Map of life expectancy at birth from Global Education Project.

Saturday, April 30, 2011

The bogus science

Brad DeLong is among the economists reflecting on the failures of his profession in the wake of the financial crisis. But I don't think he goes far enough. The problem in economics is not just a failure to re-read Walter Bagehot. It's a failure to connect to reality, on any level, methodologically or even epistemologically.

I have long watched with a little bit of amusement and a lot of annoyance as economists have claimed to be the most scientific and rigorous of the social scientists, if not the only "real" scientists of society. That's supposedly why they make higher salaries than professors in other disciplines and give each other a phony Nobel prize every year so they can pose next to the physicists and biomedical researchers.

In fact, economics is more akin to theology than it is to science. I had to pass qualifying exams in economics for my Ph.D., so I have actually taken quite a lot economics courses. Here's how economists work -- for real, this is not a cartoon.

First, they present a number of assumptions, every one of which is false. They then spin an elaborate theory, complete with calculus, from these assumptions. Along the way they forget that the assumptions are false and start to believe their theory is describing reality. When they run up against an undeniable instance in which the theory conflicts with reality, they label that an exceptional "market failure" and, like Ptolemaic astronomers, add an epicycle to their theory account for the supposed "exception" while preserving the central theory. But in fact, the theory fails in every single instance, all the time, without exception. "Market failures" are pervasive and inevitable, because the theory is completely wrong. Therefore they must ignore most of reality and only allow occasional bits and pieces of it to intrude.

Why the success of this peculiar cult? Because the theory provides a justification for wealth and privilege. It is indispensable as a foundation of libertarianism and economic conservatism. It comforts the comfortable. That is the only reason.

Economics is a vast edifice of bullshit erected on a foundation of sand.

Friday, April 29, 2011

Feeling redundant

Just when you thought American politics couldn't sink any lower, we find ourselves plumbing new depths of national depravity. This has set off an explosion of musings about why people cling to wrong and crazy beliefs and the fecklessness of evidence; to a competition find ever more eloquent insults to hurl at Donald Trump, and to jeremaiads of all varieties.

I, of course, have done all of that here, and I'm sure I'll keep doing it. But it's getting to the point where a lot of us, I fear, are catching the futility bug. If there is no power in truth, then I'd be better off being, well, a carnival barker than a doctor of philosophy. The TNR editorial succumbs to magical thinking when they say what we all should do is root for Republican elites to start speaking responsibly. Okay, fine, I'll root for that but I have to say I was disappointed a few days back when the Easter Bunny didn't show up and I have no higher expectations this time.

There might, just might be some signs of the corporate media patriciate getting a tiny twinge of conscience but I don't really expect it to last. Bazz fazz.

Update: Indeed, I spoke too soon.

Thursday, April 28, 2011

Am I missing something here?

Lizette Alvarez, in the NY Times, makes a big deal out of a proposal in Florida to move most Medicaid recipients into managed care. This is presented as an "experiment" in which "Florida lawmakers are poised to scrap the traditional model in which the state pays doctors for each service they perform."

Uh, Liz. Right now, today, as John Iglehart reports in NEJM, nationally, "fee-for-service payments to physicians make up only a minuscule portion (3.1%) of total Medicaid spending, since states, seeking savings, have increasingly contracted with managed-care plans." Florida is way behind the curve on this. As Iglehart further informs, "A key feature of budget-cutting exercises in virtually all states where managed-care plans operate is an increasing reliance on those plans to enroll Medicaid beneficiaries. In 2009, 25 states had more than 50% of their beneficiaries enrolled in such plans, but they were mostly mothers and children — Medicaid’s least expensive patients. A new trend in some states is to make enrollment in managed-care plans mandatory for elderly, blind, and disabled Medicaid beneficiaries."

Now, I don't actually have a problem with managed care for Medicaid recipients, as a generic concept. In fact, Accountable Care Organizations, which are encouraged for Medicare and private health insurance plans in the PPACA, are really a version of managed care, designed to overcome some of the problems and consumer dissatisfaction that arose during earlier attempts to implement managed care in the 1990s. I've always said that fee for service is not a good way to pay for health care, that what we need is a way of paying for results, and managed care is essentially a broad term for trying to do that.

