One man's ceiling is another man's floor

And that's also true when we're talking about health care costs -- any money we save is money somebody isn't getting. And that's the real reason we don't get real reform in this country.

Atul Gawande, as usual, is pretty good. In this piece his McGuffin is the small percentage of patients who account for a bit percentage of medical costs. He isn't talking about people who are near death, either. These are folks who are out in the community and if they appear not to have long to live, it's not because they're medically hopeless. Many of them have major psychosocial problems that make it difficult for them to follow medical advice, take medications, and keep appointments. A few of them are just victims of very bad coordination among providers.

Gawande discusses various reasons why some people have very high health care costs, or costs that are much higher than they need to be, from poor parenting to cognitive limitations to copayments that prevent them from filling prescriptions.

But I just want to focus on one point. A payment system in which teams of providers are compensated by capitation to take care of high costs patients, and get to pocket a portion of savings, completely realigns incentives. It makes sense to hire patient navigators -- lay people trained to help people take care of themselves better. It makes sense for the various providers, including specialists, to talk to each other and coordinate services. It makes sense to do home visits, offer walk-in visits, hire a social worker, for those people who are going to avoid hospitalization and ER visits as a result. It makes sense not to provide unnecessary services while making sure the necessary ones are delivered no matter what.

But, that means somebody else is losing money. Gawande tells of one model clinic -- he doesn't really use the labels but you could call it an Accountable Care Organization and a Patient Centered Medical Home -- that found that one group of hospital based physicians that saw it's hospitalized patients wouldn't work with them - meaning longer stays, and higher costs. These doctors hung out in the ER and tried to poach their patients.

And oh yeah -- why would hospitals participate? They just lose income. (Remember my post a few days ago about retiring RI Health Director David Gifford suggesting that in a world where saving money was the objective, hospitals would be sanding sidewalks to prevent people from falling.) But Emergency Department orthopedics is a profitable business. Why would they want to lose it?

And that's why wealthy specialists, drug companies, and for-profit hospitals are paying untold millions of dollars, in secret, to convince you that Democrats want to kill your grandmother by cutting Medicare spending and destroy freedom by putting bureaucrats between you and your doctor. Spending less money on health care is the only way to get better care. And no, there's no plan to install bureaucrats in doctors' offices but there is a plan to pay doctors to keep you healthy instead of rewarding them when you get sick. What they're afraid of is losing money. What ought to be your money.

It's a whole new world

The regular snow storm -- they come every five days, more or less -- hit on Wednesday while I was in Boston. So I called a plow guy to clear out the driveway of my country place on Friday. When I got out there Friday afternoon, he was about 30 feet up, and stuck. He was quite jolly about it, actually. He said he'd already been stuck a few times that day. He was digging out and he figured he's be back in business shortly. So I went next door to wait.

My neighbor was engaged in changing a tire on his bobcat. There was a mound of snow 7 feet deep all along the front of his house where he'd cleaned off the roof, and equally immense mounds all over the place interrupted by narrow channels for navigation. He told me he'd been doing nothing for the past two days but dealing with the snow. As you have deduced, the latest storm was deep and sticky.

I have now excavated my wood pile, yet again; shoveled off the roof of the sun porch, which was very arduous; and raked what I can off the relatively flat roof over the wing of my house. I also had to shovel out a front walk and the deck, of course. I'm reasonably fit but a day will come when I can't do this sort of thing any more.

I called my mother who lives about 40 miles away. Fortunately, neighbors had come and dug her out. But her friends aren't so young either and unless she can make some young friends she's going to be in major trouble if we have another winter like this one.

Oh yeah -- the forecast is absolutely horrendous, with another major storm predicted for midweek including freezing rain. If power lines come down, I've got no heat here unless I'm home to stoke the wood stove. But being home requires keeping that driveway clear, among other chores. My plan right now is that tomorrow morning I turn off the well pump, open the faucets, and get out of Dodge.

All of this would just be an overly dramatic tale to tell our children except that an increasingly popular hypothesis right now among climate scientists is that this is the new normal. Disappearing arctic sea ice has eliminated the polar vortex, allowing cold air to spill south. Meanwhile, the oceans are warmer, supporting more vigorous ocean storms, and the atmosphere holds more moisture, meaning more precipitation. Precipitation below 0 degrees centigrade is snow.

More winters like this will force drastic changes in the way people live, and where they live. It will cost a lot more to have a driveway, and getting snow off roofs will become a regular necessity. People who don't have the physical capacity to shovel snow and climb ladders will either have to hire people or more to the city. Communities will be drastically changed, life plans altered, land values affected, whole ways of life may disappear. I don't yet know if that will happen, but it's looking like a real possibility.

It just may be that a large part of Australia will be rendered uninhabitable; Pakistan also. If recent events in those places repeat, that will be the end for them. Yes folks, this is a big story.

Alternate Realities

Via PZ, a survey of public school biology teachers that bodes ill for the future of the U.S. cerebral cortex. Yup, they're either creationists, or they're too afraid of wingnut parents to teach evolution. And they probably don't understand it anyway.

I grew up in a bizarre community in which the people believed in the discoveries of science and we all assumed that the believers in biblical creation consisted of a few old codgers in the hills of Kentucky. You just never heard any of this nonsense. It wasn't part of anything I recognized as respectable society and you certainly didn't see it paid any deference in mass media or by politicians. Actually there wasn't much opportunity to pay it any deference because it barely seemed to exist.

