Simple answers to complex problems

I was down on the farm the last couple of days -- got in some more sweet corn, beans and tomatoes, and fought to keep the jungle at bay. As long-time readers know, my rural property is surrounded by state forest and farm fields. The state of Connecticut, which has been slashing funding for public health, early childhood services, and other useless commie programs, has plenty of money to spend flying the pot chopper -- a state police helicopter on the lookout for marijuana plants -- 100 feet over my head every Saturday. My farmer friend Festus tells me they visit his neck of the woods in Lebanon on Fridays. It's a 7 day a week program.

A couple of years ago they actually spotted something. A convoy of SUVs full of guys with buzz cuts in black uniforms with body armor and assault rifles went up into the woods and came back down with 8 little pot plants. Civilization was saved!

It is quite odd, in my view, but you probably don't even know that possession and use of marijuana is effectively legal in Massachusetts. It has been for more than a year since the voters passed a referendum -- overwhelmingly, I might add. In principle the cops can write you a hundred dollar ticket but they don't even bother. You aren't required to show ID or give your real name. Once they figured out that everybody they busted was named Count Chocula, they pretty much gave up. What I say is odd is that this monumental historical development has essentially been ignored nationwide, and even right here in Massachusetts. As far as I know the only discernible consequence is that the police and courts can spend their time on better things and fewer people are going to jail or bothering probation officers. But the state hasn't even bothered to report on that.

Other than that, nothing has happened. Our youth are no more corrupted or dissolute than previously, our workplace productivity is unaffected, our traffic safety remains the same. Cross the state line into Massachusetts, and you won't even get a contact high.

Meanwhile, Mexico is on the verge of becoming a failed state as violent drug gangs have taken over entire cities and regions. Federal and state governments in the U.S. spend tens of billions of dollars every year on helicopters and SWAT raids and prosecutions and locking people away who have done nothing but raise, trade and smoke flowers. Lives are ruined, and taxpayers drained.

All of this could stop, overnight, with no negative repercussions whatever. Make it legal to grow, sell, possess and use cannabis in the United States. Regulate it, tax it, keep it away from minors. Bust people for impaired driving, can workers who show up high and can't do their jobs, all that stuff, just like we already do. Just make it legal. 100% of problem solved.

Innumeracy

As I've been saying now and again (and again and again) a major reason why so many people believe in so much stuff that just isn't true is innumeracy. Orac discusses an editorial in Vaccine by Gregory Poland and Ray Spier. I link to the good doctor because the editorial itself is behind a subscription wall and at least he gives you an idea of what's in it. I'm just going to quote a bit -- this is all about why people believed in the fraudulent link between the MMR vaccine and autism, as promoted by psychopathic charlatan Andrew Wakefield.

An innumerate (the inability to use and understand numbers and mathematical concepts) press and public resonated with each other. An innumerate person or organization uses such phrases as "I don't care what the data show . . . I believe . . . ". The answer to innumeracy is a slow and long-term one -- better scientific and public education.

Well okay, but how can we accomplish that? This web site is trying, but after rooting around in it for a while I don't think it really works -- partly because it depends on the user to find her or his own way around, instead of beginning at the beginning and muddling through to some definite end; partly because it just doesn't have enough material that will really get through to people. There is some on-site content and a lot of links out, but the links out are all a pig in a poke.

At least it helps me realize more about the task. I probably jumped in too hard here getting straight to the binomial distribution and all that mathy hoo hah, when in fact a lot of people just have the wrong idea about how the world works qualitatively.

The gambler's fallacy, that a number is "due" to hit, has emptied many a wallet.

Then there is the ubiquity of coincidence. An immense, effectively infinite number of events come to our awareness every day. There are bound to be apparent patterns and associations among them, and our brains are wired to see them. But there is no way to know if they are real unless we see them repeated many times and never violated. Alas, due to a psychological proclivity called confirmation bias, we are relatively unlikely to notice or remember violations of our original hypotheses. That's how superstitions develop.

For these and other reasons, we need to investigate problems systematically, and use disciplined means to overcome the sloppiness of our intuitions. This requires structured ways of stating and evaluating questions, which is really what mathematics is all about. Math doesn't necessarily have to be mainly about numbers, although numbers are very helpful in structured thinking and sometimes necessary.

But what people really need to be able to do is not so much learn about mathematical theorems and memorize formulas. People need to learn how to think. Reality reveals itself to those who know how to interrogate it. Because so many people do not know how, we end up with all these critical debates over matters which simply are not in doubt. There aren't two sides to every question, and not every controversy should be taught. Yet people on both sides of every false controversy "know" they are correct.

The issue is that they "know" in different ways. My way keeps winning out in the end -- as Copernicus and Hubble, Crick and Watson, and yes, Darwin can attest. But people still don't get it.

Back to civilization

from the wasteland of Miami Beach. I couldn't post yesterday because a) I actually wanted to participate in the conference instead of writing blog posts about it and b) various women kept plying me with alcohol in the evenings so I was a little bit out of it. Unfortunately, they were only trying to get me to talk.

