Just how badly will we end up screwing ourselves?

As you may have heard, we are now apparently gearing up for a fight over whether to continue with the federal gasoline tax. Yep, it expires in one month, which means that Congress has to pass a bill affirmatively extending it. The tax, now 18.4 cents a gallon, has not increased since 1993, despite inflation and declining gasoline purchases per mile driven. (Yes, we have gotten more fuel efficient since then.)

Grover Norquist and his pals claim that if the federal gas tax is eliminated, the states will step up with their own taxes because they know they have to maintain their transportation infrastructure. Sure. We all know what Grover and his pals will do if the states try it. Anyway, the highways don't recognize state borders, and bridges quite often constitute state boundaries. General Motors and the Chamber of Commerce, no less, both want the tax raised to $1 a gallon. Surprised? Obviously, people won't be inclined to buy cars if they can't drive them, which is what will happen if the roads and bridges all collapse. (BTW, I know that roads and bridges don't constitute the whole of transportation infrastructure, and that we should in fact invest far more in mass transit. But that's a separate issue.)

The truth is, we need to raise $2 trillion to fix our roads, and fast. As the Urban Land Institute points out, "As Congress debates how much should be spent and where to find the money, China has a plan to spend $1 trillion on high-speed rail, highways and other infrastructure in five years. India is nearing the end of a $500 billion investment phase that has seen major highway improvements, and plans to double that amount by 2017. Brazil plans to spend $900 billion on energy and transportation projects by 2014."

We need a higher gas tax for other good reasons, of course. It will encourage conservation and reduce emissions of pollutants including C02, which is even more urgent. But you can't drive electric cars without roads any more than you drive an Escalade. And yes, we need to rebuild water and sewer systems, we need a more efficient, "smart" electrical grid, we need to fix schools and teach children more effectively, we need to replace our weather satellites, we need to do a whole lot, and we need to get going right away. By the way, if you happen to be out of work, I'm talking about jobs, lots of jobs.

But right now, ideological extremists hold all the cards. The Republican Party stands for national decline, and they have the power, right now, to get their wish.

Goddamn the pusher

For you young uns, that's a song by written by Hoyt Axton and performed by Three Dog Night, [right, Steppenwolf, thanks to a commenter. Axton did write for TDN] IIRC. As I recounted here a while back, when my father was in an assisted living facility with moderate dementia, my mother came to visit one day and found him slumped in a chair, drooling, and incoherent. It turned out they had given him "Abilify" (the most noxious and mendacious brand name in all the pharmaceutical industry). It's an antipsychotic that has a black label warning against giving it to elderly people for dementia because a) it doesn't treat dementia and b) it kills them. But institutional physicians prescribe it all the time because it drugs the people into a stupor which makes it easier for the staff. Apparently my father had wandered into the laundry room or something.

I told my mother all about it so she wrote them a letter forbidding them ever to give him antipsychotic drugs again. She handed over the same letter when we transferred him to a nursing home, but sure enough, a few weeks later she came to find him slumped in a chair, drooling and incoherent. They had ignored the letter, not to mention professional responsibility.

Via Roy Moynihan in BMJ (I think the masses will just get the first 100 words) I come upon the story of Fervid Trimble (yeah, funny name, she's English) an elderly woman living independently who entered a hospital with dizziness and diarrhea. Her daughter visited to find her delusional and stuporous. It seems they had decided she was depressed and given her an antidepressant, also a painkiller and various other drugs, including donezepil which is a useless medication heavily marketed for Alzheimer's disease. When the family asked that Fervid be taken off the drugs, she recovered completely.

Okay, so you have a plural of anecdote. For data, go to Garfinkle and Mangin who did a study in Israel. They found that community dwelling elders were taking, on average, 7.7 different medications. They also found that according to a protocol developed to assess overmedication in the elderly, 64 out of 70 were taking drugs they should not have been taking - a lot of drugs, 4.4 per patient. After they were stopped, in only 2% of cases was it decided to restart them. There were no adverse effects of stopping any of the drugs, and 88% of patients reported improvement in their overall health.

So why is this happening? For the answer, ask "Cui bono?" Somebody is making money.

The End of Civilization As We Know It

Well no, hurricane Irene was just a lot of wind and rain. Now the CW is that it was overhyped and it didn't really amount to anything, but that isn't true either. I lost electrical power at 5:00 Sunday morning and I don't expect to get it back for a week. The entirety of southern Windham County and as far as I know most of Connecticut to the south and west is without electricity. Outside of the cities, that also means no water. Most people don't have phone service either. That means you can't buy gasoline, the traffic lights don't work, the food is rotting in the grocery stores (the big ones have generators for emergencies, but not most of the mom and pop businesses).

I had 1 hr. worth of battery power in my computer so I did an Iraq Today post, checked my e-mail and the news a couple of times, and then went dead. I've bolted to my urban pied a terre from whence this missive.