Evidently that was a false impression. It was out there all the time but was just unassertive. I don't know what happened to change the situation but it's spilled over well beyond evolution to create a political culture in which the majority party in Congress is committed to defining the scientific endeavor -- biology, physics, earth science, cosmology -- as tools of a massive conspiracy to impose rule by a secret anti-priesthood that hates God and human freedom. Or something.

It's to be expected in a republic that we will have political disputes over values and competing interests. But we have fundamental disputes over the very nature of reality. What is most disturbing is that half of the disputants are completely impervious to facts or reason. They begin with their conclusions and acknowledge evidence only if it can be stacked into a structure that confirms what they already "know." Arguing is like biting granite.

Since the future of civilization and the lives of billions hang in the balance -- not to mention most of what we treasure about the natural world -- this is a most unfortunate state of affairs. What should we be doing about it?

The CPR-Charitable Complex?

I have never gotten around to taking CPR training but I've run into a lot of people who are quite -- well, sanctimonious is kind of a disparaging term, but let's just say they are big promoters of how getting CPR certified is a requirement of responsible citizenship.

This essay in NEJM by Dr. Gust H. Bardy is a bit difficult to follow in the beginning for a non-specialist, but basically what he is saying is that, while shocking the heart is effective in cases of cardiac arrest, there is actually no evidence that CPR -- compressing the chest to the beat of Stayin' Alive -- does any good whatsoever. People who have been trained in CPR are also trained to call 911 right away, and to the extent that CPR looks like it helps, that might be the only reason.

And, it turns out, organizations such as the American Heart Association and the Red Cross make a lot of money by giving CPR training. There is a very large vested interest in maintaining the belief that CPR saves lives, but Dr. Bardy has me pretty well convinced that we may be fooling ourselves. He argues that because we don't have evidence of the value of CPR, it would be ethical to design a clinical trial in which it is randomly withheld, although I can't see offhand how that could be achieved logistically.

In any case, the bottom line is that if someone goes into cardiac arrest, it is still highly unlikely that the person will survive if they receive only prompt CPR and do not quickly receive external defibrillation. First call 911! Seconds count! Putting more automatic external defibrillators in public places, and perhaps the homes of people at risk, can definitely help. But we shouldn't think of CPR be a substitute, says Dr. Bardy.

Please! I'm not saying don't do it! It's the standard right now and maybe it does work. But we really don't know.

Random Observations

If I wanted to live in Nunavut, that's where I'd be. But this year, the arctic has come to me. This relentless cold and snow -- snowfall after snowfall after snowfall, and not even an hour of an afternoon thaw to be found -- has me cranky, distracted, and unproductive. However, I don't think it's helpful to say that I have a "disorder." This winter is just for shit, and I'm in it, along with everybody else. However, as you probably know, there is an official disease for people who feel crappy in the winter. Apparently it really helps to blast yourself with bright lights, but a lot of people end up taking pills.

I don't necessarily object to slapping a disease label on this, but I do think it raises interesting questions about what constitutes a disease. People evolved in the tropics, and short days with dim light just aren't what we're built for. Freezing to death isn't a "disease," it's just what happens when we get too cold. Getting depressed when it's dark all the time may be a disease, but it's also pretty much normal.

Item #2: I don't mean to be a downer, but . . . It's natural that people want to feel a little bit better about the grotesque event in Tucson, but I do have to warn you off of all this upbeat reporting about Rep. Giffords. Yes, she's apparently doing well medically considering the horrific physical injury she suffered, but right now, nobody knows what her neurological status is going to turn out to be. In fact, they don't even know if she can speak. But traumatic brain injuries can have all sorts of not at all obvious effects that are nevertheless very significant to the injured person and those close to her. Difficulty in making and executing plans, personality changes -- quite often for the worse, including irritability and hostility -- difficulty in concentrating and focusing on tasks, are all quite common. We'll really just have to wait and see if she can go back to work.

I bring all this up because people with TBI, who have such problems, don't often get a lot of help and support. They can end up socially isolated, economically deprived, and disconnected from the ongoing services they need to improve their functioning and keep a social life. Rep. Giffords will undoubtedly be unusually fortunate in that regard, but I did a study some time ago for a state agency which found that there is often a serious failure of discharge planning. People leave the rehabilitation facility with a piece of paper that tells them where to go for help. Most of the time, they can't or won't be proactive enough to get that help. This is a well-known problem for many Iraq and Afghanistan veterans, and they ostensibly have the whole VA behind them. It's much worse for people who don't even have that level of resource.

Item #3: Speaking of feeling grumpy, I have a small lesion on my tongue -- not to worry, almost certainly nothing to worry about. Still, after I noticed it, it took me two months to get an appointment with my PCP. He looked at it and told me to see an otolaryngologist. It took me two months to get an appointment there. She saw me today and told me to come back next week for a biopsy -- for some unknown reason, she couldn't just do it. So I'm going to end up with three appointments, three co-pays and my insurance company making three much larger payments, and several months gone by, before anything meaningful happens. Surely we can do better than this.

Unfree the Market!

I just attended the annual meeting of the Rhode Island Minority Health Advisory Commission. Dr. David Gifford, the outgoing Director of the Department of Health, offered an amuse-bouche which goes well with the menu here.

Hospitals have a volume based business. They get paid to do stuff, which means they make more money when the people in their market area are more likely to be sick and injured. They lost money with the milder than usual flu season last year. (Sorry Greg Dworkin, but that's what happened. And Dr. Gifford ought to know.) This year, with all the snow and ice, they're doing well, because X-rays and orthopedic services are profitable.

