I do not give a FFOARD about Dr. Marrit and the cross he bears. Even worse, I am sure, from his point of view, I do not plan to pay him for hair plugs. Nor do I intend to pay Pfizer or Merck or anybody else for Propecia, Rogaine, or rancid boar fat (a remedy known to the ancients). No, so sunk am I in moral depravity and indifference to the contempt and scorn of humanity that I actually do not care whether I have hair on the top of my scalp or not. Say what you will about me, I care not a fart for your opinion. Bring it on.

Update: Ironically (and I believe I use the term correctly) I got a spam comment on this post from somebody touting a miracle hair loss remedy. (Deleted of course.) Just about says it all . . .


*Peter Conrad. The Medicalization of Society: On the transformation of human conditions into treatable disorders. The Johns Hopkins University Press. 2007

Creeping Socialism

The communosocialofascist government takeover of health care has had a surprising effect: Health care stocks rose Monday as the long-debated health care reform legislation heads to President Obama's desk. CNNMoney.com reports:

Hospital operators, including Tenet Health Care (THC, Fortune 500) and Health Management Associations (HMA), led the advance, surging about 8%. Community Health Systems (CYH, Fortune 500) and Lifepoint Hospitals (LPNT) added more than 4%. . . . Health insurers' stocks, which climbed as high as 8% last week in anticipation of the vote, were mixed. With the government extending coverage to more Americans, insurance companies are likely to benefit from higher enrollment, said BMO Capital Markets analyst Dave Shove. . . . Drugmakers Pfizer (PFE, Fortune 500), Merck (MRK, Fortune 500) and Bristol Myers Squibb (BMY, Fortune 500) hiked almost 2%, and medical device manufacturer Medtronic (MDT, Fortune 500) spiked nearly 3%. The bill's expanded coverage is expected to benefit drug companies and medical manufacturers as well.

Where would Stalin invest?

Dissenting voices

Robert Reich:

don't believe anyone who says Obama's health care legislation marks a swing of the pendulum back toward the Great Society and the New Deal. Obama's health bill is a very conservative piece of legislation, building on a Republican rather than a New Deal foundation. The New Deal foundation would have offered Medicare to all Americans or, at the very least, featured a public insurance option.

The significance of Obama's health legislation is more political than substantive. For the first time since Ronald Reagan told America government is the problem, Obama's health bill reasserts that government can provide a major solution. In political terms, that's a very big deal.

As I say, it's not that I like the legislation so much as I like the politics. But that means we have a long way to go. David and Steffi, however, don't even like the politics. This hasn't been posted yet, so I'll just quote from the e-mail they sent.

The following statement was released today by leaders of Physicians for a National Health Program, www.pnhp.org. Their signatures appear below.

As much as we would like to join the celebration of the House's passage of the health bill last night, in good conscience we cannot. We take no comfort in seeing aspirin dispensed for the treatment of cancer.

Instead of eliminating the root of the problem - the profit-driven, private health insurance industry - this costly new legislation will enrich and further entrench these firms. The bill would require millions of Americans to buy private insurers' defective products, and turn over to them vast amounts of public money.

snip

It didn't have to be like this. Whatever salutary measures are contained in this bill, e.g. additional funding for community health centers, could have been enacted on a stand-alone basis.

Similarly, the expansion of Medicaid - a woefully underfunded program that provides substandard care for the poor - could have been done separately, along with an increase in federal appropriations to upgrade its quality.

But instead the Congress and the Obama administration have saddled Americans with an expensive package of onerous individual mandates, new taxes on workers' health plans, countless sweetheart deals with the insurers and Big Pharma, and a perpetuation of the fragmented, dysfunctional, and unsustainable system that is taking such a heavy toll on our health and economy today.

This bill's passage reflects political considerations, not sound health policy. As physicians, we cannot accept this inversion of priorities. We seek evidence-based remedies that will truly help our patients, not placebos.

A genuine remedy is in plain sight. Sooner rather than later, our nation will have to adopt a single-payer national health insurance program, an improved Medicare for all. Only a single-payer plan can assure truly universal, comprehensive and affordable care to all.

Well okay. But politics is the art of the possible. As I say, there's at least some chance this gets us closer. So it's worth a shot. If we hadn't done this, we weren't going to get another one for the rest of my life, anyway.

Between now and November . . .

I wrote a few days ago that I wanted my Representative Michael Capuano to vote yes on the Mitt Romney health care legislation before Congress, and I am happy to say that he did so. I also said that from a purely policy wonk point of view anyway -- that is, leaving the political consequences of a defeat to the side -- I only support the legislation because I believe it gets us to new ground from which further changes can be made. That means that Democratic prospects in November are important in evaluating whether we will really find ourselves much better off in the end.

Since the major elements of the legislation won't take effect for years, you might think that the political impact will depend mostly on who succeeds in catapulting the propaganda (in the immortal words of a fool) between now and November. But as Karoli points out, there are some changes that will take effect quickly that people will experience positively.

A major success of the Republican campaign of lies was persuading older folks that the legislation would somehow take away Medicare benefits. In fact the opposite will happen immediately, the notorious doughnut hole will close and they will have lower out of pocket costs for medications. I don't suppose that will make any teabaggers reconsider, since the president's complexion isn't going to change, but Democrats can run on it.