Now here's the point. One hundred years ago, rural areas didn't have electricity and it wasn't terribly important anywhere. You could always break out the old kerosene lamps if need be; there was no telephone, radio, TV or Internet; you kept food cold in an ice box and you cooked and heated with coal or wood. If you didn't have city water you pumped it by hand.

Today, electricity is pretty much a necessity. I can't even maintain an acceptable standard of hygiene without it, which means I can't go to work. We're completely locked in, the current human population of North American cannot be maintained without steady, reliable electrical power zapping its way into every household. It cannot be undone. So Irene was a big deal, not in the sense that we're all gonna die (although a few people who need electrically powered machinery to keep them alive might, if they aren't properly rescued). But it does prove something to us. If the electricity goes away for too long, we have no way of existing.

Low hanging fruit

Have I remembered to say, "We need universal, comprehensive, single payer national health care" lately? Maybe not. So there, I just said it.

Yesterday I covered the exciting news that a lot of the money we spend on health care is wasted on harmful, useless, or non-cost effective procedures. Yeah I know, you're just astonished. But before we even worry about doctors actually doing stuff to us, physician practices in the U.S. spend $82,975 per physician year just hassling with payers. In Canada, they spend about one quarter as much interacting with the single payer. If we had single payer health care in the U.S., we'd save $27.6 billion dollars a year just on administrative costs for physician practices. Hey, it's fine with me if the doctors want to split it with us.

Listen folks, we know how to fix this problem. We know. Let's stop settling for all this tinkering around the edges and policy wonkery and playing defense. Say it loud, I'm single payer and I'm proud!

We need universal, comprehensive, single payer national health care. Say it, every time the subject of health care policy comes up. Just keep saying it. It's the truth.

Suggested reading

Via our friend Dr. Rick, NIH, after mighty labors, has come up with some seriously lame-ass conflict of interest rules for researchers. Specifically, if they take more than $5,000 a year from industry, they have to disclose it, but not publicly. Somebody has to specifically ask their university for the info. Also, the university needs to have a "plan" to manage conflicts of interest, but it can be a secret. Enjoy your ineffective, dangerous, yet profitable pills.

Now for something completely different, for some reason it's generally not permitted for the corporate media to talk about this but it did come up briefly on the Wolf Blitzer show the other night, and now Terry Gross is covering it on NPR. While everyone's yelling and screaming about Sharia law and the New Caliphate, what Rick Perry, Sarah Palin and Michele Bachmann are all about is Christian dominion. That's right, they want not only the United States, but the entire planet, to become a Christian theocracy. And no, that's not an exaggeration and it's not just some doctrine their churches officially believe in that they pay no attention to. It's an actual, active, public movement with which they associate. Still planning to sit out the 2012 election because Obama is a wuss?

See, that wasn't so hard

Ezekiel Emanuel and Jeffrey Liebman explain what I say here every couple of days, which is that "cutting" Medicare does not have to mean taking any actual benefits away from anybody. We can make a huge start by not wasting money on stuff that actually hurts people; then we can stop wasting money on stuff that doesn't do any good; and then we can stop wasting money on stuff that might do some good but so would much cheaper stuff. The only reason we don't do that is because every time we try, Republicans start yammering nonsensically about death panels.

As E&L point out, however, you can't really get there by micro-regulation. Actually I think they are a bit too dismissive of the possibilities of practice guidelines and formularies and whatnot, but they are right that restructuring the system to incentivize results rather than just doing stuff is essential.

What I don't get is why, when a) everybody who actually studies health policy knows this and b) these two guys can explain it in a simple and accessible way in a brief newspaper op ed, we don't have c) which is THE PRESIDENT OF THE UNITED STATES CAN JUST FUCKING SAY IT! What is wrong with the man?

And oh yeah, Emanuel is his best friend Rahm's brother for crying out loud. Sheesh.

Technical Fix?

I'm obviously not one to take issue with calls to increase, or at least maintain, the NIH budget and federally sponsored R&D in general. Of course I'm one of those greedy scientists who, according to the genius Rick Perry, makes stuff up in order to get funding. The stuff I make up happens to be the truth, as established by rigorous hypothesis testing, otherwise I don't publish it, but still.

Anyhow, here you have two investment bankers -- who obviously must not be greedy or making stuff up in order to make money -- arguing on behalf of NIH-funded research. They think there are two major reasons why it's the greatest thing since oxygen, and a third reason that makes it at least as good as sliced bread:

1) It's good for the economy. It creates new industries and jobs.
2) It's the only way to fix the health care system, because, because, er, well, it can save money by finding ways to do things cheaper, I guess.
3) It will make people live longer and be healthier.

One may be forgiven for suspecting that #1 is #1 for them. They invest in the medical industry and obviously they want new stuff to invest in. Now let's think about it. If #2 is also true, and we end up spending less on health care, then there must be shrinking industries and fewer jobs, ¿verdad? Hmm.