So, you don't see them out there spreading salt on the sidewalks to keep the old folks from slipping and falling. Gifford says that as far as he knows they aren't spraying water on the sidewalks at night, but their business model says that's what they actually ought to be doing. For the price of a few hip fractures -- which can mean long-term care in a skilled nursing facility and many tens of thousand of dollars or more -- we could prevent a whole lot of falls instead. But nobody has any financial incentive to do that. We need a radically different financial structure that rewards achievements in public health, not having more broken people around so hospitals and doctors can get paid to try to fix them.

Let your imagination run wild.

Ending in ice

According to the prognosticators, an ocean storm is going to pull air straight from Yellowknife into New England tonight and the CO2 will condense, although we should be okay with the nitrogen. Okay, I exaggerate slightly, but it will be cold.

Naturally, this news stimulated the epidemiology center in my brain so I wondered how many people in the U.S. freeze to death each year. (Unfortunately, if you're interested in public health you have to think about unpleasant stuff.) It turns out it's generally around 600. As causes of death go, that's not a huge number, but you would think it would be highly avoidable, and it also has a disturbing quality.

I had assumed that most victims would be homeless, but the CDC report doesn't seem to back that up as the issue per se. Rather, the major issue is alcohol abuse. Many chronically homeless people are alcohol addicts, of course, but in general homeless people have figured out how to adapt to their situation. When it gets really cold, more people show up at shelters and, in Boston at least, they fit the people in, on the lobby floor if need be.

Where people get into trouble is if they are too impaired to recognize their peril. Alcohol intoxication makes you feel warm, even though it actually lowers the core body temperature. Dementia and general frailty are also risk factors.

I am not particularly surprised that the two states with the highest rate of death by hypothermia are Alaska and Montana, but I'm not sure why New Mexico is third. Maybe some of my friends from New Mexico can weigh in.

The third shoe drops

Brian Deer's third and final installment on the Wakefield affair is out, and this time it's not about Wakefield -- it's about the editor of the Lancet, which published his fraudulent research, and executives of the Royal Free Hospital, where it happened. You can read it for yourself but the bumper sticker version is simple enough: when Deer confronted them with evidence of Wakefield's fraud, their immediate and only response was to deny the whole thing and cover it up.

That Wakefield perpetrated a fraud in order to get rich is not strange. People do that. But The Lancet's behavior, beginning with the editor at the time, Richard Horton, and continuing after his tenure, has been strange, in my view. They did not retract the article until the UK's General Medical Council completed its investigation in 2010, 6 years after Deer had first confronted Horton with his findings. They have had nothing more to say about it since. All of this discussion is taking place in rival journal BMJ, whose editor, Fiona Goodlee, has quite properly taken them to task. As of this moment, The Lancet has issued no comment.

In case you didn't know, The Lancet is arguably the world's oldest medical journal, founded in 1823, and perhaps the most prestigious. Responsible editors would have immediately responded to Deer's allegations with a full investigation and aggressively and forthrightly disclosed the results. Deer was ultimately found to be correct in every particular by the GMC, and The Lancet editors and Royal Free College dean could have established that for themselves quite readily just by looking at the medical records of the children in the fraudulent study. Instead, they let Wakefield investigate himself and pronounce himself innocent.

The Lancet was the victim in this originally, and could have earned respect and commendation for responding appropriately. Instead, they crossed over and became co-conspirators. Oh, by the way -- The Lancet has been owned by a for-profit corporation, Elsevier, since 1991. Not that there's anything wrong with that.

Insane, or evil?

That was the headline of a story on one of the major news web sites about the world's most famous human, J.L. Loughner. The question obviously proposes an absurd false dichotomy, but it prompts me to reflect a bit.

I'm not an expert on criminal justice, and I'm not particularly interested in the minutiae of the insanity defense or mitigating circumstances. Suffice it to say that state laws vary, but to varying degrees and under varying standards a criminal defendant can raise an insanity defense, which if successful would lead to a Not Guilty verdict and, probably, civil commitment. This is rarely successful. Once convicted, a defendant (or really, his or her lawyers) can raise mental illness in asking for a lesser sentence, in other words it can be seen to somewhat reduce the person's culpability. As examples, John Hinckley is not guilty by reason of insanity and so civilly committed to a mental hospital. Ted Kaczynski is guilty, but was spared the death penalty because of insanity.

This seems nonsensical to me, but that is because I do not share the prevailing view in our culture of the nature of free will and responsibility, nor of the essential rationale for criminal justice and criminal sanctions.

What does it mean to say that someone cannot appreciate the wrongfulness of his (usually -- women commit fewer crimes than men) actions, or is unable to conform his conduct to the requirements of the law? We know that Loughner could not conform his conduct to the requirements of the law by virtue of the observable fact that he did not. That probably seems a bizarre statement to most readers. Let me explain.

Granted, I have physical and cognitive limitations. I cannot dunk a basketball or read Russian. But within my possible range of action, it may appear that I make choices and could have made other choices than I did at any time. But the truth is, our actions are the effects of causes. We are what we are, operating within an environment which simply happens to us. None of us created ourselves. The subjective experience of most people is that we made a large contribution to our own development but that is an illusion.

We developed from a seed endowed with particular potential, which then unfolded in the environment where it happened to be. Interaction between the developing organism and the environment shaped both; at every point in time, we happened to have some particular capacity to respond to the environment we happened to be in, and that's how we responded. Connections among neurons developed as we grew, the brain happened to in some state when stimulus X occurred, and behavior Y then issued. We perceive most of our behaviors as choices, that we could have made otherwise, but in fact, what we did is the only thing we could have done because that is the behavior that our brain, with the traits it possessed and the state it was in, produced.