Anyway, as I reported last time, the HIV pandemic is running away from us, particularly in Africa but probably in some parts of Asia and perhaps Eastern Europe as well. In the U.S., new infections continue at a steady state of around 65,000/year. Up until now, we have been treating most people who engage in care, although that may be about to change -- right now 10 states have waiting lists for their HIV Drug Assistance Programs that purchase drugs for people who have no other way of affording them. About 1,000 people are on waiting lists and that number will likely grow sharply in coming months as states struggle with budget deficits and curtail or eliminate their contribution to the program, which is required to obtain the federal match. For example, Florida is about to start a waiting list, and North Carolina's program is closed to new enrollment with the list expected to grow sharply.

However, even many people who are in treatment fail to achieve suppressed viral loads because they don't take the pills consistently. I haven't been able to find any reliable national estimates (let me know if I've missed something) but from the various studies I've read of clinical populations, somewhere around 30% tend to have detectable viral loads. Since some people are not in treatment, the proportion of people with HIV who have unsuppressed viral loads is obviously a bit higher than that.

Everybody knows that HIV is a life threatening disease, unless they've been listening to psychopaths, but guess what? So is hypertension. The consequences can be just as unpleasant -- renal failure, stroke, heart disease. It turns out that only about 50% of Americans with hypertension have it under control. That actually represents major progress since 1990 and that's how this number is being spun, but really, there's no excuse for it. 72.5% of people with hypertension are no in treatment for it, which I suspect is not that different from the percentage of people with HIV who are in treatment; and about 70% of people in treatment have controlled blood pressure, also not that different.

A few people have really intractable hypertension, mostly because they are very obese; but for most people, two pills a day, maybe three, will do the trick. Full disclosure: I take two, lisonpril and nifedipine, and that totally works. I am absolutely committed to taking them every day; it's just part of getting up in the morning and taking a shower and getting dressed. But lots of people get the scrips and never fill them, or stop taking them. Side effects of these meds are minimal. A few people have side effects from lisonopril and similar drugs, called angiotensin converting enzyme (ACE) inhibitors, but if they just tell their doctors, they can get an alternative prescription. But lots of people don't do it, they just stop.

It's wise to question the conventional wisdom and educate yourself about your own health, but let me tell you something -- if you have hypertension, most of the time, very inexpensive and very safe pills will fix it, if you take them every day. Just do it.

Penny stupid and pound moronic

A couple of years ago, when I blogged from the International AIDS Conference in Mexico City, I reported hearing a lot of optimism, or at least hope (which I didn't really share), or at least insistence on the necessity, of meeting the the goal of universal access to HIV treatment by 2010. This goal was accepted by the world community (if there is such a thing), and at one time seemed feasible because the drug companies had accepted -- or had forced upon them, more accurately -- licensing agreements which made standard antiretroviral packages available in resource poor countries at low cost, and in middle-resource countries such as Mexico at affordable prices. The U.S. and other wealthy countries had pledged to provide enough money to make it happen -- which is in the tens of billions of dollars annually, a trivial sum compared to the cost of war and corporate welfare. Infrastructure in the poor countries was building and the personnel were trained.

But we have failed. The donor countries did not come up with enough cash and the rate of new infections is now running ahead of the rate at which people are offered treatment. We're losing the AIDS war.

Last night Julio Montaner, president of the International AIDS Society, told us why this isn't just a moral failure. It is a profound failure of wisdom. It turns out -- although we weren't 100% sure of this before -- that when people are successfully treated and have undetectable viral loads, they are far less infectious -- perhaps not infectious at all. That doesn't mean you should go out and practice risky behaviors. You don't know, at any time, if you really do have undetectable viral load. Not everybody is completely adherent to drug regimens, and resistance can develop.

But on a population level, Dr. Montaner has shown that expanding treatment can greatly reduce HIV incidence. (As you will recall from a couple of weeks ago, that's the rate of new infections.) The result is that if you invest enough, you can catch up to the epidemic and cap it like a top-killed oil gusher. In the end, obviously, you will save a lot of money as well as human lives and you'll have a lot fewer orphans. If you don't do enough, the epidemic will start running away from you, as it is doing now, and you will never be able to catch up.

So which choice is the world making?

Where I'm at

I'm in Miami Beach at the Eden Roc resort and spa, for the 5th International Conference on Antiretroviral HIV Treatment Adherence. I'll do some blogging about the conference and what it all means, but hey, today is Sunday so it's a day of rest. I haven't been to Miami Beach for more than 20 years -- also for a conference, at the Fountainbleu -- but it hasn't changed that I can tell. A solid wall of hotels and condos faces the ocean, and it's pretty much a wasteland if you're interested in real life. People do live in those condos, but I'm darned if I can figure out where they shop or get their hair done. There must be a real world section of Miami Beach but it's not within walking distance of the hotels.

I can see the ocean right from my window - the hotel is right behind the boardwalk and it's no more than 1/4 mile to the water. So far, it's a transcendentally beautiful aquamarine that looks purer than the milk of the Blessed Virgin. Let's hope it stays that way.

The weirdness is that the Eden Roc has a big pool complex between the boardwalk and hotel, from which one cannot even see the ocean. The pool is surrounded by people lying in lounge chairs while others cavort in the chlorine. For extra dough, you can have the Exclusive Eden Roc Cabana Experience, which consists of a tent by the swimming pool. In the Ocean Garden, as they call it, it is completely impossible to discern whether you are 300 yards from the ocean in Miami Beach, or in Indiana. Nevertheless most of the people here seem to prefer it to the real ocean.