Everybody's complaining that we keep spending more and more on health care and we can't afford it. Why are we spending more and more on health care? It's not so much because people are getting older. That explains a big part of why we spend more and more on Medicare, but health care spending keeps going up for younger people as well. The reason is because of #1: we keep paying for new technologies, which means doing more stuff and doing more expensive stuff. That indeed creates industries and jobs, but that's money we aren't spending on something else. If scientific and technological advances in health care were in fact bringing about #2, that would negate #1.

So what exactly do these guys really think? Presumably, the love #1 but they want to come up with some additional selling points so they trot out #s 2 and 3, without stopping to notice that 1 and 2 are contradictory. Number 3? Could be true, but not if all that money being diverted to #1 comes out of other stuff that keeps people healthy like, I dunno, having a good diet and good housing and safe neighborhoods and clean water and what not.

Now, it could happen that the historical association between technological advance and higher costs reverses at some point. If they invent a cheap shot that cures cancer, Bob's your uncle. But so far they keep inventing $100,000 shots that keep people with cancer alive for 4 months. If they do invent that cheap shot, great news for #s 2 and 3, but very bad news for the pharmaceutical industry, i.e. #1 goes belly up.

These guys need to think it through a little harder.

Life span vs. span of life

To clarify in response to CC, and because this is important, here's how to parse the following terms: Life expectancy, Life span, Length of life/age at death.

Life expectancy is a fictitious number, derived as follows. Consider a person of a given age -- the moment of birth, or age zero, is the most common, but you can start at any point. Now look at all similarly situated persons, for example you might want to consider life expectancy at birth for U.S. males, or some such category.

Now look at all the people who died last year (or as recently as you can get the data) who were in that category. A small percentage died in their first year of life, an even smaller percentage age 1-5, 6-10, etc. Making the assumption that the baby just born will have the same odds of dying during each interval, figure out how old he'll have to be before there's a 50% chance he's dead. That's his life expectancy.

In reality, he won't have the same experience as people living today. We're accustomed to life expectancy increasing over time, but it doesn't have to. We'll see.

Now, life span has to do with an incurable genetic disease with which every one of us is born, called aging. Even assuming we don't experience misfortune such as being hit by a bus or sent off to Afghanistan to be blown up, and we stay super duper healthy, we won't live forever because our cells are programmed to be able to divide a finite number of times after which the tissues cannot renew themselves and we'll just die of plain old old age. Right now the maximum human life span for the genetically extremely lucky - and we're talking very rare outliers here - is about 120 years. We used to think of the life span as more like 70 years but that's because hardly anyone stayed healthy enough to make it to the true human life span, which for most of us is probably more like 90+ years. In other words, we all died of something other than old age, but nowadays we don't necessarily. (Where Alzheimer's fits in the aging process vs. disease dichotomy is maybe a little unclear.)

How long you actually live is self-explanatory, I think. So what happened with the mice in the experiment described yesterday is that they lived longer than fat mice usually do, because fat mice tend to die of heart disease just like fat humans. But their life span was not extended, in fact they didn't even make it to the typical age of svelte mice. So the drug wasn't slowing the aging process at all, it was just counteracting some of the badness of obesity.

Does that make sense? If not, keep asking.

The headline is always way ahead of the reality

When it comes to that curious genre of news called Medical Breakthrough! The NYT puts on its front page no less a report that a chemical related to the much hyped resveratrol extends the life span of fat mice. That's very exciting if you happen to be a fat mouse but for Homo sapiens, not so much. You have to read to the end of the story to learn that:

The treated fat mice lived longer than the untreated ones, but died long before the normal mice. Although the treated fat mice lived significantly longer on average, there was little difference between their maximum life span and that of the untreated mice. The drug, in other words, helped the fat mice enjoy more of their available life span without increasing the span itself. . . .

Because of the uncertainty about several earlier findings, the sirtuin field has become polarized. “Some people are strongly in support, and others are convinced there’s nothing there,” said Brian Kennedy, president of the Buck Institute for Research on Aging. He described himself as standing in the middle, but hopeful that the sirtuins would turn out to be “key modulators of aging.”

In other words, it isn't actually delaying the aging process, it's just ameliorating some of the ill effects of obesity. In mice. And experiments with similar substances in humans so far have been a bust.

Anyway, has anybody really thought through what it would mean to extend the human life span? What if we do come up with a pill that will make large numbers of people live to be 120 years old? Is that actually such a great idea? Think about it. . . .

Pundit accuracy check

As you know, one of the perks of punditry is never having to say you're sorry or even acknowledge when your predictions are wrong. Unlike the originator of the Friedman Unit, I don't get a regular column in the New York Times, but also unlike him, I'm willing to put my past pontificating up against present reality. Here is what I wrote on October 6, 2008, as the global financial system was collapsing.

Exactly how fucked are we?

On the one hand, we are so fucking fucked it isn't fucking funny.

However, we do have choices. Even with reduced means, we will still be the wealthiest, most powerful nation that has ever existed, and we will have far more at our disposal than our grandparents during the Great Depression. We don't have to let people starve and freeze. We don't have to accept massive homelessness. We can still educate our children, still heal the sick, still succor the afflicted. We can still offer dignified work and self-sufficiency to everyone. We can still have music, and art, and meals in restaurants, and family farms, and community, and everything we need and most of what we want.