Free will and personal responsibility are fictions, but they are necessary. These fictions are essential substrates of the social mechanisms that maintain society and enable trust and cooperation. They are necessary to the mechanisms of shaming, and correction through more concrete sanctions. They are needed to teach children how to behave, and are presumed to be useful for trying to fix adults who misbehave.

As a slight digression, we could not live, and experience ourselves as human, without them. Indeed, agency is one of the most powerful predictors of satisfaction and happiness. People who are agentic -- who perceive themselves as having autonomy and control -- feel fulfilled.

But what difference does it really make to the evil of an act whether the perpetrator was operating under a bizarre delusion, or lacked empathy, or was deeply infected with anger, or felt some compelling need which outweighed the harm of the act? Any of these internal states might have produced the evil act, but it is the same act in the end, and the perpetrator somehow came to that state through some history.

In my view, the law should be designed to reduce the frequency of evil acts and optimize social trust, coherence, and the potential of society's members. On those criteria, the relative "evil" of a person who does bad things is irrelevant, actually nonsensical. The evil is in the act. We should try to understand why it happened and respond in the most constructive way we can, to protect public safety, reduce the risk of evil events in the future, if at all possible, and lastly, yes, to maximize the welfare and potential of the perpetrator within the constraints of the previous two requirements.

I will leave the implementation of those priorities for another time. But deciding how "evil" or "insane" Mr. Loughner may be is not helpful.

Is this ethical?

These people may be in the same category as the Raelians, but on the other hand it isn't totally implausible: They think they may be able to clone a woolly mammoth using DNA extracted from a specimen preserved in a Russian laboratory, using the ovum and womb of an elephant. (Don't worry, this mammoth is only a few thousand years old. Dinosaurs, except for the lineage that produced the birds, have been extinct for 65 million years.)

Mammoths, like elephants, were social creatures, and this would be the only representative of its kind. There has been talk, by the way, of trying to clone a Neanderthal -- much less plausible since known specimens are older and not preserved by freezing. That seems to me clearly wrong. But how about this?

Not really expressing an opinion, just wondering. The news article doesn't even consider the question.

We are all superhuman now

I've finished reading Galileo's Dialogue, but it will be a while before I've said all I have to say about it. First this.

While much of the Dialogue concerns philosophy -- both epistemology and metaphysics, the latter necessarily with some circumspection -- Galileo of course had the ultimate weapon, his telescope. It was no longer viable to argue from some presumed first principles to discover the place of the earth in the cosmos. Anyone who looked through the telescope would be forced to concede the truth.

For some reason it's widely known that Galileo observed the phases of Venus and the moons of Jupiter. But the killer observation came because he could resolve the disks of Mars and Jupiter. They appeared many times larger when opposite the sun, and hence close to the earth, than when they were near the sun, and so much farther away. That is all you need to know beyond doubt that the earth cannot be at the center of the solar system.

The church authorities, famously, refused to look through the telescope. Galileo's most important contribution to the scientific revolution was not so much his radical epistemology and his scientific imagination. These were not unique to him, although he was certainly among the pioneers. It was his application of a newly invented instrument to observation of the natural world.

Like Copernicus, who intuited the cosmos, Darwin needed only his senses and his reason to derive evolution. But we could not really understand evolution, and sweep away all objections, until biochemistry and X-ray crystallography enabled people to elucidate the mechanism of inheritance and demonstrate descent and relatedness among species directly. Although biologists still go out and just look at stuff, most scientific research nowadays depends on tools that enormously extend and magnify human senses, and now, with computers, the human intellect.

There is a massive structure of machinery and inference through which knowledge flows to us. And I admit, you have to trust it. Back in Galileo's time, people objected that the telescope was somehow distorting reality. Nobody doubts telescopes any more, but there are still plenty of people who doubt scientific conclusions. And being convinced is no longer quite as simple as looking through the telescope. Scientists don't even really understand each other's work, after all. They have to trust each other. But they do because it pays off. Applying physics and chemistry to biology and astronomy pays off. It all fits together. It works.

That old time religion

As I have shared here a long time ago, my uncle was a minister, my mother was a Sunday School teacher, and I was wanting to be confirmed in the Episcopal Church until, at the age of 13 or so, it suddenly occurred to me that religion in general, and Christianity in particular, is utterly nonsensical.

Nevertheless, when I was young, Christianity was a progressive force in the United States. Martin Luther King Jr., and the Civil Rights Movement which was largely Christian inspired and led, was one of my most important formative inspirations. The face of Catholicism to me was the Berrigan brothers and Robert Drinan -- who I had the privilege to meet later in life -- and nuns who worked as community organizers in the United States and Latin America. As a young adult, I served as a trainer in non-violent direct action at several events held in Washington, DC churches. I shared a house with an organizer for Clergy and Laity Concerned, an organization founded to oppose the Vietnam war which at that time was fighting against corporate exploitation of poor and vulnerable people. I understood political Christianity to be about social justice, and militant opposition to militarism.

I have to presume those people still exist but they all seem to be in the witness protection program. Christianity today, in the United States, appears to be a monolithic force for narrow minded bigotry, a shill for corporate power, and an implacable purveyor of ignorance. What happened? Maybe there's a Christian out there who can tell me. And oh yeah -- please explain why progressive Christians have utterly disappeared from public discourse and political action. It's no good to say "We're still around." Why are you hiding?

Most of this is kind of complicated . . .

But one piece is real simple. BMJ only makes its full research reports open access, when it probably should be the social and political analysis and commentary that's available to the public. This time, however, it works out with this report from RD Smyth and colleagues, PR Williamson senior author, Liverpudlians all.