Explain it to me.

Biological oceanography

I generally try to stay within my expertise here, but believe it or not I'm not going to far out of bounds by talking a bit about the ocean and the effects of the oil volcano at the bottom of the Gulf of Mexico. I have a master's degree in environmental policy, and I actually took some marine biology on the way to getting it.

It may surprise most people to learn that most of the ocean is what is called a biological desert -- it has very little biological productivity, and little life. The reason is that unless it is very close to freezing, warm water is less dense than cold water, which means that warmer surface water sits on top of colder water and the layers don't mix. Any possible nutrients that might support photosynthetic organisms and create a base for a food chain therefore sink below the depth where sunlight can reach. In the ocean depths, there are organisms that subsist on stuff that rains down, or on reactive chemicals that spew from hot vents along the mid-Atlantic ridge; but none of these are any fun to eat.

The only productive regions of the ocean, therefore, are cold arctic and antarctic waters -- yep, the cold parts of the ocean are more biologically productive than most of the warm parts, while more temperate waters can have seasonal productivity before the thermocline appears in late spring; upwelling zones, where deep currents hit a rise in the sea floor and shoot water upward (e.g. the Peruvian anchovy fishery); shallow coastal waters; and river estuaries and salt marshes. The latter are particularly important because they are highly productive, relatively sheltered places. Many species spawn there, and their larvae spend some time getting started before heading out to the open ocean.

That is why, bad as the effects of the disaster have already been, this is indeed worse news. Oil washing ashore from Port Fourchon to Grand Isle. "Councilman Tom Capella said this morning that oil from the BP rig explosion has washed up on Elmer's Island just west of Grand Isle. And Councilman Chris Roberts said oil was hitting the beaches in a wide area from Port Fourchon in Lafourche Parish to Grand Isle, which is the southern tip of Jefferson Parish. Even heavier oil can be seen just offshore, Roberts said."

Once those marshes and salt ponds are oiled, they will not come back to life for who knows how long. And the primary productivity they represent is irreplaceable.

What cannot be denied

That would be denialism. New Scientist has a collection of essays on the subject, which actually ameliorate some of the puzzlement I have had about the phenomenon. The contributors discuss several underlying causes, ranging from corporate sponsorship of disinformation campaigns to populist ideologies which view experts as oppressive elites.

Deborah McKenzie's framing essay, Living in denial, proposes that "All denialisms appear to be attempts . . . to regain a sense of agency over uncaring nature: blaming autism on vaccines rather than an unknown natural cause, insisting that humans were made by divine plan, rejecting the idea that actions we thought were okay, such as smoking and burning coal, have turned out to be dangerous." I'm not sure this generalization is true -- I don't see how it explains AIDS denialism, holocaust denialism, or that it even makes sense internally. Is the danger of tobacco somehow an example of uncaring nature depriving us of agency? On the contrary, it seems to me. We have agency, we can smoke or not.

She goes on to interview Seth Kalichman, who we have met here previously. Seth sees psychological disorders in the leaders of many denialist movements, including grandiosity and neurotic suspicion. This may be true, but perhaps Michael Shermer's formulation that denialism is essentially backwards thinking -- arguing from a pre-ordained conclusion to cherry pick the evidence -- will seem less confrontational. These are not mutually exclusive views, of course.

It is a waste of time to argue with ideological true believers; they aren't interested in finding the truth based on evidence, they just believe. However, if there is hope in winning some people away from denialism, it lies in cultivating critical thinking skills. Many people are persuaded to denialist movements simply because denialists are very successful at manipulating the way most people normally think. McKenzie interviews Greg Poland, who says that anti-vaxers are innumerate, unable to grasp concepts of probability. "People use mental shortcuts: my kid got autism after he got the shots, so the vaccine must have cause it."

So what this tells me is that I need to get back to the statistics for dummies project. I've back-burnered it because I'm trying to figure out how to do it better. But you'll be glad to know I've actually gotten some help, and I'll be talking with an expert on adult education tomorrow.

Meanwhile, I gotta love the fortune cookie I got today: "In all matters of opinion, you always say it better."

Omens

Today is the anniversary of the eruption of Mount St. Helens. In Henry IV, part 1, one of the most notable of my Cymric ancestors gets a pie in the face.

* Glendower. I cannot blame him: at my nativity
The front of heaven was full of fiery shapes,
Of burning cressets; and at my birth
The frame and huge foundation of the earth
Shaked like a coward.

* Hotspur. Why, so it would have done at the same season, if
your mother's cat had but kittened, though yourself
had never been born.

* Glendower. I say the earth did shake when I was born.

* Hotspur. And I say the earth was not of my mind,
If you suppose as fearing you it shook.

* Glendower. The heavens were all on fire, the earth did tremble.

* Hotspur. O, then the earth shook to see the heavens on fire,
And not in fear of your nativity.
Diseased nature oftentimes breaks forth
In strange eruptions; oft the teeming earth
Is with a kind of colic pinch'd and vex'd
By the imprisoning of unruly wind
Within her womb; which, for enlargement striving,
Shakes the old beldam earth and topples down
Steeples and moss-grown towers. At your birth
Our grandam earth, having this distemperature,
In passion shook.