That is, if we make the right choices, but so far, we have shown no signs of having the wisdom to do so. We do have to give some things up, starting with war, and the nearly invisible global empire of military bases that most Americans are barely aware exists.

Wealthy people -- and there are still quite a few of them, in spite of everything -- will have to pay more in taxes to secure the future of the nation that they looted to get what they have. As Joe Biden says, it's the patriotic thing for them to do.

Lenders will have to deal wisely with people who are behind on their mortgages, and accept some losses to prevent the destruction of communities and countless lives. And oh yes, they'll actually be better off than they are foreclosing and ending up with worthless property.

We can still borrow money from the Arab oil potentates, but we have to invest it wisely, instead of squandering it on profligate consumption and world historical crimes against humanity.

We have to completely rebuild our largest industry, health care, to meet human needs instead of feeding corporate profit.

We have to mobilize the energies, wealth, and good will of our people, come together in a time of terrible crisis, and turn urgency into opportunity. It will be tough, and there will be some suffering, and most of us will have to give up something. But we can certainly survive and emerge stronger. We can. We might not.

The malignant dwarf who fraudulently occupies the office of president has nothing to offer us but fear and more fear. His designated successor is even worse. In the next month, we'll be engulfed in a torrent of filth spewed by the desperate and dying remnants of the criminal order that brought us to our present straits. Will the people drown in it, or climb above it? This is one of the most critical moments in our history, have no doubt of it.

So, the malignant dwarf's designated successor didn't end up succeeding. Barack Obama became president, in spite of the torrent of filth which did indeed descend on us in the final month of the campaign -- and has continued ever since. But have we done any of what needed to be done? Has urgency become opportunity?

You probably think Michelle Bachmann is a dangerous lunatic

And you're right, but our situation just got a whole lot worse. This Rick Perry character is evil, stupid, ignorant, bigoted, and hateful, among other adjectives I might apply to him. There has never been a more dangerous politician who was taken seriously as a presidential candidate in my lifetime, and that includes Barry Goldwater who wanted to nuke Vietnam.

What is most disturbing is not his insane beliefs and moral depravity, but the nature of his appeal. He managed to get himself elected governor of Texas and he's now among the most popular of the Republican candidates precisely because of his bullying, his violent, eliminationist rhetoric and his contemptuous dismissal and vicious disparagement of everyone whose beliefs he finds inconvenient. His charisma is that of a gangster, a psychopath who cuts down all the world's difficulties and complexities with brute, unreflective, conscienceless force.

It turns out there are a whole lot of people out there who like that. He's the kind of leader they're looking for. It can happen here.

On the rise of quackademic medicine

Dr. Gorski, in case you don't already know it, is highly POd about the infiltration of "complementary and alternative" or "integrative medicine" into medical schools and academic medical centers. Yep, homeopaths, acupuncturists, reflexologists and practitioners of "energy medicine" such as Reiki and "therapeutic touch" are actually teaching courses and touching -- or waving their hands at -- patients in otherwise respectable institutions.

I share his alarm, but I wish he'd give more thought to why this is happening. Obviously the quacks* are filling some sort of need that real doctors aren't, both for patients and for the docs themselves who are encouraging or at least tolerating this jive. Part of the problem is that most people aren't scientifically literate so it's easy to fool them with pseudo-scientific sounding blather, but that is only a necessary, not a sufficient condition. It doesn't explain the attraction.

Some people say (sorry about that but I'm not going to do the work of coming up with links) that real doctors don't spend enough time with people, don't listen well, and don't establish satisfying therapeutic relationships. The quacks give them more time and attention, perform soothing rituals, and leave them feeling healed, not just treated. Maybe so, but letting them come in to do that work so the doctors don't have to is the wrong solution to the wrong problem. It's the lazy way out, and it suborns fraud.

I wish Dr. Gorski would think harder about what true integrative medicine would look like -- real doctors doing science based biological interventions and evidence based but also humane and empathic healing, partnership, and listening. This requires a different set of criteria for admission to medical school, a different emphasis in medical training, and a different concept of what physicians do. Just trashing the quacks doesn't get us there.

*And yes, that's what they are, this is all utter nonsense. If somebody wants to have that fight with me, bring it on.

Now we're talkin'

I hope more people will join this discussion -- it's very helpful to me, anyway.

Yes, doctors obviously are sometimes wrong. Some of those patients who nod and take the prescription and then go home and don't fill it are indeed better off. The problem is that if you don't believe that's exceptional, it's hard to explain why you would go to a doctor in the first place.