The elimination of recissions, unfortunately, won't be noticed because people won't know what would have happened to them without the legislation but it may help informed progressives feel better about the whole thing and get more enthusiastic about November, which God knows we need. There may be a few people out there who don't have employer-provided insurance, who have pre-existing conditions, and who can afford to buy into the high risk pool. These will tend to be small business people and professional free-lancers, that sort of thing, who probably tend to be non-insane Republicans. Conceivably it will make a few people think twice, but it's a very small number. The same goes for people with children under 19 with pre-existing conditions. A few will benefit, but enough to matter politically? We'll see.

The funding for community health centers is an unalloyed good; but it will mostly benefit poor people who won't notice a dramatic difference in their lives, I think. Still, it includes people in rural areas who tend to be conservative for all the wrong reasons and it may soften a few of them up.

So there will be some folks out there who notice quickly that their lives have gotten a little bit better; and nobody will notice anything worse. Of course the price of health care will keep going up, and maybe people will blame the legislation. Still, if the Dems play their cards right and take advantage of the immediate effects of the bill to generate strong messages and stay on them, it can help them. If Obama still has majorities in both houses next year, he can keep going. The audacity of hope.

BTW: Here's a good summary of the bill. Seniors who hit the doughnut hole will get $250 in cash this year. That might buy a few votes, who knows?

We've made the zeitgeist

Stephen Colbert "does" medication adherence. (Starts at about 3:26)

The Colbert Report	Mon - Thurs 11:30pm / 10:30c
Cheating Death - Clenched Fingers & Pill Reminder
www.colbertnation.com
Colbert Report Full Episodes Political Humor Health Care reform

Stephen's sponsor, Prescott Pharmaceuticals, has invented a medication adherence robot. If you don't take your pills, it disables you with an unbearable hypersonic ululation and shoots pills into your mouth out of it's left arm.

Stephen is riffing on a real product which I'm surprised hasn't gone commercial even sooner. Grandpa's pill bottle has a computer chip in the cap that's connected to the Internet. If Grandpa doesn't open the bottle when he's supposed to, it sets off a flashing light; if he still doesn't open the bottle, it makes a robo-call to his cell phone.

This puts together technologies that have been used for a while in research studies and intervention trials, so I don't know why it took so long for somebody to put it all together and try to make money. But Stephen's intuition that this probably doesn't work very well, and that there is something Orwellian and oppressive about it, is pretty well grounded. There are people who really, really want to take their pills on time but just forget, and something like this might do the trick for them. However, there are also lots of people who for one reason or another don't really want to take the pills, or don't want to take them all the time, or don't want to take them badly enough to put up with a computer yelling at them, whatever they might happen to be doing at the time.

Let's face it: taking pills, especially if you have to take a bunch of them, forever, can be a pain in the gazongas. Side effects or no, lots of people just don't like to do it. It's a constant message to yourself that you're sick, there's something wrong with you. You can't help but worry that it's putting stress and strain on your body to keep pumping in these powerful chemicals. And you have to either be in the right place at the right time, or else remember to take them with you, and maybe you don't actually know that you'll be out of the house at 8:00 pm tonight but you end up somewhere else and then the phone rings and the damn computer is lecturing you . . .

In other words this problem doesn't really have a technical fix. We have to look a little deeper.

This will well-reward your time

By Andrew Corsello.

What Monbiot Says

As you know, I've been screaming myself hoarse about it for years:

Distrust has been multiplied by the publishers of scientific journals, whose monopolistic practices make the supermarkets look like angels, and which are long overdue for a referral to the Competition Commission. They pay nothing for most of the material they publish, yet, unless you are attached to an academic institute, they'll charge you £20 or more for access to a single article. In some cases they charge libraries tens of thousands for an annual subscription. If scientists want people at least to try to understand their work, they should raise a full-scale revolt against the journals that publish them. It is no longer acceptable for the guardians of knowledge to behave like 19th-century gamekeepers, chasing the proles out of the grand estates.

Sing it, George. He has a good deal else to say of value here as well.

Roundup of NEJM commentaries

The New England Journal of Medicine makes something like a million dollars a year off of drug advertising but they still hide most of their content from the public. I think that's a major scandal. The least I can do is let you in on some of the interesting observations.

This week, Wafaa M. El-Sadr, Kenneth Mayer (with whom I am acquainted) and Sally Hodder discuss the HIV epidemic in the United States. Remember that? It seems that most people don't, and it's mostly because of the people who are most at risk. The prevalence of HIV among Black men in Washington DC, for example, and among men who have sex with men in various places, is higher than the prevalence in South Africa, Kenya and other places in sub-Saharan African which attract much more attention, even in the U.S. High risk for HIV in the U.S. is largely confined to isolated social networks -- poor communities with low social mobility. Even among men who have sex with men, it is African American and Latino men, and those of low and moderate socioeconomic status, who are at highest risk. Now that we no longer have a high incidence of perinatal HIV in the U.S. (thanks to pharmaceutical prophylaxis) or risk from blood transfusions, it's "those other people" who have a problem. But in fact, we still have more than 50,000 new HIV infections every year here in the U.S.

