Alternative Healing Paradigms

Hah! There's no such thing. Either it works or it doesn't.

One of the mixed pleasures of blogging is that I get e-mail from all sorts of people who otherwise live in a parallel universe. A standard claim of champions of complementary and/or alternative "medicine" is that their system or method or practice or whatever it is represents an alternative healing paradigm and therefore cannot be judged by the standards used to evaluate "conventional" or "Western" or allopathic medicine or whatever you want to call it, but needs to be assessed on its own terms. Because I refuse to enter this alternative paradigm and accept the evidence appropriate thereunto, I have a closed mind and I'm arrogant, or whatever the insult of the day happens to be.

An "alternative paradigm" is generally an assertion that all disease, or at least a good bit of it, has a single cause -- usually an "imbalance" of some kind, maybe an "energy" imbalance or low pH -- and/or that all cures derive from some unifying principle, often just a slogan that doesn't have a very specific meaning, such as "like cures like" or "energy rebalancing." A problem that all "alternative" healing paradigms face is that there isn't any good evidence for them, if by evidence we mean the usual requirements of scientific inquiry.

I could waste your time and mine writing about some of these "ideas," a status to which they aspire but do not achieve, but instead I'll just say something about the kind of healing they practice here in the academic medical center where I work. I'll just call it medicine since that's what my employers call it.

Quick -- what is the "paradigm" of medicine, to which my correspondents claim to be alternative? Give up? Good for you, because there isn't one. People are complicated and there are all sorts of entirely different things that can go wrong. Physicians don't fall back on a paradigm to fix everything, they do whatever is likely to work. Antibiotics, surgical excision of tumors, hormonal therapy, receptor blockers, physical therapy, nutrition, prostheses, cancer chemotherapy, cognitive behavioral therapy, social support, surgical repair of joint trauma, monoclonal antibodies, antivirals, vaccinations, and so on and so forth, are all specific ways of addressing various, often entirely unrelated problems.

The only "paradigm" physicians worry about is whether something works or not. The way you find that out is to subject it to rigorous testing. It's often helpful to understand as much as possible about the underlying biological processes that are making a person sick. It can help guide an efficient search for new therapies, and help select the right one for a particular case. But it isn't always necessary -- some remedies are just "empirical," as they say, i.e. they are known to work but people aren't sure why. Doctors aren't above using these, even if they'd generally prefer to know what's going on.

And so, if homeopathy worked, doctors would use it, even though the "paradigm" its proponents claim is absurd and requires overturning all of chemistry, physics, and fundamental logic. But it doesn't work. That's all there is to it. In the poorly designed, poorly conducted, biased and selectively published trials they point to, it sometimes appears to work, a little bit, mostly for vague complaints that normally get better on their own anyway. But the pattern is relentless: the higher quality the experiment, the less it seems to work. In good experiments, it doesn't work at all, it's just a placebo.

That's all we care about folks. You can have your paradigm all you want. But it doesn't work.

Composition of the moon: views differ

Rock or green cheese? CNN borrows its report of the latest international report on climate change from a Financial Times reporter. After duly reciting the findings of a group led by NOAA, she writes:

Some scientists hailed the study as a refutation of the claims made by climate skeptics during the "Climategate" saga. Those scandals involved accusations -- some since proven correct -- of flaws in the IPCC's landmark 2007 report, and the release of hundreds of emails from climate scientists that appeared to show them distorting certain data.

What she doesn't bother to tell us is that the flaws "since proven correct" were trivial, inconsequential errors of attribution and one narrow substantive error which did not bear in any way on the overall conclusions, out of thousands of pages; and that the e-mails that "appeared to show them distorting certain data" actually did no such thing. She then goes on to quote a who's who of crank climate change deniers -- mostly from oil industry-funded think tanks -- heaping scorn on the report by making assertions which are simply false.

The corporate media will continue to cover the story in this way for as long as they are, well, corporate. But it's time for you to be very, very scared. And angry. We've just had the hottest decade, hottest year, hottest month, and hottest week on planet earth since we've been keeping records. And most of that heat is going into the ocean, where it has caused a long-term decline in phytoplankton, which in case you didn't know it is the fundamental basis for life on earth. It's why you can breathe. You don't have to take it from me:

The findings contribute to a growing body of scientific evidence indicating that global warming is altering the fundamentals of marine ecosystems. Says co-author Marlon Lewis, "Climate-driven phytoplankton declines are another important dimension of global change in the oceans, which are already stressed by the effects of fishing and pollution. Better observational tools and scientific understanding are needed to enable accurate forecasts of the future health of the ocean." Explains co-author Boris Worm, "Phytoplankton are a critical part of our planetary life support system. They produce half of the oxygen we breathe, draw down surface CO2, and ultimately support all of our fisheries.

It's one thing to be a psychopath, but to destroy the planet in the cause of greed -- I don't know what to call that.

JAMA gets whacked with the newspaper

for hiding this behind the subscription wall. This is exactly the sort of thing the public needs to know about, think about and discuss. The basic story Dr. Reuben tells is simple. An 89 year old woman who is already frail and requires 24 hour care shows up at the hospital with symptoms of a stroke -- severe weakness on the right side of her body and inability to speak. She quickly develops breathing difficulties and the doctors insert a breathing tube. They do an angiogram and find a blood clot in a cerebral artery, but they can't remove it. She ends up on a ventilator, and unresponsive.

Her son, however, doesn't want to give up hope so he makes the doctors insert a permanent breathing tube and a feeding tube. Two months later, she is transferred to a long-term care facility.

Dr. Reuben contrasts this with the case of an 81 year old homeless woman with Parkinson's disease who has a urinary tract infection, but who has exhausted the 100 day Medicare limit for post-acute rehabilitation so they just have to send her back to a shelter, rather than the skilled nursing facility where she really should go. We pretty much take this limitation for granted. This woman is obviously sick, but she's thinking, feeling and interacting.

So take a look -- the 100 day limit is obviously rationing, and it's rationing that doesn't make any evident sense. But the woman with the stroke is hospitalized, so there's no such limit. As Dr. Reuben points out, 1 week of the 8 she spent in the ICU costs more than health insurance for a family of 4 for a full year. Many families have no such insurance.

So this is rationing as it practiced today in the United States. And it is totally nuts. We are rationing, we will continue to ration, we will ration more and more. The question is not whether we ration health care, it is whether we do it with at least some consideration of justice, humanity and plain old reason. People who insist that it is somehow immoral, or socialist, or oppressive, to want to change what we are doing now either haven't stopped to think; or they are simply deeply evil people who figure they have theirs and the rest of us can just go ahead and die a horrible death.

Yes, ex-Governor Palin and Hal Scherz, M.D., I'm talking to you.

Darkness at the end of the tunnel

We have a several long-term problems, which of course our dysfunctional political system and utterly corrupt and nearly useless corporate media are largely failing even to contemplate, let alone do anything about. If you are reading this, you can probably come up with a list that's pretty similar to my own -- anthropogenic climate change, petroleum depletion, long-term structural unemployment, infrastructure decay, massive unfunded pension liabilities, the permanent war economy, not to mention the dysfunctional political system and corrupt and useless corporate media. Oh, I did mention those.