More on the peculiarities of priorities

You've probably already heard about the new study in Pediatrics that finds a link between urinary levels of metabolites of organophosphate pesticides and diagnosis of ADHD in children. I've been saying forever that there is plenty of evidence that chronic exposure to low levels of organophosphates causes neurological harm with behavioral symptoms in humans. We've known this for more than 20 years, but malathion and its cousins are still sprayed all over our crops. (In case you didn't know, these are just somewhat weaker versions of the "nerve gas" invented by Nazi scientists in WWII.)

However, on the very same day, another study came out, in the very same journal, that has been completely ignored. Mothers' Spanking of 3-Year-Old Children is associated with aggressive behavior at age 5. Aggressive behavior means whether "the child argues a lot; is cruel, bullies and shows meanness to others; destroys . . . things; . . . gets in many fights; physically attacks people . . ." You know, the kind of stuff Christians endorse since non-Catholic Christian mothers, as you might expect, are more likely to hit their children. By the way, we aren't necessarily talking a lot of spanking -- 2 or more times a month is enough to do it.

And the association is about the same strength as the association between organophosphate exposure and ADHD.

I wonder why this study wasn't in the news? Oh yeah - the Family Research Council would freak out and accuse the reporters of being commies if they wrote about it.

Do not hit your kids.

Emergent matters

Even as the Boston Globe yesterday published the worst article about global warming ever (and congratulations, Globe editors, for nearly completing the utter destruction of a once-great newspaper), the truth, as I always say, has it's day.

NASA -- you know, that far left conspiracy against technological progress -- reports that:

Overall, the combined global land and ocean surface temperature anomaly for April 2010 was the warmest April on record since records began in 1880. The previous record was set in 1998. The combined global land and ocean temperature anomaly was 0.76°C (1.37°F) above the 20th century average. . . .

The combined global land and ocean surface temperature for January–April period was the warmest January-April period on record. This value is 0.69°C (1.24°F) above the 20th century average.

Meanwhile, Quest for oil leaves trail of damage across the globe:

No one's tallied the damage worldwide, but it includes at least 200 square miles of ruined wildlife habitat in Alberta, more than 18 billion gallons of toxic wastewater spilled into the rainforests of Ecuador and a parade of purple-black oil slicks that skim across Africa's Niger Delta, where more than 2,000 polluted sites are estimated to need cleaning up.

"The Gulf spill can be seen as a picture of what happens in the oil fields of Nigeria and other parts of Africa," Nnimmo Bassey, a human rights activist and the head of Environmental Rights Action, the Nigeria chapter of Friends of the Earth, said in an e-mail.

"We see frantic efforts being made to stop the spill in the USA," Bassey added. "In Nigeria, oil companies largely ignore their spills, cover them up and destroy people's livelihood and environments."

But it's absolutely futile.

There is convincing evidence that conventional oil production has already peaked, since we have been stuck at around 74 mbpd for over half a decade (despite the incentive of record high prices). There also seems to be growing consensus that global liquids production (currently around 86 mbpd) is likely to peak within the next decade and almost certainly at less than 95 mbpd.

The world we all grew up in, the one we've come to take for granted, is indeed coming to an end, although events will bear no resemblance to the Revelation of John. Jesus isn't coming back to save us. We're on our own, and this can either be very, very ugly or basically okay after all. But three decades of denial, capped by 8 years of rule by the oil companies, has left us with no time to waste at all. Our folly is catching up with us, now. Right now. Nothing else matters very much.

Let's get reasonable

In case you haven't come across it, The Skeptic's Dictionary is really interesting, yeah verily a fun site to explore. Sitemeister Robert T. Caroll gives us entries on just about every species of unreason, flummery, wackoness, superstition and woo known to humanity. He also covers the underlying architecture -- logical fallacies, cognitive biases and failures, illusions, hallucinations, and fraud. He also has a lot of introductory material on philosophy, evidence, hypothesis testing -- in other words, the good stuff.

Caroll is also fair and balanced -- which means he is the first to affirm that it isn't simple and straightforward deciding why one idea or conclusion is more rational than another. For example, he writes, "Scientism, in the strong sense, is the self-annihilating view that only scientific claims are meaningful, which is not a scientific claim and hence, if true, not meaningful. Thus, scientism is either false or meaningless." Yep, we can have a hard time arguing with people who say something to the effect that "My way of knowing," be that faith or the visions produced by LSD "is just as valid as yours."

The answer is that the truth isn't a magic bullet that slays error in a single irrefutable epigram. It comes from the accumulation of observations over time that fit together in an ever growing, ever tighter weave of successful explanation, prediction, and understanding. To really be legitimately convinced of something, you do have to do some work and know a lot. None of us, obviously, can master many fields, so we have to know a little about the basics and something about the integrity and quality of the truth-seeking enterprises in those fields.