From the point of view of physicians, when they think about, write about and study these issues, they almost always assume, implicitly or explicitly, that people are better off doing what the doctor wants them to do just about all the time. If they didn't think that, they couldn't honestly earn their boat payments. Patients, on the other hand, are often wary of medical advice because they've read about all the drug company scandals -- the concealed unfavorable trial results and selective publication more broadly, rigged trials, ghost written articles, various forms of bribery of doctors (now much less common and less socially acceptable but still . . .), and just the seemingly ever changing advice (take antioxidants! no don't! take hormone replacement! no don't!). And that's perfectly rational as well.

From the point of view of a sociologist (YT), I have to assume a stance that's above the fray on the fabulousness or lack thereof of current medical practice and just try to understand how doctors and patients interact, who's trying to accomplish what, and how they go about it. What I find is that it often appears more collaborative, more trusting, and more agreeable than it really is, to both parties. They want to please each other face to face and maintain a good relationship, but the price of that is often avoidance and silence. The real issues are missing from the conversation. You don't know what you don't know.

Patient Empowerment?

Kathy provides a link to an article about exactly the problem I'm immersed in right now. In fact I'm in the middle or two papers that wrestle with it. To plagiarize myself:

Until the mid 20th Century, the generally accepted physician-patient relationship in the West was "benevolent paternalism."(Katz, 1984; Parsons, 1951) The patient's role was to trust and to follow "doctor's orders." The “patient centered” care movement began to transform the paradigm in the 1970s. Lipkin et al in 1984 defined it as treating the patient “as a unique human being with his [sic] own story to tell.”(Lipkin, Quill, & Napodano, 1984) In accordance with this normative shift, the prevailing term for patients failing to take medication as prescribed, “non-compliance,” was seen as presuming a duty of obedience. Accordingly it was replaced by “non-adherence,” seen as having a less paternalistic implication. However, the terms were essentially used synonymously. (Bissonnette, 2008)

Increased interest in models called shared decision making(Makoul & Clayman, 2006) or concordance (O'Connor et al., 1999) since the late 1990s represents an effort to truly redefine the goal as agreement between physicians and patients about whether, when, and how medicines are to be taken, via discussion that includes and respects the beliefs and wishes of the patient (Marinker & Shaw, 2003). In their discussion of the concept, Cushing and Metcalfe (2007) emphasize the importance of two-way communication for concordance to be achieved: “The challenge here is for the professional to delve beneath the surface of…deference to ensure that important issues which might affect adherence are not being ignored” (Cushing & Metcalfe, 2007, p. 1049).

In the concordance model the patient knows his or her views are respected and any subsequent difficulties the patient has with treatment can be discussed. This prevents the patient from being in the uncomfortable position of either telling the doctor that he or she has not followed the advice or, alternatively, of lying. Cushing and Metcalfe conclude, however, that changes in the patient provider dynamic have tended to be superficial and have failed to create real partnership. Segal (Segal, 2007)criticizes the concept on fundamental grounds: that “concordance in fact harbors an ideology of compliance,” arguing that its proponents have justified it as a more effective means of gaining patients’ assent to providers’ wishes.

The fact is that despite all this blather about patient-centeredness and shared decision making, empirically, we see no real change in the way physicians and patients discuss treatment options. Pretty much, the doctor still says "Here's what you need to do," and the person says okay. Half the time, they go home and don't do it, but that hasn't changed either. The one place where we do seem to see more overt conflict is in the example in the linked story, end of life decisions.

The fundamental situation is that the reason we go to doctors is because they are experts. If we knew as much or more about how to treat our health problems as they do, or thought we did, what would we be doing there, except maybe to get a hint or a second opinion, but not one as good as our own? "Patient empowerment" means turning to quackery and having a guy pour ghee up your nose or stick needles in your (non-existent) meridians more than it means deciding whether to take an antibiotic, or a statin, or undergo cardiac revascularization.

I'm all for freedom and equality and autonomy, but knowledge and expertise are unequally distributed. By the way it's pretty much the same with my auto mechanic, except that they tend to have a less stringent ethical culture. How to truly empower people with the knowledge and wisdom to be genuine participants in their medical care is much more difficult than most people seem to assume.

This could be huge.

Really. Most of the time, these great new basic science ideas don't work out at all, or aren't what they are cracked up to be. (Remember how Judah Folkman's ideas about angiogenesis were going to cure cancer? Instead, angiogenesis inhibitors have turned out to be of some modest benefit in slowing some cancers in conjunction with regular chemotherapy. No real breakthrough at all, sadly.)

But if this novel approach to antiviral therapy works, then not only will they have cured the common cold (probably long before we send another person to the moon), they will have cured lots, maybe most, maybe just about all viral infections. Don't hold your breath -- it will be many years before we know whether this can really work in humans. But it just might. And this is why the government funds basic research. This work was 100% government funded from the beginning, and the latest work "is funded by grant AI057159 (http://www.niaid.nih.gov/Pages/default.a​spx) from the National Institute of Allergy and Infectious Diseases."

But you know, that's socialism. So it's evil.

What this country needs is a better class of rich people

I think I already used that title, or something similar, but now I've got the evidence. Brian Alexander reports for MSNBC that rich people are %$^&*)s.