But long blog posts don't get read very much so I'll concentrate on one problem today. We've discussed this before but we have a strong, specific analysis to rely on today, from Joseph P. Newhouse in Health Affairs. It really frosts my pumpkin that this is subscription only, but I'll do my best to get the gist across. This is really two articles. The first is what the title says -- how various groups of Americans will experience the effects of the Patient Protection and Affordable Care Act in coming years, depending on their current status within the health care non-system the PPACA set out to reform. The basic lesson here is that the legislative factory has built a Rube Goldberg contraption with far too many moving parts that don't really fit together. All sorts of strange outcomes and unnecessary administrative burdens may result, which it may or may not be politically possible to fix. All of these problems would disappear like the flame of a blown out candle if we just had universal, comprehensive, single payer national health care but that can't happen because Aetna (on whose board Newhouse sits and in which he owns stock) would also blow away and well, then, some rich people would no longer be able to suck our blood.

In spite of his blatant conflict of interest, however, Newhouse appears to be a fair analyst. The second half of the article, or the second article really, concerns the future of health care spending with a focus on Medicare. Here's the problem in a pistachio shell: health care costs have been growing at about 2.5% annually above the rate of GDP growth. If that continues, four percent of GDP will shift to Medicare in the next 15 years. Big deal, you say? Yes it is, because Americans are unwilling to pay more in taxes than about 18% of GDP.

Right now, by the way, although nobody will believe it who listens to our dysfunctional politicians and useless corporate media, we're paying the lowest percentage of GDP in federal taxes since 1950, about 15%, so we could conceivably pay more but it seems unlikely to happen. In any event, we'd have to exceed 18% to cover 4% of GDP shifting to Medicare. And of course it just gets worse after that. Newhouse, relying on ME Chernew and no doubt correctly, observes that if this continues, by about 2050 we will actually have less of GDP to spend on everything else, i.e. Medicare will start eating our lunch and burning down our houses.

Of course this won't happen because we won't pass the necessary tax increases. So what will happen? There are a few possibilities but the smash up of universal health care, and of Medicare, seems the only likely alternative. Unless, of course, we can stuff a sock in the idiots who are screaming about death panels and find a way to start making rational choices about medical spending.

I'm not betting on it.

War!

What is it good for? Absolutely nothing! (Say it again.)

As you may know, for several years now I have been involved in day to day documentation of the Iraq war, and now the Afghanistan war as well, at Iraq Today. We're mostly just arm-chair aggregators, with the occasional tip-off to something interesting and a habit of linking to local Iraqi, Afghan, and international media.

So, I'm not an official expert on Afghanistan but I do know enough about the situation to tell you that there is nothing at all revelatory about the massive document dump on WikiLeaks. (Most people are probably going to the NYT for their digested presentation of the material, which is fine, but I actually like The Guardian's presentation, I think it's more accessible and better organized.)

First a note that seems strangely necessary: the leaked documents describe Dick Cheney's George W. Bush's war in Afghanistan, not Barack Obama's, which did not take shape until shortly after the leaked documents end. Nevertheless, they describe the situation that was known, or ought to have been known to Obama when he undertook his own version of a "surge," and it is manifest that the essential facts have not significantly changed.

The U.S. and its partners in the International Security Assistance Force (ISAF) generally cannot distinguish reliably between combatants and innocents, and in any case they are all to be found together. So, killing suspected or even firmly identified insurgents is likely to mean killing innocent people, just as likely including children as well as adults. We have long known this, obviously, but the documents show that most deaths of non-combatants done in our name, with our tax dollars, were kept secret from us.

There is no effective Afghan government, police, or military. Few Afghans have any primary loyalty to the fictional nation-state of Afghanistan. Local officials and police are incompetent, corrupt and more likely to be allied with local warlords, Taliban or other anti-government forces than they are with the Kabul-based government the U.S. is trying to establish.

In the vast, remote, impoverished, illiterate and tradition bound expanses of Afghanistan it is absurd to talk about foreign armies somehow holding territory. They can be in it, but they are not of it. When they leave, as they must, it will be unchanged.

Few, if any Afghans care about the United States or Europe except to the extent they want foreign forces to leave their country. The enemies of the occupation have not the slightest interest (or means for that matter) in attacking targets in North America or Europe. The violent Islamist cults that hatch such plots are not particularly in Afghanistan, indeed they are scarcely there at all. While some such elements are harbored in Pakistan, most of the people who turn up are in Europe and the United States. They may have had some encouragement from places such as Pakistan and Yemen, but never from Afghanistan. As Evo Poteski makes clear, the national security justification for the war in Afghanistan is nonsensical. The occupation of Afghanistan only inflames anti-American and anti-British sentiments among people who are nowhere near Afghanistan.

The purported alliance between the U.S. and Pakistan is a con job, and we're the pigeons.

Oh yeah -- have you heard about the federal budget deficit? And possibly you have heard something about bereaved American families and injured veterans, although perhaps not very much?

Here's how we salvage what we can from the Afghanistan debacle and achieve the best possible long-term result:

Get onto airplanes. Fly home.

Yes Virginia, there is a wise capitalist

I am going to commend to your attention a sage who you may be surprised to see touted on this pinkish page: hedge fund manager Jeremy Grantham. This is a fairly large PDF, so give it time to load. You may then want to scroll down to page 7, where he discusses global warming, followed by the intermediate term economic prospect, and finally the issue of health care spending.

It particularly warms the cockles of my own heart (whatever the hell that means) that he is so droll about his fellow obscenely rich capitalist pigs. E.g.

This brings us to the U.S. Here the possibility of rationing health benefits to the level society is willing to pay is so anathema that it cannot be talked about sensibly and, if at all, the language must be tortured in order to talk around the point. Our culture demands the best that money can buy, combined with unlimited legal liability (courtesy of the legal lobby and all those lovely lawyers in Congress), and friendly conditions for the drug and insurance industries (courtesy also of their effective lobbies). Nobody gets treated badly except, of course, the ordinary user. That is to say, the ordinary taxpayer, who pays a third more for mediocre or worse aggregate health results, lower life expectancy, etc., etc., etc. Yes, I know for the very rich it is said to be the best system in the world. Yet I am rich, and have had less than brilliant experiences recently with a tiny country tick running rings around the medical industry. And never get sick during vacation season. “Dr X is fishing in Alaska so your call will be forwarded to Dr. Y, who is scuba diving in Grand Cayman. Click.” Anecdotal evidence. Heresy. Strike it from the record!

Our cost-laden health system is perhaps fine if you are willing to pay for it. But the same people who scream “death panels” at the concept of sensible rationing also reach for their revolvers, of which they insist on having plenty, at the prospect of having a tax structure nearer the average of the rest of the rich world. Now, this is a non-compute. It has to be one or the other, either rationing or taxes. Presumably we will hunker down, wait for a crisis, and then respond. (To be fair, we did modestly extend the age to receive Social Security and I, for one, had to wait an extra four months. Rage, rage.)

Perhaps a certain pediatric urologist should consider investing with him -- I'm sure he has plenty of loose change.