To try to put this in a pistachio shell, they tracked down investigators whose published clinical trials seemed not to report all of the results they had obtained or specified in the trial protocol. We all know about publication bias -- negative findings (in this context meaning, the medication didn't work) tend not to get published, partly because of drug company perfidy and partly because of the biases of journal reviewers and editors. But these folks wanted to find out from the horse's mouth (where does that expression come from, anyway?) why these investigators only published some of what they found, or didn't publish on their protocol outcomes.

I will digress to remind readers that it is very important to a) report your pre-specified outcomes and b) report negative findings. Not doing so can bias the overall weight of evidence. Pre-specified outcomes are important because those represent true hypothesis tests. Therefore the associated p values are technically valid and the evidence is strong. Reporting on findings you weren't originally looking for can result in spurious observations being accepted as convincing evidence. Negative findings are important because bias toward positive findings obviously makes interventions look better than they really are. And even more obviously, evidence of harm must be revealed.

There was a very high refusal rate for this study, and you can reasonably presume that people were more likely to refuse when they thought they had something to hide. Also, industry funding was associated with frequent claims that trial protocols were confidential. So we can bet that the situation is worse than what the Liverpudlians could uncover.

Mostly, respondents said things like, they thought that negative and non-significant findings just weren't interesting; the word limits for journal articles made it hard to talk about everything; they just didn't think one or another result was important; or it turned out they couldn't bring in the sample size they needed within their budget. Somewhat shockingly, about half of protocols -- which managed to get funding and ethical approval -- did not have specified primary outcomes. Hmm. I'd like the contact info for those funders.

So this is not good news. For those who are suspicious of how evidence based evidence based medicine really is, your antennae should be tingling because it looks like a lot of investigators aren't being trained properly and don't understand what they need to be doing. But there is also this quote:

When we looked at that data, it actually showed an increase in harm amongst those who got the active treatment, and we ditched it because we weren’t expecting it and we were concerned that the presentation of these data would have an impact on people’s understanding of the study findings. It wasn’t a large increase but it was an increase. I did present the findings on harm at two scientific meetings, with lots of caveats, and we discussed could there be something harmful about this intervention, but the overwhelming feedback that we got from people was that there was very unlikely to be anything harmful about this intervention, and it was on that basis that we didn’t present those findings. The feedback from people was, look, we don’t, there doesn’t appear to be a kind of framework or a mechanism for understanding this association and therefore you know people didn’t have faith that this was a valid finding, a valid association, essentially it might be a chance finding. I was kind of keen to present it, but as a group we took the decision not to put it in the paper. The argument was, look, this intervention appears to help people, but if the paper says it may increase harm, that will, it will, be understood differently by, you know, service providers. So we buried it. I think if I was a member of the public I would be saying ‘what you are promoting this intervention you thought it might harm people—why aren’t you telling people that?

Res ipsa loquitur. And I'd sure like to know what that shit is so I can make sure not to take it.

Stuck in the woods

I'm snowed in today, which you would think might lead to a super special blog post, but I don't seem to be up for it. I will, however, cast the blame for my situation.

The National Climate Data Center has released its report on the global climate in 2010. Break out the champagne, folks, we just tied the record. 2010 was the warmest year the planet has experienced since useful records have been available -- that would be 1880. It's actually a tie with 2005, but hot enough.

Oh yeah -- it was also the wettest, although the wetness was spread around very unevenly. So we had an unusual number of extreme weather events. A warmer atmosphere holds more water vapor, so you get more rain and snow. You also get unusual configurations of the jet stream and other weather patterns, so some places get droughts even while others are getting flooded.

This is for real folks. It's happening now, you don't have to wait until 2030. By the way arctic North America is extraordinarily warm right now, and most of Hudson Bay is ice free. That's really weird. And according to an increasingly popular hypothesis, it drives more cold arctic air south. So there's no paradox here. (Actually it hasn't been all that cold for January in New England anyway.)

How we can get people to focus on this, in the face of a very well-funded denialist campaign and a Fair and Balanced media, I don't know. But I do feel I need to do my own tiny part here, and I will.

Relative wrongs

It's a big deal when somebody intentionally and directly generates kinetic energy that injures and kills lots of people -- sometimes. Military personnel obviously have a license to do it under approved circumstances. You would think that lying to the world in order to start a war would be considered a monstrous moral offense, but apparently not if you happen to be the president of the United States. But at least some people remain outraged by that and there has been a bit of public discussion about it. We decided to look forward, not back, however, so there will never be a formal accounting.

But what about people who market tobacco, or unhealthy foods? It is estimated that tobacco addiction kills 5 1/2 million people around the world annually, an average of 15 years before their life expectancy without the disease. Well, here's a controversy almost nobody has heard of. You have probably heard of Carlos Slim, the wealthiest Mexican and a well-known philanthropist. It turns out that the main source of his wealth is tobacco. I'm afraid this Lancet article is subscription only, so I'll summarize.

Slim contributes as much as $5 billion a year to his foundation, Instituto Carlos Slim de la Salud, which supports public health programs in Latin America. Last year, he announced a joint contribution with Bill Gates to a project to promote child health in Central America. It turns out that Slim was for many years majority owner of the Mexican tobacco company Cigatam. He has since sold a majority stake to Philip Morris, on whose board he now sits. He acknowledges that the enormous cash flow generated by Cigatam was the key to building his conglomerate empire.