No, Rush and RFK Jr., scientists are not involved in a giant conspiracy to steal taxpayers money through research grants to study problems they know are bogus. I know that isn't true, that the enterprise is honest and pursues truth for its intrinsic value. I do believe that I actually have more expertise than the vulgar pigboy on climate science, and more expertise than upper class twit RFK Jr. on immunology and neuroscience, but even so, I don't have enough to prove independently that anthropogenic global warming is a fact or thimerosal in vaccines is harmless. But I know enough to trust the overwhelming scientific consensus in both areas.

Our good friend Ana writes, "Scientists themselves, hyper knowledgeable and expert in their own fields, are just as subject to irrational beliefs as everyone else. Also, as they are most often amongst the elite (or serving it directly) they do accept piles of narratives, opinions, facts, principles, for which they have absolutely no evidence at all. So a little humility might be welcome." I agree that humility is welcome but I'm not sure scientists are just as subject to irrational beliefs as everyone else. They are certainly not immune, but they are trained in critical thinking and do have skeptical habits of thought, so I think they're a little less subject than the average person.

Rather than viewing that as elitism, I ask you to view it as a plea to democratize science and its methods and make critical thinking and understanding of scientific method the property of everyone.

A persecuted minority?

These are tough times, it seems, to be a scientist. One of the two major political parties in the United States requires its candidates to publicly proclaim that the theory of evolution is false, that "this world and everything in it is a masterpiece created by the hands of God," and that "every single word" of the Bible is true." The Attorney General of Virginia is suing a former professor at the state university for fraud because he believes that humans are causing global climate change. The Republicans also claim we can achieve energy independence and reduce the price of fuel by offshore drilling. Er, no we can't.

Sadly, while conservatives in general are particularly hostile to reason, they aren't the only ones. Robert Kennedy Jr., who pretends to be a liberal and was actually seriously considered by Barack Obama to be administrator of the EPA, is a crank who believes that all the world's physicians, biomedical researchers and public health authorities are part of a massive conspiracy to poison children. The whole "vaccines are a conspiracy by greedy scientists" thing is not particularly a hallucination of left or right, but it's mostly touted by celebrities with a liberal sheen.

I could go on and on but you know all this. Charlie Pierce has put it very well:

The rise of Idiot America is essentially a war on expertise. It's not so much antimodernism or the distrust of intellectual elites that Richard Hofstadter deftly teased out of the national DNA forty years ago. Both of those things are part of it. However, the rise of Idiot America today represents—for profit mainly, but also, and more cynically, for political advantage and in the pursuit of power—the breakdown of a consensus that the pursuit of knowledge is a good. It also represents the ascendancy of the notion that the people whom we should trust the least are the people who best know what they're talking about.

It seems impossible to crack the granite walls of smug, self-regarding ignorance with facts and reason. To my mind, the basic problem is what Robert T. Carroll calls communal reinforcement. For most people, belief is not a matter of evidence and logic; it's a matter of tribal loyalty. If you try to reason with them, and show them why their beliefs are mistaken, it's taken as an assault and an insult to their friends and their virtue.

Like many people on the side of reason these days I'm starting to wonder why I bother. Truth is all I've got. If that's worthless, I'm helpless. Oh well, gotta keep on doing it.

Update: BTW, I probably should have mentioned that one reason I got all het up to write this post was this. Do check it out.

Oh yeah, it turns out Orac is having some of the same angst today.

The most dangerous place in town

Go ahead, take a guess? What is the sixth leading cause of death in the United States? (Jeopardy theme song plays.)

According to one way of looking at it, the answer is Hospital Associated Infections -- the cause of about 99,000 deaths in the United States in 2002. There were a total of 1.7 million such infections altogether.

Now, this is a bit tendentious, as is any claim about "causes" of death, because what you call the cause of death all depends on how far back you want to go. Why were those people in the hospital in the first place? Most of the ones who died were probably already pretty sick and frail and likely didn't have a long life expectancy anyway. Still, it's a big problem. Peleg and Hooper, in the new NEJM, discuss a particular class of bacteria that cause a lot of HAIs, called gram negative bacteria. Abstract only, for you contemptible swine. Since you aren't allowed to read it, I'll play Prometheus and steal what you need:

Infections caused by gram-negative bacteria have features that are of particular concern. These organisms are highly efficient at up-regulating or acquiring genes that code for mechanisms of antibiotic drug resistance, especially in the presence of antibiotic selection pressure. Furthermore, they have available to them a plethora of resistance mechanisms, often using multiple mechanisms against the same antibiotic or using a single mechanism to affect multiple antibiotics. Compounding the problem of antimicrobial-drug resistance is the immediate threat of a reduction in the discovery and development of new antibiotics. Several factors have contributed to this decline, including the increasing challenges of screening for new compounds, the high capital costs and long time required for drug development, the growing complexity of designing and performing definitive clinical trials, and the concern about reduced drug longevity due to the emergence of resistance. As a consequence, a perfect storm has been created with regard to these infections: increasing drug resistance in the absence of new drug development.

Let me put that in plain English. Drug companies aren't all that interested in developing new antibiotics because there isn't a whole lot of profit to be made. They like to invent pills that people have to take forever, like statins and antidepressants; stuff you only have to take for a week or two, that actually cures you, just isn't worth it.