Multitasking

The 18th International AIDS Conference in Vienna was to be the stage for a major push to decriminalize currently illicit drugs worldwide. Unfortunately, this effort was upstaged by the equally pressing problem that funding for HIV prevention and the universal treatment promised just a few years ago is falling well short. Uganda, for example, has essentially run out of funding for antiretroviral drugs and can no longer treat new patients. Shockingly, as I noted here a couple of weeks ago, the same is true of Florida and Alabama.

But, the decriminalization campaign is still happening. This is the web site for the Vienna Declaration. You can read it, and if you like what you read, you can sign it!

Here's the gist:

Unfortunately, evidence of the failure of drug prohibition to achieve its stated goals, as well as the severe negative consequences of these policies, is often denied by those with vested interests in maintaining the status quo.25This has created confusion among the public and has cost countless lives. Governments and international organisations have ethical and legal obligations to respond to this crisis and must seek to enact alternative evidence-based strategies that can effectively reduce the harms of drugs without creating harms of their own. We, the undersigned, call on governments and international organisations, including the United Nations, to:

* Undertake a transparent review of the effectiveness of current drug policies.
* Implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use.
* Decriminalise drug users, scale up evidence-based drug dependence treatment options and abolish ineffective compulsory drug treatment centres that violate the Universal Declaration of Human Rights.26
* Unequivocally endorse and scale up funding for the implementation of the comprehensive package of HIV interventions spelled out in the WHO, UNODC and UNAIDS Target Setting Guide.27
* Meaningfully involve members of the affected community in developing, monitoring and implementing services and policies that affect their lives.

So go for it -- everybody's endorsement matters, but there will be extra weight if you are a health care provider, legal advocate, social worker, counselor, law enforcement professional, a person in recovery or have any other connection to this issue. It's time for an entirely new public discussion, unencumbered by the failed ideologies that fuel the war on drugs.

Socialized Medicine Kills People

But apparently not very effectively. Death rates at lowest levels ever in England and Wales.

Between 1999 and 2009, death rates fell by more than a quarter for men and over a fifth for women, according to the figures from the Office of National Statistics, which said they were now at their lowest since records began in 1841.

Circulatory conditions like heart disease remain the most common cause of death, contributing to a third of the deaths registered. But over the decade, mortality from these diseases fell by 40% for both men and women.

The infant mortality rate in the UK is now under 5/1,000 live births. In the U.S., it's 6.22. Of course we have the absolute best pediatric urology.

Right at the moment, I don't need a pediatric urologist

But if I did, I could probably get an appointment tomorrow. However, last time I made an appointment for a routine visit with my primary care doc, I had to wait four months. NEJM's most excellent national correspondent John Iglehart discusses the problem of the primary care physician workforce, particularly in light of the promise that 95% of the population will have health insurance by 2014. As Iglehart puts it, "[M]andated coverage is only one of many challenges facing Democrats as they implement the most sweeping piece of social legislation since the enactment of Medicare and Medicaid. Another challenge that has attracted far less attention is whether newly insured individuals will actually have access to health care once they become insured."

Which means, if I have to wait four months now, I might have to wait eight months in 2014 -- if I can find a physician who will take me on at all. Iglehart's piece is fairly wonky so if you are prone to eyeball glazing, I'll just give you the bad news quickly. The Council on Graduate Medical Education says we need to increase the primary care workforce from the current 32% of docs to at least 40%. But it isn't happening: only about 17% of new medical residents appear to be headed toward primary care practice, in other words the situation is just going to get worse.

The health reform legislation takes only baby steps toward fixing this problem, which will accomplish little or nothing. Ultimately, it comes down to income, working conditions, and prestige, and specialists get the better of all three right now. As we know, many of these highly paid specialists don't like health care reform because they figure that eventually, it will force policy makers to deal with this problem and reduce the disparity in reimbursement rates. It doesn't help that some part of what they do, and bill for big time, isn't actually worth it, and payment reform might catch up to that problem as well.

But universal -- okay, near universal -- coverage won't be real unless we fix the crisis in primary care.

Review Review

I'm currently revising a manuscript for resubmission, which is a rather noxious chore since, of course, it was a thing of lapidary perfection to begin with. Or at least I thought so.

It is a famous fact that one of the defining features of the scientific institution -- as we sociologists call it -- is peer review. An "institution" in this sense is not a specific organization or enterprise, but rather a cultural system embedded in the larger culture. We have, for example, a medical institution, a legal institution, an educational institution -- broad areas of social activity with their own rules, norms, characteristic organizations and social roles. Obviously these intersect to some extent -- there is a medico-legal sector, a sector of legal education, etc.

Science is a way of investigating reality, a body of knowledge and explanatory models, all rooted in an epistemological attitude; but as a social institution it also operates by rules and conventions which rest implicitly on values, goals, cultural norms and ultimately the substrate of human social behavior. We have our formal ranks and titles, hierarchies of power and privilege, exclusive clubs and semi-secret languages. We also have this ritual of peer review, which is the trial by ordeal we must endure to get money for our work, and to get it published.

Some while back I wrote a bit about the NIH funding process. Now let me say a bit about peer reviewed publication. For the defenders of the scientific institution, it is the foundation of the credibility of scientific findings; for its detractors, such as my homeopath friends, it's how we keep the truth from the people. I frequently serve as a peer reviewer and I also have it done to me. I can assure you that I never base my reviews on whether a study reaches a conclusion that makes me happy, nor have I ever thought that a paper of my own was reviewed in accordance with any preconceived notion of the truth. Reviewers focus on the credibility of methods, the rigor of analysis, the clarity of presentation, the relative importance of findings, and the suitability for the particular journal.

Based largely on reviewers' comments, with some discretion, editors can reject papers outright; invite resubmission after substantial revisions; or accept papers, usually with some indications for changes. Outright acceptance on the first submission is uncommon, however.

Editors can't publish everything they get just because the work is well done. They have to consider whether a manuscript is a good fit for their publication, and whether it advances the field meaningfully. As your findings become less exciting to the establishment in your field, you'll fall down the "impact factor" ladder to a lower impact journal. But if you have a credibly done study, you can probably find some obscure place to publish it.

This is not by any means an unalloyed good. Studies that replicate earlier findings are unlikely to get published in a high impact journal, and therefore provide less fuel for an investigator's career. The same is generally true of negative findings -- determining that a treatment does not work or an exposure is not associated with risk. But replication is essential to the credibility of findings and there is nothing inherently less valuable about ruling out than ruling in. These are called publication biases and they do have the consequence that incorrect findings often take longer to expunge from the corpus of belief than they should, and that useless treatments often persist.

Still, some observations are just trivial and don't deserve to take up the very limited prime real estate in scientific journals. Whether this applies to my very important discoveries is a matter of opinion, however.

Peer reviews can be very frustrating when it comes to those substantive issues -- credibility of methods, rigor of analysis, clarity of presentation. Here one often feels that the problem is not the credibility, rigor and clarify of the manuscript, but the density of the reviewer. I suppose some investigators have felt that way about my own reviews. But if I don't understand it, other people probably won't either, so a certain amount of strategic stupidity on the part of a reviewer may actually be good. It forces you to go back and explain it for dummies.