“We have now done 12 separate studies measuring empathy in every way imaginable, social behavior in every way, and some work on compassion and it’s the same story,” [social psychologist Dacher Keltner] said. “Lower class people just show more empathy, more prosocial behavior, more compassion, no matter how you look at it.”

According to Keltner, rich people also think society is already more egalitarian than it really is, and that they deserve their station in life, so they tend to oppose government action that would reduce inequality. The even worse news is that they have lots of money to pay for politicians who will carry out their cruel and selfish wishes. They're getting their money's worth.

Dire straits

Yesterday -- Monday -- was a bizarre holiday exclusive to Rhode Island, which celebrates the nuking of Japan. (Really.) I came to work anyway, parked in an empty garage, and used my key card to get into a deserted, non-air conditioned building. Absolutely weird. Anyway, I did get some work done but I found the idea of doing a post here in the midst of the current unpleasantness too overwhelming.

With millions of our young people coming of age and finding that there is absolutely no prospect of employment for them, one has to think it is only a matter of time before we see the same kind of social explosion that is now happening the England. Actually it's a mystery that it hasn't happened already. While I agree with Brad DeLong's syntactically awkward observation:

If you were to ask me what thing--aside from the complete and immediate collapse of the Republican Party and the resignation of all of its legislators from both houses of the Congress: if the previous fifteen years had not taught me that Republican politicians have nothing useful to contribute to national governance the last three years would certainly have done so--would most give me confidence that America would surmount this current economic crisis, it would be personnel changes to put qualified people who saw the world as it was in the summer of 2009 into the key economic jobs [in the Obama administration] . . .

Well okay but that isn't going to happen. Instead we have a president who is neurotically anxious to confer legitimacy on the lunatic right. As desperation grows in the land, as cities go bankrupt, bridges collapse, dams break, raw sewage starts to pour into the rivers, school buildings crumble, children go hungry, our fossil fuel addiction rages on and the plains turn to deserts, will anybody in power even take notice?

Evidently not. Until what, exactly, has to happen?

"Cutting spending" means not buying stuff you might actually need

In the bizarro world of Washington, "government spending" apparently means "causing money to disappear." Actually it means carrying out functions of government, such as, for instance, developing basic knowledge which private investors won't do because knowledge is a public good that they cannot own. As Elizabeth Lopato and Bryan Faler of Bloomberg News point out:

Prospective government spending cuts may slow Alzheimer’s disease research, stunt the careers of young scientists and prevent the U.S. from working with allies on alternate energy, scientists and lobbyists say.

If Congress doesn’t approve $1.5 trillion in savings by Christmas, a broad swath of federal programs will be automatically slashed, including the National Institutes of Health, which funds medical research; the National Science Foundation, which pays for basic science; and the Department of Energy, which runs national laboratories.

I'm not exactly sure why they single out Alzheimer's disease, except for the penny-wise pound-foolish point that the disease imposes huge costs on Medicare and Medicaid so prevention or effective treatment could conceivably save money down the road. But that's true of a lot of diseases. (Unfortunately, so far, it hasn't worked out that way -- medical advances have added to costs, not reduced them. The new emphasis on comparative effectiveness research and better understanding of basic mechanisms of disease could change that dynamic -- but that's not why we do research.)

In fact, NIH has already endured a $317 million cut this year. But if the automatic spending cuts president Obama agreed to in response to Republican extortion kick in -- and they likely will because there is no way 7 members of the phony deficit reduction commission will agree on a plan -- programs like NIH will get totally clobbered, by 7.9%. If that happens, it will be impossible for NIH to make anynew grants for a year or two, because most of its funding is committed to 2, 3 and 5 year grants already. That won't just stunt the careers of young scientists, it will kick them to the curb, shut down whole labs and research groups, and probably put some senior scientists out of work as well. The U.S. will turn over leadership in science and technology to China and Europe.

Why? Because billionaires don't like paying taxes.

Cervantes News Network

Fair and Balanced.

If you enter "We don't have a revenue problem, we have a spending problem" into your favorite Internet search engine, you will find that the top link is to a certain cable news network which informs us, in its typically fair and balanced way, that:

"The election result reflected the fact that people get Washington does not have a revenue problem. It's got a spending problem," Rep. Eric Cantor, R-Va., the expected next House majority leader, said on "Fox News Sunday."

"We do not have a revenue problem. We have a spending problem. Let's focus on the problem," Rep. Paul Ryan, R-Wis., the likely next House Budget Committee chairman repeated later on the same show.

"Well, I think it's not a revenue problem; it's a spending problem," said Sen.-elect Rand Paul, R-Ky., on ABC's "This Week." "A lot of times people would come to me and say, well, you don't believe in any government. And I would tell them, you know what? I believe in $2.4 trillion worth; I just don't think you can have $4 trillion worth if you only bring in $2.4 trillion."

For some mysterious reason, it seems, according to this story, that no-one in the world has a contrary opinion to express. (Sorry, for some reason, my link creation utility was on the fritz when I tried to give you a link to that story.)