Problems arise when you a) don't pay enough to get decent results now matter how well you manage the care; b) define "management" as denying services and do it crudely and inappropriately; c) make patients and doctors go through bureaucratic obstacles which in fact waste money (and time) and frustrate all concerned; or d) don't provide adequate protection for the most vulnerable and sickest people who are likely to come out badly if you aren't very careful and precise in how you go about this.

Right now, all the Republicans seem to care about is spending less money so they build in point a -- don't spend enough -- from the beginning and don't care what happens with b through d, which a fortiori means nothing good will happen.

Unfortunately for our political discourse, the specifics of how to avoid these pitfalls are mildly complicated. They don't involve death panels but they do involve changing the ways in which physicians practice and putting less money into narrow specialties and more into primary care, among other goring of oxes. It's so much easier just to say we're going to turn Medicaid into a block grant, pay less for it, and let the states deal with the consequences. Easier, but also profoundly evil.

Wednesday, April 27, 2011

Extinction is forever

And we generally feel bad about it. But I haven't heard anybody complain about the eradication of smallpox. Now the Carter Center says we are very close to eradicating the Guinea Worm, the parasite Dracunculus medenisis, which just 15 years ago afflicted about 3 1/2 million people in Africa and Asia. It causes severe pain and disability, and it's just about the yuckiest thing you can think of.

There's no treatment for Guinea worm infestation, but it depends on a human host to complete its life cycle. That means that it can be controlled by fairly simple physical means -- filtering and sterilizing drinking water, and making sure that the worms, when they emerge from the flesh (yep, that's what they do) are destroyed, and don't wind up back in the river where they can produce progeny. Jimmy Carter, who is a top notch ex-president, has been leading the world-wide campaign to eradicate them, and they're now very close. Last year there were fewer than 2,000 cases.

Tropical regions are inherently unhealthy because parasites and other pathogens easily thrive where there isn't any winter to kill them off. That's part of what keeps much of Africa and south Asia poor -- when sickness and disability are highly prevalent, it really holds you back. Control, and ultimately eradication of diseases such as dracunculiasis can actually give people a better chance to build more prosperous lives.

Unfortunately, malaria is a very widespread scourge which is much more challenging. But there are numerous other diseases which do not have non-human reservoirs and could be eradicated. We're also pretty close to wiping out polio, as you probably know, although the last yard is turning out to be the longest. (Technically, by the way, HIV is among them although it presents considerable difficulties because of its prolonged latency and incurability.) If we invested the money we spend on invading and bombing people, we could eliminate quite a few human diseases from the planet.

That's a great investment because once they're gone, your related expenses going forward are zero. Some people are uncomfortable with this idea, on philosophical grounds having to do with our relationship to the rest of nature. I am not -- humans have far more horrific and profound impacts on nature that we seem to accept, than the elimination of a few specific species whose only ecological niche is to exploit humans. Eliminating these diseases doesn't even cause an increase in the human population in the long run, since people ultimately have fewer children when they expect them to survive and be healthy, and when they are more prosperous.

So I say go for it.

Tuesday, April 26, 2011

Performance Art?

Your Intertubes are abuzz with speculation over what the non-self-made ostensible (though 4 times bankrupt) billionaire with the four-dimensional comb-over is really up to -- is he running for President, trying to bump up ratings for his inane "reality" show, or just amusing himself in a semi-psychotic way?

Who the hell knows and who really cares? But he has certainly eliminated all doubt about the true beliefs of Republican primary voters. He shot right to the top of the polls by going all-in birther, and now he's showing us full frontal racism, which I will bet you four cans of hairspray is only going to boost his numbers. That, along with his foreign policy wisdom -- we should just "take" all the oil in Iraq as payment for freeing the country -- demonstrates conclusively what we're up against if we really want to defend representative government. The people who say they will vote for this evil idiot do actually get to vote.

Andrew Sullivan, who vacillates between good sense and insanity like a Lorenz attractor, thinks this is all very bad because it will further legitimize insanity and lies as instruments of politics. "My fear is the following: that by merely trumpeting these claims and stirring these fears, Trump gets more and more media platforms to promote them. And they slowly penetrate the culture, delegitimizing the president even more deeply among the Fox News base."