Where we do get into trouble quite often, however, is when we encounter some of the other human weaknesses. Reviewers may have ulterior motives, probably unacknowledged even to themselves, of undermining the competition. They don't want somebody getting into print first with something they have been working on. This has happened to me, actually. I managed to figure out what was going on and get it fixed. Or they may indeed be on one side of a scientific controversy and have some bias against findings that seem to support an opposing view. In the social sciences, it is often impossible to completely disentangle a question from values or ideology, and we do indeed have movements and fads.

And this is where we have a job to do fighting off the homeopaths and climate change deniers and creationists. They claim that peer review is a conspiracy against the truth. The only way I can think of to prove them wrong would be to go through their writings one by one -- I won't say research reports because quite often what they promote is not research at all, but mere argumentation -- and show why they legitimately should not be published in scientific journals.

Homeopaths purport to do clinical trials but real clinical trials consistently fail to find any efficacy for homeopathy. Their trials with positive findings are not blinded, indeed may have no controls at all, and the results can be explained entirely by the placebo effect, regression to the mean, and investigator bias. But unless you are willing to take my word for it, and that of the many responsible scientists who have looked into the matter, you would have to just go through them, one by one, and see for yourself. Ultimately, yes, you do have to trust us.

Unless somebody has a better idea.

The American Disease

It seems to be a pathological aversion to self-examination. As you are unlikely to know from the U.S. corporate media, which has largely ignored the story, the UK is currently holding a public inquiry into the Iraq war. I think it would be way fun to do that here, but not going to happen. Dame Eliza Manningham-Buller, who was head of the British spy agency MI5, has just testified. The only real surprise is that MI5 was telling Tony Blair the truth all along and, as a pious Christian, Blair was compelled to lie to the public about every single fact. Some major highlights:

• MI5 did not think the Saddam Hussein regime posed a threat: "We did think that Saddam Hussein might resort to terrorism in the theatre if he thought his regime was toppled but we didn't believe he had the capability to do anything in the UK," she said.



• The evidence of Saddam Hussein's supposed weapons of mass destruction (WMD) had been "fragmentary", she said, and she dismissed Tony Blair's argument that action had been necessary to prevent them falling into hands of terrorists.



• The toppling of Saddam had, she suggested, also given al Qaida a foothold in Afghanistan [sic -- I believe she said Iraq] for the first time. "Arguably we gave Osama bin Laden his Iraqi jihad," she said.



• As additionally reported by AP, "those pushing the case for war in the United States gave undue prominence to scraps of inconclusive intelligence on possible links between Iraq and the 2001 attacks. She singled out the then-U.S. Defense Secretary Donald Rumsfeld. "It is why Donald Rumsfeld started an alternative intelligence unit in the Pentagon to seek an alternative judgment," said Manningham-Buller, who was a frequent visitor to the U.S. as MI5 chief. "Saddam Hussein had nothing to do with 9/11 and I have never seen anything to make me change my mind," she said.



• Manningham-Buller also indicated that MI5 disagreed with then-Prime Minister Tony Blair over a key justification for the war — Iraq's purported harboring of weapons of mass destruction. She said the belief that Iraq might use such weapons against the West "wasn't a concern in either the short term or the medium term to either my colleagues or myself."

What this all means in sober fact is that the United States and the United Kingdom conspired to launch an illegal war of aggression, based on a campaign of lies. Iraq was laid to waste, something on the order of a million Iraqis have died, and Iraq today remains with its water and soil polluted, its people living in squalor under constant threat of violence, its social fabric shredded. It seems rather self-centered to mention the more than 4,000 American dead, the tens of thousands of Americans scarred physically and emotionally, and the trillions of dollars squandered, but let's just say it anyway. This is, by every accepted definition, a crime against humanity.

We will never have a similar inquiry here because all segments of the political elite -- including the opposition party and the corporate media -- were complicit in the crime; and because our political culture admits of no blame to the United States.

Alright, the president says we're looking forward, not back. But we aren't doing that either. No American politician will tell the people the truth, because that would be a career ending gaffe. The United States, according to the Stockholm International Peace Research Institute, accounts for 46.5% of world military spending. This does not include defense-related spending outside of the The United States, such as veterans' benefits and the secret "black ops" budget which U.S. citizens are not permitted to know about, so we can only estimate, but total annual U.S. military spending is probably more than $1 trillion per year. The United States publicly admits to having 737 military installations abroad, and has additional secret bases, where among other activities it holds secret prisoners, without charges or any recourse to courts, who it tortures.

The United States has no significant international enemies; it is threatened by no-one. There is no significant opposition in Congress or in the corporate media to this trillion dollar annual expenditure, but we can't afford to fix our roads, invest in renewable energy, or pay teachers, police or firefighters.

Why?

Just because you have a medical degree . . .

. . . doesn't necessarily mean you know your anus from the lateral epicondyle of your humerus. I got an e-mail from a flack for a physician named Hal Scherz who is the president of an organization (about which I have so far found no independent information) called Docs4PatientCare. He writes:

Just as the Administration rolled over the American people with the health care bill, this recess appointment shows a similar contempt for the democratic process and a ruthless determination to impose government-run health care. To place Dr. Berwick, someone with an admitted love for socialized medicine, to assume such an important position without proper vetting is dangerous for the health of our entire nation. People don’t want politicians coming in between them and their doctor.

and

The recess appointment of Dr. Donald Berwick to head the Center for Medicare and Medicaid Services, put to rest any doubts about what President Obama’s true motives are in pushing for so called health care reform. Don’t be fooled by flowery words or big pipe dreams. By virtually every measure, socialized medicine fails and people die. Obamacare will turn off the engine of innovation and medical advancement. It will usher in a new medical dark age that will have a ripple effect worldwide."

This is obviously characteristic right wing rhetoric, but let's step back for a second and deconstruct it as argumentation.

The administration rolled over the American people with the health care bill.

The bill was passed by both houses of the duly elected Congress of the United States and signed into law by the duly elected President of the United States, in accordance with the United States Constitution and the mechanism by which laws have been promulgated in the United States since 1787.

This recess appointment shows a similar contempt for the democratic process.

George W. Bush made 47 recess appointments, many of them to higher offices than Director of CMS.

and a ruthless determination to impose government-run health care.

Pure speculation, does not logically follow. Berwick is appointed to an administrative position in which he does not make policy and can only implement the requirements of the law.

To place Dr. Berwick, someone with an admitted love for socialized medicine . . .

Berwick has expressed admiration for certain aspects of the British health care system. He has never asserted that the United States should adopt a government run health care program. The insinuation is unsupported. (Whether or not you think that would be a good thing anyway is beside the point.)

People don’t want politicians coming in between them and their doctor.