The Gates Foundation has previously withdrawn cooperation from a Canadian charity whose director turned out to have tobacco industry ties, so Simon Chapman asks why Gates is willing to work with Slim. But I have a deeper question. Why is this man considered respectable in any way? He is a mass murderer on a scale that makes Pol Pot look like a petty criminal.

We have an astonishing capacity for selective attention.

"A deranged killer"

For reasons which should be obvious, I did a little research into the association of schizophrenia with violence. This review article offers a good, clear discussion of the issues.

Although various numbers are bandied about for the degree of risk of violent behavior associated with schizophrenia, they should all be viewed with a degree of skepticism. There are several reasons why it is difficult to put a firm number on this association:

1. Schizophrenia is not a definite entity. There is no "gold standard" diagnostic test, it's based on clinical judgment. In research settings, it's often based on something short of adequate clinical judgment, such as a single encounter with a clinician. And the term undoubtedly encompasses more than one disease. The etiology of schizophrenia is unknown, and its associated biology very poorly understood.
2. All this means there are big problems with ascertainment bias. Maybe people who commit violent acts are more likely to be diagnosed with schizophrenia, because they come to the attention of potential diagnosticians; or because their behavior itself predisposes to a diagnosis.
3. On the other hand, selection bias probably works in the opposite direction. People with major mental disorders who are violent are less likely to agree to participate in studies, more likely to drop out, and harder to follow and recruit.
4. Studies based on people who have been convicted of violent crimes may understate the prevalence of schizophrenia because people with mental illnesses are often diverted from the criminal justice system. Also, schizophrenia could affect one's likelihood of being caught and convicted. One would think it would make it higher since the ability to plan and act rationally is impaired.
5. Ascertaining violent behavior is just difficult. Reliance on self-reports could obviously bias conclusions either way.

Still, triangulating on this question from many directions -- trying to ascertain the likelihood of violent behavior in people diagnosed with schizophrenia; trying to ascertain the prevalence of schizophrenia in people who have committed violence; and cross-sectional or even better, prospective cohort studies of community populations -- it appears that the risk of committing violence is higher among people with schizophrenia. It's still a a minority of all people with the diagnosis, but it appears that the risk of committing homicide is somewhere around 8 to 10 times that of people without diagnosed mental illness. Substance abuse disorders also predispose to violence, and definitely create a strong additive risk in people with schizophrenia. It has been said that conduct disorders are also strongly associated with risk but that's obviously circular since violent behavior is a diagnostic criterion for conduct disorder. Keep in mind, however, that people who are diagnosable with schizophrenia commit a small percentage of all violent acts, and that the vast majority of people with schizophrenia are not violent. We need to be honest about this problem without promoting stigma or discrimination.

As far as politically motivated, or apparently politically motivated violence is concerned, there are a couple of famous cases that are relevant. John Salvi, who went on a murderous rampage at two abortion clinics near my home, was indeed a devout Catholic who attended anti-abortion protests and associated with anti-abortion activists. He was also without a doubt psychotic. He ultimately took his own life in prison after receiving a life sentence. Ted Kaczynski was diagnosed with schizophrenia by a court appointed psychiatrist, but I find this highly questionable. He clearly has impairments in social skills and empathy, and he's a weird guy, but his thinking is neither delusional nor disordered as far as I can tell. (I don't condone long distance diagnosis and I'm not a psychiatrist, but I just don't think he meets the criteria for schizophrenia so there.) Both of these individuals did indeed subscribe to coherent political ideologies, which were broadly similar to ideas promoted by movements and organizations, although Kaczynski appeared to believe that his thinking was highly original.

But it's a pretty big stretch to say that those ideologies and their champions are to blame for these people's actions. Other anti-abortion terrorists clearly were acting with intent based on the logic of their ideology, but Salvi actually believed that he would be ordained as a priest after committing his crime. And I know of no other deep ecology proponents who mail bombs. Earth First! and similar organizations attack property, but not people. We've heard a lot of nonsense of all descriptions about the tragic events in Tucson, but here's what I think. The guy is completely nuts. Yes, the violent and eliminationist rhetoric coming from the extreme right -- which is the center of the Republican Party -- is atrocious and must stop. But it's a real leap to say it had something to do with this incident.

Update: To clarify, I'm not saying it didn't. I'm just saying we don't know yet. And it is certainly true that all the violent rhetoric that's out there is dangerous in part because it can influence delusional systems such as John Salvi's. I'm just trying to carefully sort these matters out, that's all.

Fraud

Scientific fraud is not terribly rare in one sense. Just about every month NIH publishes official Findings of Scientific Misconduct. But these are almost always a post-doc or a junior faculty member who faked a slide in a proposal or something on that level. I'm sure a lot of fudged data finds its way into the literature, and I know for sure that quite a bit of data mining goes on.

For the uninitiated, that's when you look around in a data set for significant associations, and then pretend you hypothesized them when actually, you just stumbled on them. That's bad because it means your tests of statistical significance are invalid and your findings may well be spurious. It's one of the big reasons why a lot of findings don't hold up actually, because they weren't really legit in the first place.

What you're supposed to do when you come across an unexpected association is treat it as a hypothesis and then try to confirm it with fresh data. But the reason why people don't always do that is the same reason the post-doc faked the slides and data gets fudged -- there's tremendous pressure to publish and get funding, and if you don't, you are likely to get squeezed out of academia entirely and you're selling insurance or something. At best your grand ambitions go unfulfilled and you're working as a drudge in somebody else's lab or teaching as an adjunct for a few thousand bucks a course until you've finally had enough. So the temptations are strong.