Eminence gris Victor Fuchs weighs in with a fairly basic essay on health care spending. I say it's basic but it's basic stuff that politicians and "reporters" don't seem to understand. We can project future spending but that's largely guesswork. A lot can happen in 10 years that will affect how much we spend on the medical industry regardless of the policy decisions we make. However, the long-term phenomenon for at least 70 years is clear: medical advances largely drive increased medical spending. Some innovations can be cost saving, but most cost more. It might be worth it, but that's a separate question. It's a question we have to ask, as a society, and we stubbornly refuse to confront it. How much is it worth spending for a given incremental benefit in population or individual health? Screaming about "death panels" is just a fairly deranged way of sticking your fingers in your ears.

And so, Jordan VanLare and colleagues discuss the sort of comparative effectiveness research program we need. Of course, they won't go so far as to talk about cost effectiveness. Oh no, that would be rationing. Nevertheless the Institute of Medicine proposes that public participation -- including patients and caregivers -- is fundamental. (Notice they didn't say drug companies, but unfortunately we know what is likely to happen given the political conditions in this country.); that priorities for CER need to be established and made transparent; that we need to a coordinating body for CER; that we need to push for innovation in CER methodology; that we need to develop large-scale data networks to support CER; and we need a way to promote rapid adoption of recommendations coming from the CER enterprise.

Will this happen? We'll see after the November elections. One more reason to get out the vote.

Discourse Analysis

I contribute to the long-running blog Iraq Today, which used to be Today in Iraq. (We had to move due to a very weird episode involving a psychopath who accidentally was given administrative privileges. It kind of reminded me of an episode in my youth when, due to a psycho housemate, we all had to secretly organize to move out simultaneously on a Tuesday while Bob was at work.)

Anyway, as you may know if you've been frequenting the blogosphere for the past few years, there's no troll like a pro-war troll. They're kind of like soccer hooligans, and during the Emperor Chimpoleon the First administration, when they were all getting liquored up and breaking store windows to show their loyalty to their boy, policing the comments was a real chore. Things have settled down quite a bit since Americans have largely lost interest in Iraq and Afghanistan, which we also cover, but a couple of weeks ago we were subjected to an organized hack. We had haloscan commenting, which as you probably know has been bought out, and somehow in the transition the thugs managed to gain control over our commenting account. We were hammered for two weeks with a repulsive stream of obscenity, insanity, brutality and sheer depravity. I finally managed to solve the problem yesterday.

I enjoyed a brief spell of notoriety here once when I was named one of the top 50 science blogs and then posted on Blogs of Note. Wouldn't you know it, along came a howling mob of creationists and libertarians -- including self-proclaimed Christian libertarian creationists -- and I had to deal with a plague of identity theft, including commenters posting under my own identity; pro-Christian obscenities, insults and death threats; continual derailment of attempts at civil and rational discussion; and outright idiocy. I am pretty sure that a lot of those people were psychotic. Anyway, I had to ban a couple of them and eventually they all lost interest, which seems to happen. I notice that even Atrios lost most of his trolls by 2009. It's kind of sad in a way since I don't get many comments now. Trolls actually do gin up discussion, if nothing else.

The interesting observation is that there is a big and obvious difference between the discourse styles of the left and the right. Which ought to speak for itself. Any hypotheses as to why that is?

Pronouncement ex cathedra

After deep deliberation, I say unto you my Representative Michael Capuano, pass the damn bill.

It clears three high hurdles that can get us to a better place from which true goodness can be attained:

1) It imposes nationwide regulation on health insurance that incorporates the essential principles of community rating, minimum standard benefits, and guaranteed issue. No, we don't quite get community rating, but we get an endorsement of the principle, and we get closer;

2) It expands subsidies for low and moderate income people and makes insurance more affordable for more of them. No, it doesn't go far enough, but we get an endorsement of the principle, and we get closer;

3) It contains a nod toward expanded comparative effectiveness research and some small scale experiments in the reorganization of services and financing, and the rationalization of allocation. No, it doesn't actually go anywhere, but we get an endorsement of the principle, and it will help us get closer some day.

4) Update: I forgot to mention (nearly) universal participation, also absolutely essential.

Best of all, it will be a victory over Big Insurance and Big Pharma, and it will be a proof of principle that something can get done which is at least intended to be a blow for democracy and justice.

And Rep. Capuano, if it doesn't pass, there won't be enough Democrats in Congress in 2011 to do anything at all; and you don't even want to try to imagine who might be president in 2013. Vote yes, or be a tool.

Conspiracy theories

I more or less accidentally acquired a Facebook Friend who spends all day posting links about way-out-there conspiracy theories -- the Illuminati, the controlled demolition of the WTC towers, the FBI killed JFK, etc. She apparently never came across one she didn't believe. Oh yeah, vaccines cause autism.

I am what you call a skeptic, i.e. I remain agnostic about questions for which I have insufficient evidence. And oh yeah, I prefer to disbelieve stuff that seems unlikely, even if it might be fun to believe it. Nevertheless, just because we don't really know something doesn't mean we shouldn't be worried about the possibility of deeply concealed but major evil. It so happens that the integrity of the elections during the Rove/Cheney administration are in that category.

I am far from satisfied that George W. Bush was in fact re-elected in 2004. You shouldn't be satisfied either. Just sayin'. There is too much that is suggestive, odd and unexplained. If we had real journalists working for the corporate media, we'd know more by now.