I suspect that most people would agree with that statement, but it is irrelevant. Berwick has never proposed such a thing, nor is that a defensible conclusion about the consequences of anything he does propose. He advocates that physicians be given a better base of scientific knowledge on which to discuss treatment options with their patients. He is in fact known as a radical advocate of so-called patient-centered medicine in which patients are the ultimate authorities on their own health care. He has in fact been criticized for insisting that physicians should give their patients what they want, even if it is against the physician's best judgment about what is in their interest. Here is an actual quote from Donald Berwick:

I freely admit to extremism in my opinion of what patient-centered care ought to mean. I find the extremism in a specific location: my own heart. I fear to become a patient. Partly, that fear comes from what I know about technical hazards and lack of reliability in care. But errors and unreliability are not the main reasons that I fear that inevitable day on which I will become a patient. For, in fighting them, I am aligned with the good hearts and fine skills of my technical caregivers, and I can use my own wit to stand guard against them.

What chills my bones is indignity. It is the loss of influence on what happens to me. It is the image of myself in a hospital gown, homogenized, anonymous, powerless, no longer myself. It is the sound of a young nurse calling me, "Donald," which is a name I never use—it’s "Don," or, for him or her, "Dr. Berwick." It is the voice of the doctor saying, "We think...," instead of, "I think...," and thereby placing that small verbal wedge between himself as a person and myself as a person. It is the clerk who tells my wife to leave my room, or me to leave hers, without asking if we want to be apart. Last month, a close friend called a clinic for her mammogram report and was told, "You have to come here; we don’t give that information out on the telephone." She said, "It’s OK, you can tell me." They said, "No, we can’t do that." Of course, they "can" do that. They choose not to, and their choice trumps hers: period. That’s what scares me: to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep.

Call it patient-centeredness, but, I suggest, this is the core: it is that property of care that welcomes me to assert my humanity and my individuality. If we be healers, then I suggest that that is not a route to the point; it is the point.

By virtually every measure, socialized medicine fails and people die.

This is manifestly inconsistent with easily observable reality. As I have noted here repeatedly, and as anyone can easily discover with minimal effort, those countries that have what Scherz would call socialized medicine have better health outcomes than we do. Their people are healthier, they live longer, they are happier with their health care, and they save 50% of what we waste on useless or harmful medical interventions.

Obamacare will turn off the engine of innovation and medical advancement.

On the contrary, the Patient Protection and Affordable Care Act, and related legislation and executive initiatives, include increased investment in scientific research to discover more effective treatments.

In short, everything this man says is false, absurd, and generally the exact opposite of the truth. Let me tell you what really bothers him: he is a pediatric urologist, a narrow medical specialist. That means that under the current system of medical financing, he makes much more money than primary care doctors. Berwick, and as far as I can tell Barack Obama, want to reorder health care financing so that more resources go to primary care and specialty care is somewhat less lucrative. Scherz is afraid that some day, he'll only pull down a quarter million dollars a year or so, and that's not enough for the upkeep on his mansion.

BMJ gets a dog biscuit

for making analysis and commentary on drug prohibition open access. (Scroll about halfway down the page to the box headed "tackling injection drug use," where you'll see links to several articles and multimedia. You have to click through a couple of links to get to the articles, but they're available. This link will only be good for a week or so since it's the front page of their web site. I'm not sure where the material will go after that.)

I particularly want to commend this piece by Stephen Rolles of the Transform Drug Policy Foundation. His first paragraph just about says it all:

Consensus is growing within the drugs field and beyond that the prohibition on production, supply, and use of certain drugs has not only failed to deliver its intended goals but has been counterproductive. Evidence is mounting that this policy has not only exacerbated many public health problems, such as adulterated drugs and the spread of HIV and hepatitis B and C infection among injecting drug users, but has created a much larger set of secondary harms associated with the criminal market. These now include vast networks of organised crime, endemic violence related to the drug market, corruption of law enforcement and governments, militarised crop eradication programmes (environmental damage, food insecurity, and human displacement), and funding for terrorism and insurgency.

Much of the world has figured this out. I'll bet you didn't know that drug possession has been decriminalized in much of Latin America, and there is considerable movement in that direction in Europe. And did you know that the Mexican government wants the U.S. to decriminalize? It's obvious that the most serious social, and for that matter individual harms associated with drug abuse stem directly from prohibition, not the drugs themselves. No prohibition, no violent criminal drug cartels destroying Mexican society. Oh yeah -- how do you think the people the U.S. is fighting in Afghanistan get their financing?

Two of the countries where entrenched political ideology is preventing a common sense approach to drug abuse are Russia, and the United States. And whaddya know, those happen to be two of the countries with the biggest problems associated with illicit drug use. In Russia, drug injecting is the basis of its HIV epidemic. That's a significant problem here in the U.S. as well, and we also have the highest percentage of our population incarcerated in the world, with the exception of a couple of totalitarian competitors we probably don't want to emulate. And our prison-industrial complex is fueled by one thing only, drug prohibition, as implemented in a blatantly racist manner.

In a kind of Mobius strip logic, the harms caused by prohibition get assigned to the drugs themselves, and become a justification for continuing, and reinforcing, prohibition. We can either have drugs with prohibition and its attendant harms; or drugs without prohibition and instead rational, evidence based harm reduction policies. Countries that decriminalize do not experience an increase in abuse or addiction. Decriminalization makes possible regulation, containment, taxation, easier access to treatment, and it instantly eliminates a whole lot of crime. Of course it puts prison guards out of work, which is one reason why it doesn't happen -- they have powerful unions that fight against liberalization of drug laws.

There are major, legitimate debates to be had about exactly what would be the right policies concerning specific substances, age groups, and drug using behaviors. Alcohol policy presents an obvious template for some substances, but others no doubt need to be approached somewhat differently. I'm not going to lay out any detailed prescriptions here, but let's at least have the discussion.

It's amazing what doesn't get noticed

I was astonished to read today that Russia has been suffering from a historically unprecedented heat wave since mid-June. Melting asphalt has been blamed for traffic accidents, people are being urged to take siestas to avoid the mid-day heat, and wells are drying up.

The heat has combined with the country's severe alcohol problem to produce an epidemic of accidental drowning.

Vadim Seryogin, a department head at Russia's Emergencies Ministry, told reporters Wednesday that 49 people, including two children, had drowned in the last day. More than 1,200 total have drowned, 223 of them between July 5 and July 12.

"The majority of those drowned were drunk," Seryogin said. "The children died because adults simply did not look after them."

I haven't read the book "Merchants of Doubt," by Naomi Oreskes and Erik Conway, but this review by John Atcheson gives us the gist. The basic impetus behind the pseudo-scientific disinformation campaigns about tobacco, the (misnamed) ozone "hole," acid rain, and global climate change has been the same. Free market fundamentalist ideologues cannot concede that regulation is necessary to protect humanity from the ravages of unrestrained capitalism. Given that the mythical "free market," by stipulation, produces the best outcomes when government doesn't interfere, the conclusion that burning fossil fuel causes climate change must be wrong.

Can you spot the logical flaw here?

Ben Goldacre Runs it Down for You

No doubt I have a few readers who are wondering why I have recently been so nasty and dismissive to advocates for homeopathy. Shouldn't I be mature and dignified and engage constructively with people with whom I disagree?