Fortunately, what Sullivan fears is impossible: there is no place deeper than the bottommost pit of lowermost sewer, and that would be Fox News. Trump is just painting a clown face on the devil, and thereby, I hope and believe, sapping his power. We shall see.

Guest Post

This is something I haven't done for a while, but I'll be happy to entertain guest posts in the future. Must be on topic, no commercial promotion, and in accord with our overall perspective and values and what not. Author Pat Walling also writes for the Medical Billing and Coding blog. As I told her I would mention, one of the major sources of waste in our current health care non-system that relies on a mess of different insurance plans is the need to spend absurd resources on billing and coding. With a single payer system, we'd do a lot less of it. But, that's the world we live in now, and somebody's got to do it. -- C

Illiterate Fistula Surgeon Brings Hope to Women

Mamitu Gashe is not an ordinary surgeon, at least not in the way most people think of a surgeon. She did not grow up with medical aspirations, but instead assumed the profession as a way to help women deal with a problem she once faced herself. Mamitu's journey started in a remote Ethiopian village when she was 15 years old. She married a local man, became pregnant and eventually lost the baby. Soon after, she discovered body fluids leaking from her vagina.

What Mamitu had was a condition known as an obstetric fistula. A fistula in general refers to any abnormal passageway or connection between vessels or organs in the body that do not normally connect. Fistulas may occur in the lungs, stomach, nose and other parts of the anatomy. Obstetric fistulas specifically refer to damage in tissues of the vagina that cause leaks from the bladder or bowels. This particular condition was a common occurrence in the United States in the 1800s, but improved medical treatments and procedures have made the condition almost non-existent in industrialized nations. Most of the cases today occur in underdeveloped nations, mostly located in Africa.

The young women who suffer from fistula in impoverished parts of the world often lead a lonely life in solitude until they die. They are forbidden from being near community drinking water for fear of contamination. Some of these women commit suicide due to their life of isolation and shame. Mamitu, who was illiterate at the time she was suffering from the condition, found relief thanks to a pair of Australian doctors. Australian obstetrician Catherine Hamlin and her late husband, Dr. Reginald Hamlin, started Addis Ababa Fistula Hospital, located in Ethiopia, in 1974. The couple originally planned on staying in the area for only a few years, but ended up dedicating their lives to helping women in this part of the world receive treatment for a condition that dramatically reduces their quality of life.

In order to make the trip that changed her life, Mamitu spent seven years begging for change at a local bus station to save up the money for the trip to Addis Ababa Fistula Hospital. Dr. Hamlin performed the surgery on Mamitu free of charge. Afterwards, Mamitu ended up working at the hospital changing beds. Eventually Dr. Reg Hamlin became confident enough in her abilities to ask Mamitu to help with removing the stitches of other patients. From then on Mamitu became more involved in the process of repairing fistulas. After observing the surgeries for a few years, Mamitu went to school and eventually became a surgeon and began performing the surgeries herself.

Mamitu is now considered an expert in obstetric fistula surgery. She continues to work side by side with Dr. Hamlin at Addis Ababa Fistula Hospital (nicknamed "puddle city" because of the condition treated there) to provide hope for women who once had no real alternative, except to live a life in isolation while quietly suffering from an embarrassing medical condition. In addition, she provides instruction to other surgeons who travel from around the world to learn the basics of this type of surgery. Mamitu has never forgotten how Dr. Hamlin, now 83, and her husband helped her achieve a productive, healthy life. Addis Ababa Fistula Hospital performs the reconstructive surgery on African girls free of charge. The surgery itself normally costs $300, but many who need it simply cannot afford it or have no way to get to a facility where the operation is preformed. As result, the hospital has helped an estimated 25,000 young women live a better life in the years since it started operations.

In order to help make obstetric fistulas a thing of the past, The United Nations is seeking $750 million to treat up to 3.5 million women who suffer from obstetric fistulas by 2015. Following a successful surgery, many of these women can be integrated back into their communities. Additionally, Mamitu (along with several others) is seeking increased funding to combat the condition. The funding would go to education efforts, as well as providing the surgery to those in need. Treatments for an obstetric fistula will vary based on the cause and extent of the condition, but typically include a combination of surgery and antibiotics. In cases involving younger patients, surgery is sometimes delayed with medications until a certain age is reached. However, it is estimated that upwards of 300,000 lives could be saved with education and medical efforts.