The value of enemies

I have often said that Osama bin Laden is the best friend George W. Bush ever had. But their symbiosis could only succeed because of some unfortunate proclivities of human psychology. Alan Block reviews the book "Terrorizing Ourselves". Here's the core of it:

Terrorism is the tactic of the weak, of those who oppose a given state or culture but know they do not have the power to face it openly on the field of battle or even in a guerrilla insurrection. So they strive to turn the power of the state against itself. . . . The Patriot Act was passed in a flurry of panic, and the privacy of every American was compromised, with little or no impact on terrorist activities. It was recently renewed with little notice by a Congress peopled with politicians who had previously criticized it but found it acceptable now that a man with a D after his name occupies the Oval Office. Americans have become accustomed to removing their shoes and not putting shampoo in their carry-on bags and waiting in long lines to travel. Many Americans justify torture and indefinite detention without trial of people simply accused of cooperation with terrorists.

Several chapters dissect the threat posed by bioterrorism and find it minuscule, yet the government has spent $64 billion on it since 9/11, which has probably made us less rather than more safe.

So why is this tactic so successful? Tom Jacobs makes it crystal clear. We want to have powerful enemies. They comfort us. "It is less scary to place all our fears on a single, strong enemy than to accept the fact our well-being is largely based on factors beyond our control. An enemy, after all, can be defined, analyzed and perhaps even defeated. . . A research team led by social psychologist Daniel Sullivan of the University of Kansas reports on four studies that suggest people are 'motivated to create and/or perpetually maintain clear enemies to avoid psychological confrontations with an even more threatening chaotic environment.'"

Indeed. But, the fact is, our real enemies can be defined, analyzed and perhaps even defeated; it's just that they are more complex and less palpable than al Qaeda or the communofascist plots of the Obama administration. Structural unemployment, growing economic inequality and declining living standards of working people; multiple environmental crises; the threat of emerging infectious diseases; these and other pressing problems are understandable and they are not insoluble. But they require us to give up some cherished illusions and confronting them requires accepting the likelihood of troubled times and struggle ahead. For many people, it's just easier to worry about the bearded guy holing up in the mountains halfway around the earth.

Science News "They" Don't Want you to Know

Every week the news readers will breathlessly tout some breakthrough by heroic geniuses in white lab coats that ten years from now might, just might, give people with terminal cancer three more weeks to live. For some mysterious reason, they have completely ignored what I happen to think is actually an important discovery, coming out of a major Big Science project and published in a leading medical journal. Try to figure out why.

Kiyah J. Duffy et al, with Barry Popkin as senior author, report on 20 years of longitudinal data from the CARDIA Study in the new Archives of Internal Medicine. (You are a mere commoner, so you only get to read the abstract.)

The Coronary Artery Risk Development in Young Adults study (they apparently changed the Y to I in the acronym so they could put the logo on their jackets) recruited more than 5,000 people in four U.S. cities, and managed to follow 72% of them for 20 years. That is pretty damn impressive and it gives us information we can't get any other way. Of course, they didn't discover any new drugs or surgical procedures, they just found out something very important about the world we live in.

During those 20 years, the price of milk, fresh fruits and vegetables rose; and the price of sugar and soda fell -- by 48%. And why, you may ask, did the price of soda fall? Because you, the American taxpayer, paid to subsidize the growing of sugar. (I'm not sure about the price of pizza, which also fell but not as much.) Since the people were in different places at different times, the investigators were able to estimate the effect of changes in the relative prices of foods on people's diets.

It turns out that raising the price of a soda buy a buck will result in reducing average daily calorie intake by 124, lower average body weight, and lower insulin resistance, i.e. lower risk for diabetes. The authors estimate that the proposed 18% tax on junk food in New York would result in an average weight loss of 2.25 kg per person per year.

Bob Roehr in the new BMJ reports that an analysis presented at the American Heart Association conference found that consumption of soda can be blamed for 130,000 cases of diabetes and 14,000 cases of coronary artery disease in the U.S. in the decade of the '90s. Stopping that holocaust would be much bigger news than any medical breakthrough. And oh yeah -- it wouldn't cost a penny, it would save money, although it wouldn't be so great for Jack Frost or Pepsi.

So who are "They" and why don't "They" want you to know? Inquiring minds . . .

It's my body . . .

It is very common for people taking antiretroviral medications to believe that they should not take them whenever they use alcohol or illicit drugs. I don't know whether this is true for other categories of medications, but I suspect it is.

In fact, however, physicians do not believe that. They will definitely tell you that if you drink, you should take the pills anyway. They will still work, and as I explained a few days ago, you really don't want to miss doses. I have interviewed quite a few people who have this belief. Most of them have not discussed the matter with their doctor, perhaps because they don't want to get into a discussion about their drinking. I did a focus group, however, in which one participant said, basically, that he totally trusted his doctor, his doctor was the greatest medical genius who ever lived; but he didn't take the meds when he drank. I asked if he had discussed this with his doctor, he said yes and the doctor told him to take the pills anyway, but he did not believe that.

Why? His body just can't take that. It's too much stress on the body. Some people are specifically concerned about their liver, but for most of them it's just a general feeling that it's not a good idea to mix toxins. And they know better about this than their doctors.

I once interviewed a guy with HIV who decided not to take a prescribed nutritional supplement because he could tell that it "fed the virus." He just knew. It was more important to starve the virus than to feed himself. Another guy decided not to take the meds because it was more important to bring "order and harmony" to his life.