But the vast majority of fraudulent or questionable publications are basically inconsequential. They don't lead anywhere, and the worst that happens is that better work gets crowded out of the journal and possibly some other investigators gets sent briefly down a blind alley. What is actually rare is a consequential fraud like Andrew Wakefield's that convinces a lot of people of something that isn't true and is actually important. Even Marc Hauser, if he did indeed commit fraud rather than succumb to wishful thinking (a distinction without a difference, I think, since appropriate methods would have precluded the latter), didn't do much substantive harm. The cognitive abilities of macaques are not a matter of life and death.

But for someone to perpetrate a fraud as consequential as Wakefield's takes a very special kind of personality. He wasn't just fudging some numbers to win a grant or get a paper published in an obscure journal on an arcane subject. He went right to the heart of medical practice and attacked what has been, without question, the single greatest boon to humanity ever delivered by biomedicine. (I'll assign clean drinking water and sanitary child birth to public health, since they aren't medical interventions but rather harm avoidance based on understanding of pathogens.)

The only reason an anti-vaccination movement can exist is that vaccination has been so successful. If kids were dying of smallpox and polio and measles today, believe me, Jenny McCarthy would be screaming and yelling to make sure every kid got every shot. People today just have no idea of what human existence was like before the development of modern vaccines. Life was cheap. People didn't expect most of their children to become adults, they just hoped for it. If you didn't die, you might be disfigured by smallpox or paralyzed by polio or sterilized by mumps. Women who had rubella during pregnancy had profoundly retarded infants, who filled institutions. That's how it was.

If Andrew Wakefield had his way, that's how it would be today. And why did he do it? The way I read Brian Deer's story, he did it for money.

Not much I can add to this . . .

Orac and the gang are all over it of course. Pit bull reporter Brian Deer, who has had his jaws clamped onto psychopathic mass murderer Andrew Wakefield for years, finally drags his quarry to the ground. He demonstrates what we have all always suspected -- Wakefield's study suggesting a link between the MMR vaccine and autism wasn't just sloppy and wrong, it was intentionally fraudulent. Whether Her Majesty can find a way to prosecute him remains to be seen, but it will be a shame indeed if he gets away with it.

I'll bet you can predict how the corporate media are covering this. Yep, they're Fair and Balanced. Here's CNN's headline and lede:

Doctor Defends Retracted Autism Study

A physician accused of an "elaborate fraud" in a now-retracted British study that linked autism to childhood vaccines is defending himself, telling CNN his work has been "grossly distorted."

Speaking on CNN's "Anderson Cooper 360," Dr. Andrew Wakefield said Wednesday he has been the target of "a ruthless, pragmatic attempt to crush any attempt to investigate valid vaccine safety concerns."

The story then briefly summarizes the accompanying editorial in BMJ, gives Wakefield another shot: "Wakefield dismissed Brian Deer, the writer of the British Medical Journal articles, as "a hit man who has been brought in to take me down" by pharmaceutical interests. Deer has signed a disclosure form stating that he has no financial interest in the business," gives Deer a chance to deny that he is a tool of the pharmaceutical industry, then brings in Wakefield's fans to pile on more horse manure:

Wendy Fournier, president of the National Autism Association, defended Wakefield in a CNN interview.

"I cannot imagine for a second that Dr. Wakefield would have any reason to falsify data," she said. "He's a man of integrity and honesty and truly wants to find the answers for millions of children who have been affected by autism."

Fournier accused pharmaceutical companies of trying to protect their turf.

"You can't question vaccines without being destroyed," she said. "There's too much money at stake here."

J.B. Handley, the father of an 8-year-old with autism and a co-founder of Generation Rescue -- a group that believes there's a connection between autism and vaccinations -- also questioned the motivation behind the investigation into Wakefield's work.

"Children are given 36 vaccines in the U.S. by the time they reach the age of five," he said. "This is an attempt to whitewash, once and for all, the notion that vaccines cause autism."

There's is some more He Said/She Said and then Wakefield's defenders get the last word:

Wakefield's defenders include David Kirby, a journalist who has written extensively on autism. He told CNN that Wakefield not only has denied falsifying data, he has said he had no way to do so. "I have known him for a number of years. He does not strike me as a charlatan or a liar," Kirby said. If the BMJ allegations are true, then Wakefield "did a terrible thing" -- but he added, "I personally find it hard to believe that he did that."

Of course Wakefield had a way to falsify his data -- just make it up. And that's what he did.

So that's it -- your typical "Shape of the Earth, Views Differ" story. This matter is settled. It is not controversial, it is not a debate on which reasonable people can differ, in which both points of view must be given equal consideration. On one side you have people who are stating facts, and on the other hand you have liars and their victims. Yet the corporate media seems incapable of grasping the situation.

If they can send a man to the moon . . .

Actually I've used that title before. Anyway, they're still working on the urgent public health problem of baldness, this time in the general realm of regenerative medicine. That's all about how newts can grow new limbs and hearts, so why can't mammals? Basically, we don't have the progenitor cells needed to regenerate tissue, and in the case of people afflicted as I am, that happens to be hair, which is not exactly tissue but it's a similar idea.

Obviously, baldness isn't actually a health problem.