Bacteria are a real PITA to deal with because they can pick up genes from any old place -- they don't just have to "mate" with their own species. They don't exactly mate anyway, although they can rub up against each other and exchange genes; but they can also pick up genes from dead cells and even just debris that's lying around in the slime. So once a gene that confers resistance is in your hospital, it can get around fast.

It's a bit disconcerting to be walking through the halls here every day, but basically health people who work in hospitals, including physicians and nurses, are at low risk of acquiring these infections. The problem is that the patients tend to have extra holes in them, with tubes and appliances going into those as well as some of their natural orifices; and to be weak and immunocompromised. However, as Peleg and Hooper discuss, people are showing up with what are presumed to be community acquired infections that really come from something that got loose from a hospital. These little nasties are out there, more and more.

Just one more way we may get our comeuppance.

In a nutshell

I was given the rather difficult mission of writing 3 separate entries for a new encyclopedia. Since it hasn't been published yet I probably shouldn't be more specific but it has to do with health and stuff, obviously. Since I did all that work, I thought I'd share some of it -- but only fair use since I assigned the copyright. (It's complicated.) Here's a bit of what I had to say about physician-patient communication.

Until the mid 20th Century, the generally accepted physician-patient relationship in the West was of a nature now characterized as "benevolent paternalism." The expertise and wisdom to choose the appropriate treatment of disease resided entirely with the physician. The patient's role was to trust and to follow "doctor's orders." During the 1970s, and with increasing prominence in the 1980s, a movement grew in medicine to promote “patient centered” care. Patient-centered interactions were defined by Lipkin et al in 1984 as treating the patient “as a unique human being with his [sic] own story to tell.” The various definitions of patient-centered care share consistency with the bio-psycho-social model for health and health care, which sees health in more than just biological terms. For example, Epstein, et al, propose that patient-centered communication must include: “1. Eliciting and understanding the patient’s perspective – concerns, ideas, expectations, needs, feelings and functioning. 2. Understanding the patient within his or her unique psychosocial context. 3. Reaching a shared understanding of the problem and its treatment . . . 4. Helping patients to share power and responsibility. . . .”

These ideals live uneasily with the reality that physician-patient encounters are asymmetrical in power, expertise, and usually in social status. After all, the reason for the encounter in the first place is that the physician has exceptional expertise. Physicians ultimately control what information they share with patients and what options they present. They monopolize the power to prescribe medications, authorize tests, and perform surgery. They have unique privileges to invade people’s bodily integrity and inquire into intimate matters that are never ordinarily discussed with strangers, or perhaps with anyone. They have immense cultural authority and prestige, and typically earn multiples of the income of their average patient.

Patients may not understand much of the vocabulary that physicians routinely use and may lack the background knowledge to accurately interpret what physicians tell them. They may be overawed by the physician’s elevated social status and reluctant or entirely unable to express doubt or objection, admit lack of understanding, or ask questions. It has been found consistently that people typically do not accurately remember or understand much of the information and instructions from physicians even immediately after a visit; and that people adhere to prescribed medication regimens only about half of the time.

The decision making heuristics of physicians and patients may be quite different. Physicians base diagnostic conclusions and treatment recommendations on biomedical theories and statistical reasoning: the probability of a beneficial outcome of an intervention versus the probability of adverse effects, weighted by the physician’s judgment of the magnitude of possible benefits and harms. Patients may not understand these calculations or may simply use other criteria, such as prior experiences of people they know, social norms of their community, shorter time horizons, idiosyncratic aversions, cost and convenience, or alternative theories of health and illness, whether from formal systems or lay conceptions. They may or may not ever discuss these criteria with their physicians.

So this is the essence, to me, of a difficult problem: How can a physician best serve the patient, and put the patient at the center of the medical encounter, given the inherent asymmetry of knowledge and power which is, after all, the point of the whole thing in the first place? It's hard work.

Science and medicine

Harriet Hall, at Science Based Medicine, discusses Druin Burch's Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and Our Difficulty Swallowing It. Discussion and debate ensues about what percentage of accepted medical interventions today have an adequate base in scientific evidence. Here's my take:

I would say that the greater challenge right now is not so much to increase the evidence base for medicine and find new and better treatments, although that should certainly continue; but rather to implement what is already known. This is particularly a problem in the United States where we have no equivalent of the UK’s NICE and it is, in fact, politically toxic even to suggest such a thing.

I’m looking right now at Bridget Kuhn’s article from the April 28 JAMA about inappropriate prescribing of antipsychotic drugs. In spite of a black box warning, doctors keep giving these to elderly people with dementia. She notes that in an analysis of VA data, 60% of people who got a scrip for an AP in 2007 had no record of a diagnostic indication. These drugs have potentially terrible side effects and shorten people’s lives. She quotes Douglas Leslie of Penn State College of Medicine as saying that docs are prescribing these drugs off label because they have heard “anecdotal stories of benefit.” They are also widely prescribed to children, by the way, who ostensibly have "bipolar disorder," although there is no evidence whatsoever to support that and they cause diabetes and dyslipidemia and all sorts of horrible stuff that you do not want to happen to children.

Of course it’s because of illegal marketing by the drug companies, and they’re getting away with it.

More science is great, but let's use the science we already have.