I'm not talking here about specific side effects -- symptoms such as nausea, diarrhea, dizziness, dry mouth, whatever it may be. It's obvious (and very common) that when people ascribe such symptoms to medications, they may decide not to take them. Which, by the way, is why doctors often don't tell their patients about possible side effects, because they fear that if they put the idea in people's minds, it will be a self-fulfilling prophecy.

I'm talking about a more abstract reasoning. "It's my body, I know what's going on inside. I just know." Personally, I don't think we really do. If you can't be very specific about what adverse effects you think the pills are having, I would say don't worry about it. On the other hand, if you can be specific, I would say by all means do not be reluctant to talk to your doctor about it and don't stand still for a dismissive response.

I'll have more to say about side effects anon.

Why not do things right in the first place?

I got an e-mail from the Centers for Medicare and Medicaid Services:

The Centers for Medicare & Medicaid Services (CMS) today terminated its contract with Fox Insurance Company. After an onsite review of the plan and its services, CMS determined that the plan’s significant deficiencies – not meeting Medicare’s requirements to provide enrollees with prescription drugs according to recognized standards of care – jeopardized the health and safety of Fox enrollees. CMS found that Fox committed a series of violations, including improperly denying its enrollees coverage of critical HIV, cancer, and seizure medications. The termination of the contract is effective immediately. . . .

Among the audit findings CMS found include:

· Failing to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law.

· Not meeting the plan’s appeals deadlines,

· Not complying with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.

· Failing to notify enrollees about prior authorization and step therapy determinations as required by Medicare.

Apparently Fox hasn't gotten the memo yet: Their web site is still touting the fabulousness of their Medicare Part D plans.

But, the fact is, there is no reason for this company or others like it to exist in the first place. Congress could have just established a prescription drug benefit in Medicare, and let CMS negotiate with the drug companies for the best price and then pay for the damn drugs themselves, just like they pay for doctor and hospital services. But nooooooooo, they have to promise to enrich these predators in order to get a bill passed. Beneficiaries can't figure out who to sign up with or what plan to enroll in because you have to solve differential equations to get the right deal; and even if they could figure it out, they'd get ripped off anyway.

How's this for an idea: We need universal, comprehensive, single payer national health care. We don't need health insurance companies. At all.

Just check it out . . .

Here. That's what I'm talkin' about.

Indignation?

I got your indignation right here. The money shot in this story is that these "pain clinics" employed five physicians who collectively wrote scrips for more than 2 million hits of oxycontin last year, and, oh yeah, were each paid about a million bucks for their "medical services."

My indignation in this case does not particularly extend to the entrepreneurs behind these businesses. They are no different from typical business people like tobacco merchants, the guys on the corner with the little plastic bags, WellPoint, or Monsanto. However, there ought to be a special place in hell reserved for the physicians involved. As a social problem, prescription drug abuse has been growing rapidly in recent years; in the U.S., it's a common gateway to heroin addiction for many young people.

Okay, that's bad. But it has a major secondary effect in that it makes it much more difficult for doctors to prescribe opioids legitimately. In the past, the DEA has not been appropriately selective about prosecuting doctors for inappropriate prescribing. There have been tragic instances of doctors having their lives ruined when apparently, they were just trying to do right by patients in need.

It can be a tough judgment as it is, but if you're constantly looking over your shoulder for the narcs you are going to end up depriving people with unbearable pain of the mercy they desperately need. Sure, you're going to have some people trying to get over on you but who's to say that occasionally erring by writing a prescription you should not have written is worse than not writing when you should? But with operations like this Florida scam going on, there are more people out there who have developed dependencies, a bigger market in general, and the risks for responsible physicians are that much higher.

What really gets my blood boiling, though, is that the competition to get into medical school and earn that license is almost as tough as the competition to make it in Hollywood. There are thousands of smart, altruistic, qualified young people who want nothing more their whole lives, and for all the right reasons, who never get that chance. If you are lucky enough to make it through a medical education, you can make a very good living by doing good. You do not have to become a criminal psychopath in order to achieve affluence and status. And here these schtickdrecks are fucking it up for everybody. Federal prison is much too good for them.

Blithering Idiot of the Century Award

Former Republican vice presidential candidate said on Saturday that as a child growing up in Alaska she "used to hustle on over the border for health care" in Canada.

To their credit, the good folks at the CBS Hotsheet do briefly note that there is something deeply absurd about this. But I want to go a step farther. At Brandeis, my political science professors used to annoy me because they saw politics as essentially a debating society. They seemed to think that bills would pass or not pass because William Safire wrote a better column that Anthony Lewis, basically. One of them even started a book with some platitude about ideas being more powerful than money or guns or votes. Hah! I always complained that politics is not ultimately about discourse, it's about power; that I would hardly characterize Willie Horton and the Pledge of Allegiance as "ideas." (My grad school days are hereby dated to the Dukakis - George Bush the First campaign.)

But at least Willie Horton really did get furloughed from prison while Michael Dukakis was governor, and there really was some controversy about the Pledge of Allegiance. I can't even remember whether it was the "under God" part or whether people ought to say it before school board meetings or something, it was so ridiculous. But it existed.