It would be uncivil for any Democrat or TV elocutionist to mention this, but I will just note that the United States collects less taxes, as a percentage of GDP, than any country in Europe. Also, too, taxes in the United States are the lowest they have been in 60 years. And who is it, exactly, who is not paying those taxes? Why it's the highest .01 percent -- the highest 1 in 10,000 taxpayers, who make more than $3.6 million per year. Their taxes have gone down precipitously since the 1970s. Tax rates for the top 1% of income have also fallen, though not quite as steeply.

There. It didn't take me very long to show you all that. Maybe some Kenyan socialist would feel moved to mention it also. Or maybe not.

Sue the bastards!

I am totally down with this article by Simon Stern and Trudo Lemmens in PLoS Medicine.

I have written before about academic -- and specifically medical -- ghost writing, which makes my blood boil. As you know, research sponsored by drug companies is likely to be favorable to the manufacturer's products (fancy that), so the companies commonly resort to fraud. They find a high-powered academic type to pretend to be the author of a research report which he (almost always -- never heard of a woman doing this but I can't rule it out) had nothing to do with.

The harms of this practice are, what's the word I'm looking for? Ah, multifarious. I.e. there are a lot of them. E.g.:

1. Peer reviewed publication is the currency of academic careers. These schtickdrecks get undeserved credit for publications which pad their resumes, increase their chances for advancement ahead of more deserving colleagues, and increase their chances of getting grant awards, other publications and invitations to speak at conferences, etc. -- all fraudulently obtained;
2. The publications themselves gain false credibility which may persuade doctors to prescribe in ways which harm patients or deprive them of better alternatives;
3. The publications displace more deserving material from the journal;
4. The publications have a false credibility should their be litigation concerning the products in question, thereby distorting the outcomes of legal proceedings.

Physicians and other investigators who participate in this practice are obviously contemptible. Not only do they gain undeserved benefits for themselves, they harm patients and ultimately may be responsible for killing people. Yes. They ought to lose their jobs, be permanently debarred from federal funding, and from academic publication. But the actual response of universities, journals, and funders is . . .
Nothing! Stern and Lemmens discuss the reasons for this but it basically comes down to not wanting to rock the boat and mess with the powerful, highly paid bigfooted scum who do this.

So they have a solution, and believe me, it's long past due: sue them for fraud. They have perpetrated a fraud upon the journals, first of all, which generally require putative authors to sign a form saying they made "substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data," and "drafting the article or revising it critically for important intellectual content." Ghostwriters are lying when they sign this form. Second, they have perpetrated a fraud upon the readers of the journal. Third, if the article ever is introduced in litigation, they have perpetrated a fraud upon the court.

The drug companies could also be sued, and even prosecuted criminally under the RICO statute.

I say let's do it. If anybody needs a volunteer to join a class action, you know where to find me.

A bit of good news from the land of the bowler and the bumbershoot

The Brits have a couple of things going for them that we don't, one of which is the socialistcommunofascist National Health Service -- you know, that evil institution that deprives them of their God-given right to overpriced, overaggressive, ineffective medical care and thereby makes them all slaves. Oh yeah, death panels too. And thank God Steven Hawking doesn't live there.

Anyhow, despite all those downsides, it does mean that they can establish and enforce policies throughout all of their hospitals. And they're beating MRSA! I think it's been a little while since I wrote about this, so in case anyone doesn't know, that's Methycillin Resistant Staphylococcus Aurea. Staph is a ubiquitous bacterium and most of us have it on our skin and nasal passages, but it can cause infections in wounds, or otherwise attack people with weakened immune systems.

This used to kill people all the time, but then they discovered penicillin. For your entire life (unless you're in your 70s or older), these sorts of common infections have not been a problem. A course of pills, or a shot in the ass in severe situations, and you're good to go. But then this antibiotic resistant strain emerged, mostly found in hospitals but in the U.S. in particular increasingly in the community. It's thought that the community acquired infections can mostly be traced back to origins of the resistant bugs in hospitals, although that's not entirely clear. Anyway, once again people are dying or suffering severe tissue damage from staph infections that are very hard to kill. Many people are quite alarmed by where this might end up.

The first thing to do is not to overuse antibiotics, but in hospitals there's no avoiding them. By definition hospitals are full of sick and debilitated people, most of whom have extra holes in them with tubes going into the holes, also tubes going into the usual holes which can also carry infection, and you just have to soak them with antibiotics. But you can also use very strict infection control methods to make sure you kill as many bugs as possible that might be trying to hide out in the cracks and crevices of the tile and the machinery and the linen and on the hands of the workers and everywhere else you can think of.

The Brits have been doing that and now they've driven down the incidence rate by 80% from its peak in mid decade. Twenty five hospital trusts have had no cases at all for a year. Our fragmented system means we don't have the kind of monitoring that would even tell us how we're doing with such specificity and completeness, but I can guarantee we aren't doing nearly that well.