It's actually more complicated . . .

I expect most readers have seen news stories about the President's Cancer Panel report. The headline is that the panel claims that environmental exposures -- by implication at least, meaning mostly to human-produced chemicals -- make a far more important contribution to the burden of cancer than has been recognized. This has long been what I must, sadly, call an article of faith among environmentalists, but the report actually does not come to that conclusion, nor does it present any direct evidence for it. This spin must come from a press release, is the only conclusion I can make. In fact, in the executive summary, they say this:

At this time, we do not know how much environmental exposures influence cancer risk and related immune and endocrine dysfunction. Environmental contamination varies greatly by type and magnitude across the nation, and the lifetime effects of exposure to combinations of chemicals and other agents are largely unstudied. Similarly, the cancer impact of exposures during key “windows of vulnerability” such as the prenatal period, early life, and puberty are not well understood.

In other words, we don't know, but maybe it's worse than we think, so we ought to try to find out. That's a less exciting headline, but it has the virtue of being accurate.

Here's some context. Environmental epidemiology is a notoriously difficult endeavor. First, it's quite difficult to measure how much of any given agent people are exposed to. You can find people who live in a place where something or other is known to be in the air, for example, but they will all vary widely in how much time they spend at home, how much time they spend outdoors, how much they open the windows, etc. And living in that place also means that they likely have all sorts of other things in common that might be relevant to their cancer risk. We can try to measure and account for as many of those factors as we can think of, but we can't be sure we haven't missed the one that matters.

What is worse, it might be that exposure to X only matters if also Y. For example, radon exposure was found to increase the lung cancer risk of uranium miners, but it turned out to mostly be a synergistic effect with tobacco smoking. The effect was difficult to detect in non-smokers. Since smoking and environmental tobacco smoke were -- and still are -- by far the most powerful environmental cause of cancer, overwhelming everything else, people in public health (public healthists?) found it hard to get as excited about other kinds of exposures. Also, a lot of much hyped suspected links, for example between environmental endocrine disrupters such as many pesticides and breast cancer, haven't panned out.

Another inconvenient truth is that we do know about other environmental cancer risks, but they don't indict giant soulless corporations but rather your grandmother and your own sorry self. Smoked and grilled meat products and starchy fried foods contain carcinogens. Also, excessive alcohol consumption promotes cancer. And of course, so does getting a sunburn.

Now, we do know that some products of incomplete combustion -- ergo compounds found in motor vehicle exhaust and smokestack emissions -- called polycyclic aromatic hydrocarbons, are carcinogenic. More complicated versions called dioxins are found as contaminants in pesticides as well as smokestack emissions (including, by the way, your fireplace chimney) and paper mill effluent. A lot of reactive hydrocarbon compounds probably can cause genetic damage, mess with hormones, and just cause inflammation and irritation which makes cells divide more than usual, which also may increase cancer risk. The problem is that all of these exposures mix and match and interact, and that it probably matters how old you are and how long it lasts and whether you are overweight or underweight or male or female and what your particular genetic endowment is and who the hell knows what else.

Most chemicals approved for various uses, including as ingredients in food or food packaging, believe it or not, have not been adequately tested for safety. But that is also very hard to do. You can't do experiments by feeding them to people. You can feed stuff to mice, despite PETA's objections, but a) mice aren't people and b) you can't feasibly mimic human exposures. It's just too expensive to give millions of mice a tiny bit of something for a long time. Instead you have to give a small number of mice a whole lot of it. That just ain't the same thing; and mice don't live nearly as long as people anyway so you can't do twenty or thirty year follow up. And sorting out what people are exposed to from their natural history, and trying to relate that to their lifelong risk of cancer, is just really, really hard and can very easily lead you to wrong conclusions.

So yeah, we need to keep studying these questions, and we probably need to do it bigger and better. But so far there are only a few specific things we can tell you. Don't smoke. Don't do shots every night. Don't live near the highway. Maintain an appropriate body weight. Don't work as a hot tar roofer or a paver -- although somebody has to do it.

A notable and exemplary career

I just got back from a farewell luncheon for Stephen Shestakofsky, who is the retiring director of state legislation (i.e. lobbyist) for the Massachusetts Medical Society. Steve symbolizes in his person the very interesting historical fact that for the past 15 years or so the MMS, unlike physicians' organizations elsewhere, has been on the light side of the force. Steve had a lot to do with that, it isn't just because this is the People's Republic of Massachusetts.

Steve was involved in many campaigns for justice and health equity, but one of the most important, because the trickle we started here in Massachusetts turned into a nationwide flood, was tobacco control. It started with the successful referendum campaign to impose a tax on tobacco products, to be used for programs to combat tobacco use. The industry poured in millions of dollars and conscripted convenience store owners and, yes, pharmacies to their fight, but they lost, and the voters passed it. Then the MMS joined with its coalition partners for the workplace smoking bans, strong and enforceable bans on tobacco sales to minors, and other measures that made our state a leader and have now been adopted all over the country.