However, nothing that the Republicans are saying about the legislation in Congress is actually true, or even has a real world referent. There aren't any death panels, there is no government takeover of health care, there aren't any government bureaucrats coming between you and your doctor, health care is not worse in countries that have universal coverage, etc. They just spout completely false bullshit, and furthermore they know it's bullshit and so do the reporters who transcribe what they say. The only people who don't know it's bullshit are the ordinary folks who are subjected to this crap without the reporters bothering to point out to them that it is, in fact, crap. Without the bullshit, and without corporate media that does not distinguish between unalloyed bullshit and assertions that at least have some marginally defensible claim to reflecting a warped perspective on the truth, there would be no debate at all. There would be nothing to talk about.

I'll retire to bedlam.

The toughest case

Taking antiretroviral (ARV) medications for HIV makes a good test case for the problem of medication adherence in general.

Digression alert: We stopped saying "compliance" and started saying "adherence" because we didn't want to sound paternalistic. But even the term "adherence" reflects some underlying assumptions that we might do better to reveal and transcend, at least for our beginning explorations. It implies that there is a right way to do things, the physicians' way, and that our goal is to get people to walk the straight and narrow, just as we expect them to adhere to law and custom. So let's try to be more neutral and say "medication taking practice" instead.

Okay, that's out of the way. ARVs are very effective in preventing the progress of HIV disease, but doctors find the evidence to be pretty clear that it's important to take them very consistently, on schedule, until death do you part from your prescription. Let me do my best to explain why.

Human Immunodeficiency Virus, HIV, is a retrovirus. The exact details of what that means aren't really essential to this story but I'll give you the basics anyway because I think it's easier to understand an explanation that is largely complete. As I presume my readers know, genes -- the instructions for making proteins and ultimately for the operation of cells and the development of multicellular organisms -- are stored in the two-stranded chemical DNA. One strand contains the actual instructions, and the other is a template for making new copies when the cell reproduces. The instructions are carried from the DNA into the cell by a one-stranded chemical called RNA.

Viruses are little packages of genetic material that get into cells and take them over, turning them into virus factories. Viruses can't reproduce on their own, they need to hijack cells for this purpose. Most viruses consist of DNA in a protein envelope, but retroviruses consist of RNA. When the RNA gets into the cell, it tricks the cell into writing its genetic code into the cell's DNA. (When we use words like "trick" that seem to imply intention or intelligence, it's just a convenient way of talking. Viruses have neither, these are just chemical reactions.)

This viral DNA inside the cell's genome is called a "provirus." Sometimes it just sits there for a long time and the cell can go about its business unaffected. But, if the viral genes are activated, the cell turns into a virus factory, releasing viral particles (called virions) into the blood stream and eventually exploding and dying. HIV gets into cells through a receptor -- a protein channel into the cell -- called CD4+. The most important cells that have these CD4+ channels are specialized cells of the immune system called helper T-cells. When they encounter cells infected with viruses, they call in other specialized cells to kill them. The body can fight HIV infection for along time, but eventually, in most people, HIV depletes the number of CD4+ cells to the point where the immune system collapses and people can no longer fight off infections. That's called AIDS.

ARVs, unfortunately, can't cure AIDS because all they can do is stop the virus from replicating; as long as there are still cells that harbor proviruses, they can start pumping out more HIV virions if the drugs aren't around to stop them.

So imagine what happens if you take your ARV meds some of the time, but not all of the time. When you skip a dose, viruses start replicating, getting out into the blood stream, and infecting new cells. If you then take the next dose, they stop replicating again. Should be okay, right? Sadly, no. The copying process is imperfect and sometimes a copy is made with a gene mutation that confers resistance to the drug. So if you then take the drug, that copy survives, successfully replicates, and pretty soon your body is full of virus that the drug can no longer control.

By the way, folks, that's called evolution, just like Darwin explained it. And if an intelligent designer is making this happen you might want to ask him just what exactly the hell he think he's up to. But again I digress.

So to give yourself the best possible chance that won't happen, you need to suppress viral replication as much as you possibly can. That way, statistically, the chance of resistant virus emerging will be very unlikely. (If you don't take the pills at all, you are very unlikely to wind up with resistant virus because it won't be selected for. In the absence of the drugs, the mutations are disadvantageous and should not lead to an expanded population of resistant virus. However, you will get AIDS.)

So what you need to do is take every dose, on schedule, for the rest of your life. Oh sure, you can miss once in a while, it's very unlikely missing once a week or so is going to be fatal, but it's still best not to. If you do develop resistant virus, you can switch to other drugs, but the reason you didn't take those other drugs in the first place is because they are more expensive, have worse side effects, and/or are harder to take. And if you do that two or three times, you will eventually run out of options entirely.

You would think that for the sake of saving your life, you would be able to do this thing, take those pills every day, on schedule. But it is actually very hard for most people to do. Other medication taking situations may pose less extreme challenges or dangers, but people have the same sorts of problems following the prescription. I'll get into some of those in coming days.

Creeping Socialism

I was walking up Centre St. today, which is JPs Main Street, when a police car suddenly stopped. The officer put on his flashers and backed around, blocking traffic in both directions. I thought, "WTF," then I saw what was happening. There's a guy in the neighborhood with a serious spinal deformity, which has him bent over horizontally at the waist. He walks using a four-legged cane and every step is agonizing. But he's out there, every day, going about his business one four inch shuffle at a time. The cop was letting him cross the street.

So here we have an armed agent of the state, depriving people of their God-given liberty to propel their two tons of steel from the dry cleaner to the mall, so he can redistribute their precious time to a loser who can't even stand upright.