Sorry, but in the case of homeopathy, it's utterly useless. I know better than to try. Ben Goldacre says everything I could possibly say about this. He explains why the "evidence" in favor of homeopathy is a total crock. That is why I do not waste my time reading the crap that people send me. And he explains how homeopaths respond to criticism:

Here is the strangest thing. Every single criticism I have made could easily be managed with clear and open discussion of the problems. But homoeopaths have walled themselves off from the routine cut-and-thrust of academic medicine, and reasoned critique is all too often met with anger, shrieks of persecution and avoidance rather than argument. The Society of Homeopaths (the largest professional body in Europe, the ones running that frightening conference on HIV) have even threatened to sue bloggers who criticise them. The university courses on homeopathy that I and others have approached have flatly refused to provide basic information, such as what they teach and how. It’s honestly hard to think of anything more unhealthy in an academic setting. . . .

But when they’re suing people instead of arguing with them, telling people not to take their medical treatments, killing patients, running conferences on HIV fantasies, undermining the public’s understanding of evidence and, crucially, showing absolutely no sign of ever being able to engage in a sensible conversation about the perfectly simple ethical and cultural problems that their practice faces, I think: these people are just morons. I can’t help that: I’m human.

So there you go folks. That's why I don't bother to try to reason with you, I just call you idiots. Because that's what you are. And there's nothing more to be said about it.

The platonic ideal . . .

of what's wrong with health care in the U.S. From NYTimes stenographer -- perhaps voice recognition software connected to a word processing program, although ostensibly a human being -- Gina Kolata. A consensus panel on Alzheimer's disease is about to recommend new guidelines for diagnosis:

Under the new guidelines, for the first time, diagnoses will aim to identify the disease as it is developing by using results from so-called biomarkers — tests like brain scans, M.R.I. scans and spinal taps that reveal telltale brain changes.

The biomarkers were developed and tested only recently and none have been formally approved for Alzheimer’s diagnosis. One of the newest, a PET scan, shows plaque in the brain — a unique sign of Alzheimer’s brain pathology. The others provide strong indications that Alzheimer’s is present, even when patients do not yet have dementia or even much memory loss.

Earlier, we have been told:

If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.

This sounds like a great advance, right? The idea is that people in their 50s will routinely be given PET scans and spinal taps, and then their doctors will tell them that they have "pre-clinical Alzheimer's disease" and can expect to start forgetting stuff in ten years or so. Meanwhile, presumably, they will periodically see neurologists who will give them assessments to see if it's happening yet.

There's only one teensy weensy little reason why this might not be such a great idea after all. Doctors can do absolutely nothing about it. The knowledge will be completely useless. However, it will represent a whole lot of income for radiologists and neurologists, as well as a whole lot of anxiety and pain for 5 or 10 million people who will now be officially diagnosed with a disease which is causing them no symptoms whatsoever and which nobody can do anything about.

Sounds like a plan.

I have nothing to add to this . . .

Res ipsa loquitur. Michael Hiltzik in the LA Times. Nature publishing group, which puts out 90 academic journals, wants to hike its online access fees for the University of California by 4 times -- costing the already strapped university more than a million bucks a year. They're considering boycotting Nature -- really. But:

[T]he dispute underscores a more far-reaching debate in academia: Whether the old business model of scientific publishing, in which researchers turn their work over to commercial entities for free, then pay through the nose to access it in print or online, hasn't reached the point of ultimate absurdity.

"Why are we paying to read the results of our own research?" asks Patrick O. Brown, a biochemist at Stanford's School of Medicine. In 2000, Brown co-founded the Public Library of Science, or PLoS, which today publishes seven journals on the open access model. That model charges researchers for publication of their accepted papers, but allows them to retain their copyrights and makes their work available to all users for free.

And it's not just us who are paying -- and we can afford it, because our universities pick up the tab. It's the students, of course, whose tuition is higher because the university has to pay for its faculty to be able to read the journals they contribute to.

Subscriptions are a major cost problem for UC, as they are for all public institutions, because of the relentless squeeze on budgets. For the current round of renewals, UC's goal was to cut costs by 15%, which plainly would be exploded if Nature held firm.

Already, because of the rise in fees for scientific and technical journals, "we've had to decrease what we spend on books for the humanities, and that trade-off is very stark," Farley says. "Ultimately it hurts the whole institution."

And of course, the general public cannot afford to read these journals at all, unless people happen to be fortunate enough to live near a university library that allows access to the local community -- which most do not. For science to put up such barriers of exclusivity is a crime against its animating spirit. It has to change.

The Way of Wu

Wu is the very widespread east Asian system of shamanistic healing, which involves shaking bells and chanting and burning slips of paper and what not. Usually spelled woo, it has been adopted by defenders of rational, scientific medicine as a generic label for the mystic arts promoted in late night infomercials and the Huffington Post. Probably the most popular form of woo around is homeopathy. I won't bore you, or reinvent the wheel, by describing and debunking this utterly ridiculous belief system, but check out the thorough historical treatment at the Skeptic's Dictionary.

I recently got into an e-mail pissing match with a proponent of homeopathy and it has provoked me once again to contemplate the allure of the irrational. After I avowed that there is no such thing as "legitimate homeopathy," her first response was to insinuate that I denounce homeopathy because I have some sort of financial stake in my opinion. You can imagine what happened when she pushed that button. At that point further conversation was undoubtedly useless, but let me carry on here.

It is well known that the first recourse of the wumeisters is to claim that medical science is all a conspiracy by Big Pharma to defraud us, that "They" don't want you to know about the miracle cure because it would hurt "Their" profits, and that the critics of wu are all shills for Big Pharma who are lining their pockets with consulting fees, kickbacks, and stock dividends.* Unfortunately, they can't claim this about their bete noir, Dr. Stephen Barrett, who is a retired psychiatrist, so they just accuse him of having a closed mind and continually sue him. When I pointed out to my correspondent that Barrett has never been successfully sued for libel or defamation -- or anything else -- she responded that he has too lost a lawsuit. Well, yeah, except he was the plaintiff. Here's the truth about this case, from Barrett:

In November 2000, Attorney Grell, Dr. Polevoy and I filed suit in Oakland, California against Hulda Clark, the Bolens, JuriMed, David Amrein, the Dr. Clark Association, Ilena Rosenthal, and others who have spread or conspired to spread the defamatory messages [11]. New Century Press was subsequently added as a defendant. In July 2001, the judge ruled that defendant Rosenthal, who had republished messages from Bolen to several news groups, was shielded from liability by the Internet Decency Act, which the judge believed was intended to protect anyone posting messages to newsgroups. The judge also ordered us to pay $33,000 in attorney's fees. We believe this ruling was incorrect and extremely unfair. In March 2002, we filed an appeal which noted that the judge's ruling, if upheld, would abolish all protection against Internet libel because a "clever libeler" could easily escape liability by having an anonymous or remote "Internet user" publish libelous statements that any other Internet user" would be free to republish [12]. We also appealed the judge's order for attorney's fees. In October 2003, the appeals court agreed with our view of the Internet Decency Act and ruled that Rosenthal could be sued for posting a defamatory message about Dr. Polevoy. However, the California Supreme Court reversed the Appeals Court, so Rosenthal was dismissed as a defendant. The other defendants remained, but in 2009, the local judge concluded that we had not pursued the case quickly enough and dismissed it.