I take that back. If "health" means a state of well-being, then it is whatever makes you think you are well. But if bald men feel unwell, it's because of their worries about how others see them. This same problem comes up with short stature -- which has become a disease now that hormones are available to make children grow taller -- and homosexuality, which used to be a disease but is no longer, because social attitudes have changed. Originally, as a matter of fact, calling homosexuality a disease was seen as a step forward for homosexuals, because it's better to have a disease than a moral failing. In Leviticus, baldness may or may not be a moral failing depending on specific criteria. Simple male pattern baldness seems to be exempted, but if the priest were to make a misdiagnosis, a bald man could end up driven into the desert to die:

40 “A man who has lost his hair and is bald is clean. 41 If he has lost his hair from the front of his scalp and has a bald forehead, he is clean. 42 But if he has a reddish-white sore on his bald head or forehead, it is a defiling disease breaking out on his head or forehead. 43 The priest is to examine him, and if the swollen sore on his head or forehead is reddish-white like a defiling skin disease, 44 the man is diseased and is unclean. The priest shall pronounce him unclean because of the sore on his head.

All this is banal, but there is a deeper point. Our well being is partly a function of how our physical and behavioral characteristics are regarded by others. It is socially as well as biologically determined. Exactly how unhealthy a person is who has, say, difficulty walking, or who stutters, or has a benign but visible tumor, or a so-called paraphilia, is determined by the rest of us and the environment we create. We could create a lot more health by investing in cultural change, in many instances, than in biomedicine, even before we get to the problems of social class and material resources.

The Straight Dope

You may have come across this dispute in New York City over graphic HIV prevention advertisements. The city health department is concerned that young gay men are thinking that HIV isn't so bad after all, just take a pill and you'll be fine. So they're using scare tactics, with graphic images of anal cancer and warnings of dementia and dissolving bones.

Lots of people are unhappy with the ads, on various grounds. Jarrett Barrios, an acquaintance of mine who was once a Massachusetts state senator and now head of the Gay and Lesbian Alliance Against Defamation, says they just aren't accurate -- living with HIV isn't really all that bad. Others fear the ads are stigmatizing, of both gay men and people with HIV.

Others support them however, because they really, really want young gay men to stop getting infected with HIV. On the other hand, it isn't at all clear that such scare tactics really work in changing people's behavior. The latter point is obviously a very strong one. The downsides are only acceptable if the ads have a big effect in HIV prevention. Unfortunately nobody can say for certain. The common wisdom is that in most contexts, trying to scare people into not doing stuff they otherwise want to do isn't very effective.

The American Legacy Foundation youth tobacco prevention ads, which the article asserts were comparable, were not comparable at all. Rather than trying to scare people into not smoking, they (truthfully) portrayed tobacco as a product pushed by old, greedy fat cats and hence decidedly uncool; while way cool rebellious and hot looking young people hit the fogeys with anarchistic direct actions.

I can't exactly think of a comparable tactic to use against HIV, and I wouldn't want to make the drug companies a target although it is true that they're advertising in gay-oriented literature does make it seem as though living with HIV is not a prob. They shouldn't do that. But I will tell you what it's really like to live with HIV.

It is true that if you are diagnosed in time, before you lose too many T-cells; and you get access to good medical treatment, which you have insurance or other means to pay for, you will have the opportunity to remain reasonably healthy for a long time. That is if and only if you take medications consistently, for as long as you live. You may be unlucky and have unpleasant or even intolerable side effects from the first regimens you try, although most people don't.

But over time, long term side effects are common, including disorders of lipid metabolism which can include disfiguring redistribution of fat deposits; high cholesterol; diabetes; and weight gain. Painful peripheral neuropathy is also encountered with some medications. If you don't take the pills consistently, you may develop viral drug resistance and have to switch to more complicated, less well tolerated regimens. And in spite of effective treatment, it does appear that HIV can continue to slowly damage the brain and lead to early onset dementia. You might be lucky enough to escape the worst of these consequences, but don't bet on it. Chances are your life will be shortened.

I don't want to exaggerate any of this. Lots of people with HIV do very well for decades. Your lot today will be much better than it was before there were effective treatments - these side effects beat the hell out of uncontrolled HIV disease and AIDS. But believe me, this is something you would much rather live without.

Yes,the ads are inaccurate because the dire consequences they portray aren't going to happen while you're still young, and the anal cancer thing is a bit of a red herring since that is caused by a different virus, although it's still a good reason to always use condoms so I can forgive it. I would rather see messages that are unassailably accurate and are more about positive motivation than negativity and fear. I think the health department could have done a lot better.

But I can also understand why some people are getting frustrated enough to try anything. Nobody has to get HIV from voluntary activity. And you really, really don't want to. So don't.

The big public health story of 2011

As Yogi said, I believe, or at least he said something like this, it's hard to make predictions, especially about the future. But I am pretty sure that in 2011, people are going to be talking about the weather even more than usual.

Everybody has heard of the flooding in Australia, where half of Queensland is under water. I pay pretty close attention to the news, but I only noticed recently that Colombia is in even worse shape. Mozambique got hammered last spring, and of course you've heard about Pakistan although it fell off the corporate media radar pretty quickly. Unprecedented flooding in the U.S. in Nashville and the Rio Grande area, and now in Southern California, also made the news last year. New Year's day tornadoes in the midwest? That too.

A warmer earth means a more energetic atmosphere, that holds more water vapor. We don't have to wait until 2050 to see the result, it's happening now. In the U.S., where we generally have adequate warning of these events, and people have means to evacuate, we don't often have large numbers of deaths, at least not as an immediate, direct result of flooding. But when people are displaced, communities destroyed, homes and livelihoods lost, the consequences can be severe in the long term.

Insurance companies are convinced, even if Republicans are not. So are the leaders of China, and the U.S. military. I've given a couple of links to Climate Progress already, and I recommend that you bookmark it. This is for real, folks. And it's coming faster and harder than just about anybody predicted even two years ago.