I wonder what the Cato Institute thinks of that.

Adherence

No, that's not about glue or sticky tape, it's what we called "compliance" back when I was a grad student, a term which is no longer politically correct. It means, is the patient following the therapeutic "regimen" -- itself an interesting term -- as prescribed by the physician. In the vernacular "regimen" usually means some strict and probably painful discipline, such as running 100 miles a week and eating precisely 3,500 calories per day in order to train for the marathon, but in medical practice, it usually just means taking pills. People given other regimens, such as exercise and diet, very rarely follow them anyway.

Readers ask if doctors inquire about what we call adherence and if so, how they talk about it with their patients. The answers are sometimes; and usually not very effectively.

It's hard to measure people's pill-taking behavior accurately because their self-reports tend to overstate their adherence, and other methods are intrusive, expensive, and/or imprecise. But, generally speaking, people follow their dosage schedules to a clinically acceptable degree something like half the time. It's relatively unlikely, obviously, that people will follow very complicated regimens to the letter. Nowadays as people get older they tend to have more and more prescriptions. People with chronic conditions like diabetes and kidney disease can easily get up to a dozen or even two dozen prescriptions. I kid you not. But even people who have just been prescribed one or two pills for asymptomatic conditions like hypertension just stop taking them about half the time.

Often people are afraid that if they tell their doctors they aren't taking the pills, the doctor will give them a hard time, so when the doctor asks, "Are you taking the pills?" they just say, "Yeah, yeah" and that's the end of it. But, their fears may well be justified and may in fact stem from experience. Doctors often don't know what to do when their patients don't take the pills except lecture them, scold them, and basically threaten them with death. It seldom works.

The problem is that when it comes to taking pills, doctors and patients are often in different worlds. To the doctor, the pill is characterized by a statistical prediction: the probability of averting some adverse event, weighed against the probability of causing one or more others. Many of the possible side effects, to the physician, won't really count for anything because they're just inconvenient -- odd feelings, constipation, itching, that sort of thing. Others, that aren't direct biological consequences of the chemical, such as being reminded that you have a diagnosis or a $15 copay, don't even exist in the physician's world.

For us patients, i.e. people, however, the stories are far more complicated, and they often aren't the sorts of stories we feel comfortable sharing with our doctors. This is a huge problem because it does absolutely no good to make progress in biomedicine and to discover terrific new ways of preventing and treating disease if people ultimately don't take the pills. We're talking tens of billions in investment every year that just isn't paying off half as well as it could, and tens of millions of physician visits that are pretty much a waste of everybody's time.

Of course there is overprescribing as well and there are undoubtedly cases in which the patient makes a correct decision not to take the pills. I have personal knowledge of more than a few. Those represent a different kind of failure, but it often comes down to communication as well. I'll get into these stories more specifically in coming days. Maybe some of them will even be interesting.

Baby steps

The FDA is finally starting to notice misleading claims on food labels. I would say that the products they have singled out so far happen to clearly violate some technicalities. Most of them do deserve to get slapped although I might cut the olive oil some slack -- yes it is fat but the point is it's better than the alternatives. The baby food gets whacked because basically, you can't make any claims about baby food. On the whole these aren't necessarily the most important examples of misleading food marketing, although the claims on green tea about treating Alzheimer's disease are definitely over the top offensive. But at least it's something.

The biggest problem is that the food which is actually the best for you is unprocessed, often unbranded, and generally makes no health claims at all. When was the last time you saw a health claim on a head of broccoli or a bag of dried beans? Marion Nestle (who bears an unfortunate appellation) has proposed doing away with health claims on food packages altogether. No matter how you try to regulate them, they are going to be tendentious. I tend to agree. Let the FDA and the CDC inform the public about what constitutes healthy eating; improve the readability and utility of the required nutritional label; and keep the propaganda off the box.

Recommended Reading

The new Health Affairs is a theme issue on childhood obesity. Unfortunately, if you don't subscribe you'll mostly just be able to read the abstracts but even that is worth it.

Editor in Chief Susan Dentzer indicts the United States for child abuse. With almost one third of our children now overweight, likely to suffer from diabetes, heart disease, colon cancer, arthritis, and many other ailments and ultimately to live shorter lives than their parents. Articles in the issue pile up the evidence: this is a political problem, a disaster caused by the food industry and food and agricultural policies that they control on behalf of greed.

Kelly Brownell and colleagues demolish the case that the food industry has spent from its billions to promote, that this devastating epidemic results from a failure of "personal responsibility." Apart from the absurdity of blaming four-year-olds for their dietary "choices," and even granting that letting them suffer for the sins of their parents would somehow constitute justice, nobody has proposed any reason why we should suddenly have an epidemic of "personal irresponsibility." And if there were such a reason, then a fortiori it would not be the fault of the people so afflicted after all.

In fact, the industry recently spent $24 million to defeat a tax on sugary beverages, which happen to be one of the most important reasons why children are fat. If you present mammals with unlimited amounts of high calorie density, nutrient poor food, they eat it, and they eat too much of it. That's because our appetite regulatory systems evolved under conditions of scarce calories and high levels of physical activity, and we needed what little sugar and fat we could get for fuel. Add to that intensive, psychologically sophisticated marketing of junk food to children, and they'll eat even more. When their parents go to the store, they'll find that the price of low quality foods has fallen over the years, while the price of fruit and vegetables has risen, and that's not a result of anybody's "personal responsibility" either. It's because of the way the agricultural and food industries are organized, and government policies that favor production of low quality foods. And of course the industry and government are locked in a close partnership to make sure the status quo continues.