Hardly evidence against Barrett's integrity, but this is the sort of tendentious, facts-be-damned argumentation style that the wumeisters generally adopt.

A scientist named Edward Calabrese is interested in the phenomenon of hormesis, which is a label for a perfectly well-known phenomenon. Essentially, the biological response to low doses of some substances can be dissimilar to the response to higher doses, in other words the response to more is not just more of the same. Obviously, low doses of any medication may be beneficial whereas doses that are too high are toxic, but this idea goes a little bit further. A mild irritant can recruit a reparative response, such as inflammation, which may also repair some pre-existing lesion or disease process. Peppermint oil, for example, is a mild irritant which may actually be helpful in some gastrointestinal and other conditions.

However, this has nothing to do with homeopathy. Homeopathic remedies are water; they are biologically inactive except for the prevention and treatment of dehydration. Nor is it in any way a promising organizing principle for a broad program of research. There might be a useful remedy or two based on the idea. However, there is no single, secret key to all disease and healing. Organisms are extremely complicated; they are systems of systems, with all sorts of feedback systems to maintain homeostasis and competing positive feedback systems to respond to challenges; beset by pathogens; and disturbed by sub-optimal inputs such as malnutrition and environmental toxins.

Accordingly, medicine is eclectic. There isn't any single principle, or even just a few principles, on which scientific medicine is based. Rather, biomedical scientists try to understand each situation as it is, and evaluate treatments based on their specific merits and risks. Antibiotics kill pathogens; antivirals restrict viral replication; antihypertensives target various signaling systems; insulin replaces a hormone the body fails to produce; surgery repairs physical lesions; some treatments, such as analgesics, are largely palliative; etc.

Some people apparently find it tempting to believe that a single magic principle will banish all disease and suffering but it just doesn't work that way. Homeopathy grows out of a sort of mantra: Like Cures Like. Well, generally, it doesn't. Just believing in a slogan doesn't constitute evidence. There is plenty of evidence regarding homeopathy and it all points, inescapably, to a single conclusion: homeopathy is useless.

There isn't any evil conspiracy against homeopathy, and we don't denounce homeopathy because we have closed minds. Homeopathy is nonsensical. And no, it isn't harmless. When people's belief in nonsense causes them to refuse potentially beneficial therapies, they can be seriously harmed, or die. Now, that's an evil conspiracy.



*For the record, I am a medical sociologist, who earns a modest academic salary mostly based on funding from the National Institutes of Health to study physician-patient communication. NIMH does not know, or care, what I think about homeopathy, nor does my employer.

Thank you Maestro

[T]he fount and matrix of the [19th Century world] system was the self-regulating market. It was this innovation which gave rise to a specific civilization. The gold standard was merely an attempt to extend the domestic market system to the international field; the balance-of-power system was a superstructure erected upon and, partly, worked through the gold standard; the liberal state was itself a creation of the self-regulating market. The key to the institutional system of the nineteenth century lay in the laws governing market economy.

Our thesis is that the idea of a self-adjusting market implied a stark utopia. Such an institution could not exist for any length of time without annihilating the human and natural substance of society; it would have physically destroyed man and transformed his surroundings into a wilderness. Inevitably, society took measures to protect itself . . .

Karl Polanyi. The Great Transformation: The Political and Economic Origins of Our Time. (1944)

Polanyi goes on to describe the cataclysmic fall of 19th Century civilization and the horrific struggles which produced the new world he saw emerging as World War II came to its bitter end. Astonishingly, in the 21st Century, the wealthy elites of the United States came to believe they could recreate their imagined 19th Century utopia.

And dream on: 55% of likely voters think Barack Obama is a socialist.

The awesome power of Stayin' Alive . . .

. . . demonstrated yet again. As anyone who remembers anything I wrote here knows, should such a person exist, I have been practicing behavior modification on the New England Journal of Medicine for several years now. Every time they make an article of broad public interest open access, I feed them a bit of kibble; and every time they hide it, I hit them with a rolled up newspaper. The effort, I'm pleased to say, is paying off, and we're seeing more and more open material.

This week, they've really opened up with analyses on tobacco control, Medicare reforms and challenges associated with health care reform, including specific discussion of the Independent Payment Advisory Commission, a wonky but actually important discussion of how rules about paying for drugs in clinical trials create a problem for comparative effectiveness research, and even a fairly technical but not impossibly arcane discussion of Genomewide association studies. And oh yeah, the latest on limiting the work hours of residents.

The bad news is that Medicare payment policy and the other policy-related subjects are too damn complicated. When the public hears that Obama and a bunch of elitist eggheads are conspiring to "cut" Medicare that means putting Grandma on the ice floe, right? Actually the idea is to make her better off by:

• Making sure that less of the money spent on Medicare goes to fatten the profits of insurance companies and more of it goes to her health care;


• Making sure that specialists aren't overpaid so that there's more money for primary care docs and the other stuff she really needs;


• Making sure she gets the most effective drugs and other treatments, and that Medicare doesn't waste money on more expensive stuff that isn't any better, or on stuff that just doesn't work.

And oh yeah, making sure that Medicare stays solvent and the grandkids can afford the Medicare taxes. That's Donald Berwick's job, and it's because he really wants to do all that good stuff that he likes the National Institute for Clinical and Health Excellence and yup, rationing. And that's what makes him a bureaucrat-loving socialist mass murderer. Unfortunately once you get into the weeds on all this it doesn't fit on a bumper sticker, or even one of those extended 5 minute NPR reports. Katie Couric sure isn't going to explain it in 37 seconds. Start reading those articles I linked to and you'll see what I mean, if your eyes don't glaze over too quickly.

But I still think we can get the basic idea out there. More isn't better. What's better is the right stuff, the right priced stuff, for the right person at the right time. And that will end up being less, and being cheaper, and making us healthier and wealthier, just like they do in the grown up countries. Which the United States is not.

Probably the best way out . . .

President Obama has decided to seat Donald Berwick via a recess appointment, avoiding what would have been weeks of idiocy and lies by Republican senators and a likely filibuster.

On the one hand, CMS needs a director, Berwick has work to do, and Obama has other battles to fight. But somehow, some way, we need to have this conversation. Maybe it's impossible after all, I don't know. But if we don't do it, we're screwed.

Reality Bites

We now have at least the third independent investigation of the "Climategate" hoax scandal which finds, yet again, that the scientists involved were not faking data or conclusions and acted with complete scientific integrity; and that the conclusion that the earth's surface and ocean are getting warmer due to human activity is absolutely unshaken. And yet CNN wants us to weigh in on whether we "still believe" in global warming, and climate scientists are being barraged with hate mail and death threats. The issue, in the view of the corporate media and much of the public, remains a political dispute and a matter of "belief," not a scientific fact.

You may recall that a popular claim of climate change deniers in recent months has been that the extent of arctic sea ice has been increasing. Nope, we're headed for another record low. A snow storm in DC this past winter was touted as proof that the whole climate change thing is a hoax, but the record setting heat wave now gripping the east? Pay no attention.