However, Australia, believe it or not, is ahead of us. This is what all cigarette packages are going to look like in Australia in 2012:



The packages will all be standard, with the strong and graphic health warnings you see here. The merchants of death won't be able to use any of the imagery, colors or lying words they put on packages to seduce children into a deadly addiction. The kangaroo jockeys are also going to raise the sales tax on tobacco by 25% and spend more on anti-tobacco advertising. Naturally, British American Tobacco Australia says they are "surprised and disappointed." Awwww. I'll tell you what guys -- why don't you go to hell.

People are Stupid

Isaac Asimov spoke at my college back in the day, and those were his opening words, still as true as ever. I was thinking about why our political culture seems incapable of confronting the real problems we face when I happened to come across an essay by David Hemenway in the new NEJM that seems quite relevant, titled "Why We Don't Spend Enough on Public Health." He breaks down four reasons: medicine often has immediately perceivable benefits, whereas the benefits of public health programs are somewhere off in the gauzy distance; we know specifically who benefits from medical intervention but the beneficiaries of public health programs are individually unidentifiable -- you will never know that you are the person who didn't get sick; physicians are often famous heroes but who ever heard of the guy who invented sewers?; and powerful vested interests often oppose public health programs, such as (and he names the names) "the alcohol, tobacco, firearm automobile, coal and oil industries."

When I started to think about this post I was pondering the comparable, if not greater attention given to Faisal Shahzad and the petroleum gusher in the Gulf of Mexico. Shahzad apparently attended a terrorist training school in Pakistan and majored in bomb making. If that is true, the first thing his lawyer should do is try to get his money back. But we pay so much attention to the relatively inconsequential threat of "terrorism" because when these attempts occur, they are specific, immediate, and visible. There is an individually identifiable malefactor and had he succeeded, there would be individually identifiable victims.

We are suddenly re-evaluating deep water oil exploration but of course the risk of a blowout was always there, and the most important reason not to do it -- that we have to stop using so much petroleum in the first place rather than spending tens of billions of dollars to find more -- is a) based on abstract, long-term concerns and b) furiously opposed by the world's largest, most powerful vested interest.

Until we can rewire our brains we are just going to march on to our doom like cattle in a chute.

(I missed two consecutive weekdays for probably the first time ever, due to proposal hell. Friday is a big NIH deadline. Maybe in the future if that happens I'll throw up some classics. Anyway, I am now coming up for air.)

Hijacking our lizard brains

As usual of late, the Red Sox were producing intense dysphoria yesterday so I surfed over to CNN a few times for the latest. All they could talk about, in spite of, you know, some other stuff that's going on in the world, was the clownish "car bomb" attempt on Times Square.

As the details come out, it seems pretty clear to me -- even though I'm not a genius reporter for a major news gathering operation -- that this was a lot more like a weird prank than an actual attempted bombing. The car contained propane tanks for your backyard barbecue; some cans of gasoline; a box full of ordinary (non-explosive) garden fertilizer; two clocks attached to wires which were in turn attached to nothing, apparently; and some toy firecrackers that wouldn't even blow your fingers off. Apparently they guy lit some of the firecrackers before he bolted, which set fire to the upholstery.

Those propane tanks are almost impossible to blow up. That's why they sell them at Home Depot to grill your burgers and franks with. You'd be surprised how hard it is to set a can of gasoline on fire, but even if you do, it won't explode per se, it will just burn like crazy. And it won't cause propane tanks to explode. The fertilizer would never have done anything, under any circumstances. Lots of people are now pointing this out but here's one relatively amusing discussion.

So either we had a totally inept clown who thought that by throwing together in one place some random objects that he had vaguely heard were somehow related to possibly blowing stuff up he could emulate his hero, whether that be Timothy McVeigh or Mohammed Atta; or the whole thing was intended only to get a lot of attention it didn't deserve. I lean toward the latter but either way, it got a whole lot of attention it didn't deserve.

I have read that a big reason why Scott Brown was elected to the Senate was because of the UndieBomber. People were suddenly afraid that Martha Coakely and the other Democrats are soft on terrorism because she wanted him prosecuted in the ordinary way by civilian justice. It's utterly ridiculous. If all al Qaeda can do now is have one guy set fire to his nads and another guy set his car upholstery on fire, we probably shouldn't spend time worrying about them or electing Senators on the basis of whether the U.S. Constitution should still be in effect.

An evil, evil day

I picked this up from a commenter at Grist:

A reader who is an engineer of considerable experience says watch this
one evolve carefully because it is destined to continue to grow and he shares this long (but worthy) explanation why:

"Heard your mention of the oil disaster in the Gulf of Mexico this morning, and you (and most everyone else except maybe George Noory) are totally missing the boat on how big and bad of a disaster this is.

First fact, the original estimate was about 5,000 gallons of oil a day spilling into the ocean. Now they're saying 200,000 gallons a day. That's over a million gallons of crude oil a week!

That's an enormous catastrophe. (I removed some of the quote because I think it was a bit over the top, on reflection -- but I do believe it is very unclear when they will be able to cap this well and it might indeed be many weeks. So yes, it's really, really bad.) This is a product of a hubristic ideology that claimed that allowing people to do whatever the hell they want to make as much money as they possibly can will create the best of all possible worlds; and that anyone who tries to interfere on behalf of some imagined greater interest or common cause is an enemy of humanity. Is this what it will take for people to finally confront the enormity of our folly?