Add to that all the time kids spend hypnotized by TV and computer games - time that I spent as a kid outdoors running around and playing physical games -- and what do you know, we've got a whole lot of fat kids. Well duhh.

This is a national emergency and there's plenty we can do about it. Instead of subsidizing sugar crops and animal feed, which in turn of course is used to make fatty beef and cheese, we can start supporting produce growers, including small scale growers who can deliver fresh produce to local markets. We can tax junk food, just as we do tobacco and alcohol, to discourage consumption, and apply the revenues to parks and playgrounds and physical activity programs for kids. We can get junk food out of schools and have healthy school meals for a change. We can make neighborhoods safe for children to play out of doors. We can bring grocery stores and farmers markets into poor neighborhoods. In spite of the evil bastards who control the Supreme Court, there are ways we can restrict marketing of poison to children. We can do this. We must.

Here's some good free content from HA. And here's some more.

Window on the world . . .

or a narrow slit? Lately I've been deeply immersed in people's experiences with their doctors - I've read more than 100 transcripts of actual medical encounters, run four focus groups of patients, and interviewed five people individually in the past couple of months. I've seen comparable amounts of data over the past four years or so, and I saw an earlier burst of data about ten years back. And of course I read numerous journal articles on the subject every week.

Recently all the people I've interviewed and all the recorded visits I've reviewed have been of people living with HIV. They have a high prevalence of comorbid substance abuse disorders and mental illness, and a lot of them, obviously, have had hard lives. I find that for the most part, the people like their doctors, and the doctors treat them respectfully and compassionately. Surveys we also do of the patients confirm that they overwhelmingly say they like and trust their doctors. That doesn't mean they necessarily communicate effectively, in a few ways. There are plenty of conflicts but they tend to be concealed -- manifesting as evasion, people talking past each other, dissembling, negotiating without anybody declaring that's what's happening, answering the wrong question or ignoring the tough problem. This is how people with misaligned agendas, of course, maintain peaceful relationships.

Okay, we can surely do better than that. But when I tell people what I do for a living, they more often than not let me know that their own problems with doctors have been experienced much more overtly. I suppose it's the bad experiences that tend to stand out and when things seem to go okay for us, we take it for granted.

But still, there's a difference between what I see, which is best understood as a skill deficit in the face of the normal vagaries of human behavior; and what many people tell me they experience, which includes condescension, callousness, and inattention to their needs. I mean yes, people's needs don't always get met, but in my data it's from missing the clues, not lack of caring; whereas my friends in the Real World often have more serious complaints.

So I'd like to understand why that is. It may have to do with the settings where we collect our data; and the doctors who chose to go into HIV care, knowing they are going to see a lot of vulnerable people. Or it may be that the way people answer surveys, and the way I perceive the interactions from the outside looking in, isn't necessarily how people experience these interactions. Or maybe they just like to blow off steam when they're talking to a friend.

The ineluctable persistence of fallacy

Before I get to more of the particulars of NICE, I must digress to a subject which has long befuddled me but which I am now at long last beginning to understand. Both the UK and the US suffer from a very similar regulatory defect. In both countries the legislature has forbidden the licensing authority from requiring that homeopathic remedies be shown to be effective. More specifically, substances listed in the Homeopathic Pharmacopeia of the United States as of 1938 have legal protection. The FDA has occasionally taken action against substances labeled as "homeopathic" that don't meet the definition, but actual homeopathic remedies are widely marketed in the U.S. although they are utterly useless. The situation in the UK is even worse. Not only are homeopathic remedies automatically licensed, by the National Health Service actually has to pay for them! (Efforts are underway to change this, but it is, believe it or not, politically controversial>)

I won't take up space here demonstrating that homeopathy is absurd, utterly implausible, preposterous, ludicrous, ridiculous, and idiotic. The theory of homeopathy contradicts everything we know, not only about biology, but also about physics, chemistry, and the basic way the universe works. It's completely delusional, insane, and crazy. True homeopathic remedies are first-order harmless: they all consist of the same chemical compound, in reasonably pure form, specifically an oxygen atom attached to two hydrogen atoms, which in amounts under a couple of gallons is well tolerated. They are differentiated only by the label. Second order, however, they may bamboozle people into not pursuing effective remedies, and they do separate fools from their shillings.

So my befuddlement has been over how this and similarly delusional beliefs not only persist, but maintain dedicated and even fanatical followings in spite of mountains of irrefutable contrary evidence. Vaccines cause autism, HIV does not cause AIDS, the WTC was destroyed by controlled demolition, the health care reform legislation includes death panels, God answers prayers, you name it.

I stumbled across some insight into these matters on the blog of a smart-ass condescending east coast liberal elitist, who links to additional useful exegesis. The fact is, a whole lot of people don't reach conclusions based on evidence, they reach them based on identity. And when you present them with facts and logic that show they are mistaken, you haven't done them a favor, you have insulted them and shown yourself to be arrogant and conceited.

I'm not actually sure what can be done about this. I do my best to know what I'm talking about but apparently that's counterproductive.