So chalk up another point for socialism.

You're probably sick of this topic by now . . .

Screening mammography, that is. (Yep, let's get back on topic here.) It's a tough subject because a lot of women are convinced that screening saved their lives. They got screened, it found a lesion diagnosed as cancer, they had surgery and possibly chemotherapy and radiation, and now they're alive and they don't have cancer. QED.

But, as I have explained here many times, it ain't necessarily so. Most of the lesions found by screening are small and non-invasive and nobody knows which of them might go on to cause a problem in the future. Many of them, we now understand, simply disappear on their own. In addition to overtreatment of what would have been harmless lesions (not necessarily correctly called cancer in all or even most cases, although that term is normally used), screening results in false positives resulting in further investigation, expense, and anxiety, and just costs time and money to begin with.

The conventional wisdom in the U.S. is that, on balance, it's worth it and does save lives. But how much worth it, and for whom, and how often, has been controversial -- a controversy that has gotten inappropriately nasty. Let me point out that the American Cancer Society and the various physician and surgeon groups that weigh in on this all have a vested interest in finding and treating more tumors. (The ACS gets big-time funding from drug companies.)

So, for what it's worth, the differential timing of wide-scale implementation of mammographic screening in various European countries created a natural experiment, which these investigators have now analyzed. It turns out that there is no apparent relationship whatsoever, at the population level, between general screening mammography and the death rate from breast cancer.

I mean none. Zip, zilch, nada. Death rates from breast cancer have steadily declined in Europe and the U.S. for some 40 years, but the introduction of screening mammography had no evident effect in the countries in this study. By the way, similar comparisons have shown cervical cancer screening to be highly beneficial, so this kind of study can indeed have a different outcome. But, in the case of mammography, it is what it is.

As always, I'm not a real doctor, and I'm certainly not your doctor, and you should do what you think is best. But the evidence for recommending mass screening of women by mammography continues to be highly conflicting at best and there is certainly, in my view, no compelling case for it. More selective use of mammograms, among women at elevated risk, would seem to be the policy with better support, although these studies appear to call even that strategy into question. Hmm. (Note how little attention this study received in the U.S. Whatever the truth may be about this matter, we don't want to be confused with the facts.)

Obama Sucks Department

One of the numerous inexplicable phenomena of American politics is the unkillable (think ailanthus) movement among the punditocracy and free range political consultants for a "non-partisan" "radical centrist" "third way" "no labels" Platonic wonkocracy which would forever transcend and doom to futile shouting in dark corners the believing rabble who pollute our discourse with commitment and ideals.

What's particularly odd is that they don't seem to have noticed that the president of the United States is already their messiah. Barack Obama's mission in life is to be David Broder's wet dream. The Republicans, obviously, know this, so they squeeze him for every last drop, which he is all too happy to surrender.

Update: I swear I came across this after I had written this post.

Only now, as the phony controversy appears to be resolved with a typical Obama compromise of utter, abject capitulation, do the corporate media feel they have license to tell the truth about the situation. Yep, only now does the Associated Press get around to explaining a little bit about what cuts in domestic discretionary spending actually mean, focusing on federal payments to states and cities. You know, all that socialistic "Head Start school readiness program, Meals on Wheels and worker training initiatives to funding for transit agencies and education grants that serve disabled children." In the Great Recession the states are already struggling horrifically, and now:

"We have the potential for disaster should there be a major realignment in federal funding that results in a cost shift to states," said Nevada state Sen. Sheila Leslie, a Democrat from Reno who recently discussed the issue with Obama administration officials in Washington. "In short, we are teetering on the edge right now, and a cost shift could send us over the cliff." . . .

Among the programs that could be affected is a service that delivers meals to the home-bound elderly. Connecticut received about $4.5 million from the federal government for the program this year and $1.8 million from the state. Marie Allen, executive director of the Southwestern Connecticut Agency on Aging, said the program is a staple for many senior citizens on tight budgets. The federal aid ultimately saves taxpayers money because it helps keep people out of costly nursing homes, she said.

"If we don't have the support for them in the community, people end up in nursing facilities because they don't have proper nutrition," Allen said. "These are the real reasons why we spend more money on skilled nursing care."

Oh, so that's what this has been all about? They could have mentioned it a couple of months ago. The New York Times could have mentioned this as well. (Okay, Paul Krugman did on the op-ed page, thereby revealing himself to be shrill and non-serious, but I'm talking about you know, a news story):

Last week brought the disconcerting news that the economy grew no faster than the population during the first six months of the year, in part because of spending cuts by state and local governments. Now the federal government is cutting, too.

“Unemployment will be higher than it would have been otherwise,” Mohamed El-Erian, chief executive of the bond investment firm Pimco, said Sunday on ABC. “Growth will be lower than it would be otherwise. And inequality will be worse than it would be otherwise.” He added, “We have a very weak economy, so withdrawing more spending at this stage will make it even weaker.”

Thanks a lot Mr. President. You're a real statesman.