There are probably a few reasons why denialism is so deep and broad on this issue, but one is that the truth happens to conflict with the prevailing political ideology which holds that a mythical "free market" produces the most efficient allocation of resources. What it produces, of course, is the greatest amount of privilege, wealth and power for the most ruthless and fortunate few, while turning the earth into a wasteland.

Very soon, however, if not right now, denial will become impossible. We are all drowning in the truth, and no raving by Rush Limbaugh or the demented James Inhofe can withstand it. Only it's too damn late.

Major bummer

One of the downsides of globalization is that all sorts of critters are ending up in all sorts of places they didn't used to be, and not fitting in well. One of them is the Asian longhorned beetle which was discovered in Worcester a couple of years ago, with the result that every tree in the city was cut down and chipped. The beetle kills maples, willows, and birches.

Now they've found it in my neighborhood, and right across the street from the Arnold Arboretum no less. If it got from Worcester to Boston, it obviously must be at points in between. Now I have to worry about my woods in Connecticut, and indeed, all of New England. Sure, over geological time, land masses are joined and then severed, mountains rise and fall, and species that were once excluded from an ecosystem suddenly show up and wreak havoc. It's nature. The point is, it's happening much more often nowadays than it did before Homo sapiens came along and started stitching together the entire globe.

Maples and birches are as essential to the New England landscape as the Berkshires and the Connecticut River. It would be unbearable to lose them.

And it's gonna get worse, in a hurry . . .

As state and local government's run out of stimulus funds and accounting tricks, we're going to have teachers, firefighters, police, social workers, librarians, custodians, pavers and construction workers hitting the unemployment lines. Massachusetts is a comparatively wealthy state and our economy has held up better than most with its base of higher education and high tech industries, but we're about to see big time layoffs of municipal workers and continuing losses of state workers and contractors.

Illinois, however, faces utter catastrophe, due in part to its utterly dysfunctional politics. In California, well, getting terminated by a cyborg from the distant future would probably be a mercy.

We can expect absolutely dismal conditions in November. Who will the voters blame? Do you need to ask?

234 years later . . .

Where do we find ourselves? What is essential about this moment in the story of the United States?

Looking back on my own views for the past 15 years or so, I discover that they haven't really changed. The presumption of endlessly more prosperity, that each generation would surpass its parents in opportunity and plenty, was at the heart of the political culture. And it was doomed to bitter disappointment.

This piece by Ravi Somaiya in Newsweek, for all its corporate media tentativeness (and its weird conflation of atheists with right wing extremists calling for armed insurrection), does make an essentially correct point: the essential complaint of the resurgent right, embodied in the Tea Partiers, is that they, the deserving, are being taxed to subsidize the unnamed undeserving. Since Newsweek isn't allowed to name them, I will. The Tea Partiers believe they are being taxed to support lazy, shiftless negroes and unclean foreigners. This belief comforts them because it explains why they don't have what they expected and know they deserve.

As Yglesias notes, however, the United States today has a lower employment/population ratio, and lower household income, than it did in 1999. And for nearly two decades before that, household income managed to hold steady only because more household members worked. Now that employment has stagnated along with wages, families are worse off than they have been for most adults' entire working lives.

The cold truth is that this is not going to change in the foreseeable future. The days when people could achieve a comfortable middle class existence on the income of a single person bolting cars together are never coming back. Many of the jobs lost in the Great Recession are gone forever, and others will never pay as well. Professionals who have been laid off and rehired as contractors, with lower pay and no benefits, will never get their former status back.

The U.S. Empire is bleeding the country, not only of its economic life force, but of its vision. We cannot maintain our enviable way of life by military domination of distant lands. We need to make drastic changes in the organization of our economic and social lives. The aggrieved middle classes have been sold a fundamentally false diagnosis of their troubles, of course. Their taxes are being squandered in ways that do not benefit them, but they are being handed, not to the undeserving poor, but to the undeserving wealthy. Even so, their biggest problem is not taxation, not by a long sight. The tax burden in the United States is actually low by international comparison, and even with a tax cut -- which in fact Obama has already given them -- the U.S. middle class would keep losing ground.

The only way our population can thrive in the post-industrial, and ultimately post-petroleum era, is by creating new categories of public goods and services and reorganizing our economic life for equity and sustainability. But we are having entirely the wrong discussion. Until that changes, we have no hope.

BTW, in case you didn't know . . .

Provisions of the Affordable Care Act are indeed starting to take effect. Here's a simple and good one: HealthCare.Gov. Just might do you some good, even though it's communistic and fascistic for the government to offer services to the public.

More on our dysfunctional political system

The New York Times manages to trigger symptoms of Intermittent Explosive Disorder about, oh, half the time, but mad props to Kevin Sack for doing this story and to the normally witless editors for putting it in the place of honor in the upper right hand corner of Page A-1. It really does say it all about the idiocy of our Congress.

For background, among the provisions of the Ryan White CARE Act is the HIV Drug Assistance Program, known as ADAP from the days when we didn't distinguish properly between HIV and AIDS. People who don't have adequate insurance can get their antiretroviral drugs paid for. Usually it's a temporary bridge, for people who are temporarily unemployed or haven't yet qualified for disability benefits and hence Medicaid. It's mostly financed by federal funds, with state contributions and a bit thrown in by the drug companies. (That's mighty big of them -- they profit in the end by keeping the people alive long enough to qualify for insurance.)

Well, you guessed it. With the Great Recession throwing people out of work and hence off of insurance; and state budgets swirling down the drain, states are starting to run out of ADAP funds. "Eleven states have closed enrollment in the federal program, most recently Florida, which has the nation’s third-largest population of people with H.I.V. Three other states have narrowed eligibility, and two of them — Arkansas and Utah — have dropped scores of people from the program," Sack tells us. There are already thousands of people without their meds.

Now, you may think this is stupid just because those people might get sick and die. But if you're Rand Paul or any libertarian, or a Republican in Congress, you couldn't care less about that. Tough shit, you say, not my problem, and anyway it would be far worse to add a few million dollars to the deficit than to give those people life saving pills.

But that's why you aren't so smart after all, for a few reasons.

1) People who are on ARVs and have suppressed viral loads have very little chance of passing the virus on to others. This will increase the incidence of new HIV infections and cost money. (Yes, people living with HIV should be responsible and not engage in unsafe practices, and most are, but there will always be exceptions.)

2) People who have interruptions in ARV treatment or take ARVs inconsistently, due to cost or any other reason, are likely to develop drug resistant virus. That means that once they do regain insurance, they will require more expensive drug regimens, which will cost money.

3) People who develop life threatening opportunistic infections or advanced AIDS are entitled to life saving urgent care in hospitals, which will obviously cost money.

4) People who have lost insurance due to unemployment, and then get sick from HIV disease, will not be able to return to work, and instead will have to apply for disability and Medicaid, which will obviously cost money.

Duhh. If instead we kick in the $10,000 year we need to keep these people on the meds, none of that will happen! It's called an investment. That it will also keep people healthy and save lives, well that's not important, but it's at least a minor side benefit that doesn't cost anything, but would actually save money. Therefore, obviously, it's not going to happen.