Mamitu has devoted her life to helping others receive treatment for this treatable condition. Her efforts today are focused on raising awareness and funds to help those in need lead a better life. Similarly, Dr. Hamlin appeared on Oprah in 2004 to tell the story of Mamitu and the hospital she operates in Ethiopia. While the appearance did help to raise awareness and bring in additional revenue, there is still much work that needs to be done. Efforts by Hamlin and others will continue until obstetric fistula is a thing of the past worldwide. The Fistula Foundation supports efforts at Addis Ababa Fistula Hospital, and has raised over $3 million to help keep the hospital in operation.

Dr. Hamlin and her colleagues in the field are often frustrated by the fact that a curable condition such as an obstetric fistula remains a big problem in certain parts of the world. The United Nations is assisting with efforts to raise funds to hopefully bring an end to the condition. According to the U.N., about two million women and girls may suffer from the condition. However, success stories like Mamitu’s, are providing inspiration to women around the world. "No woman should have to suffer what I suffered," Mamitu told reporters at a recent luncheon. Mamitu does not normally seek the spotlight, but she hopes that by telling her story other women with the same condition will get the help they need to lead full, healthy lives.

Friday, April 22, 2011

Ineluctable insanity?

Ed Kilgore thinks that even though the Republican establishment will no doubt dispose of risible malignant clown Donal Trump in due course, the hunger of Republican primary voters for a candidate worthy of their delusions is such that they will ultimately get one. Or I think that's what he's saying.

Wacko conspiracy theorists are certainly nothing new in the U.S.A. Joe McCarthy and the John Birch Society were right in the middle of things. Some commentators, such as Andrew Sullivan, who himself vacillates between reasonable Toryism and more than a touch of wackiness, sees equivalence between the current psychosis of the right and academic post-modernism of the late 20th Century, which claimed some vague leftishism.

I really don't see that. The PoMos were never politically influential or even relevant. They were college professors in vague disciplines like "cultural studies" and eclectic departments such as sociology and literature who spent all their time talking to each other in a language even they probably didn't understand. They had no definable political project, but only an amorphous aspiration that undermining the "hegemony" of rational empiricism would somehow be "liberatory" for somebody. About their only impact outside of the academy was to encourage quack medicine and New Age hucksterism.

What we're seeing today is quite different. It's obviously a substantial movement out there among real people, with a majority of Republicans telling pollsters they do not believe the president was born in the United States and large numbers of actual crazy people actually elected to the United States congress. And they have definite, concrete beliefs, such as Dearborn, Michigan, is under Sharia law; the socialist president is plotting a government takeover of Medicare; the best way to solve the unemployment crisis is to stop collecting income taxes from billionaires; and the earth is 6,000 years old. I really don't see any parallel in the history of the left or liberalism in this country.

What I do see, however, is not in fact a spontaneous epidemic of nuttiness. All of this crap was deliberately ginned up by political operatives in order to bamboozle people into voting against their own interests. It's just gotten a bit out of control, and now Donald Trump is the bamboozlers' Frankenstein monster. As ye sow . . .

Thursday, April 21, 2011

Now this is interesting

Via PZ, it turns out that there's a passage in the Book of Matthew that for some reason doesn't get read on Easter Sunday:

50 And when Jesus had cried out again in a loud voice, he gave up his spirit.

51 At that moment the curtain of the temple was torn in two from top to bottom. The earth shook, the rocks split 52 and the tombs broke open. The bodies of many holy people who had died were raised to life. 53 They came out of the tombs after Jesus’ resurrection and[e] went into the holy city and appeared to many people.

The fact is that the most devout Christians simply have not read the Bible and do not know what is in it. If you want to keep the faith, you can't just sit down and read the whole damn Bible because you will very quickly discover that it is full of nonsense, self-contradiction, exhortation to evil and injustice, and that God is one nasty, repulsive son of a bitch.

If the preachers weren't embarrassed by the idea that not only Jesus, but a whole lot of other folks, were resurrected, they'd at least mention it once in a while. But even though it's still in the Bible, it's completely censored from the Easter story and is carefully skipped over in church. Next time you get a chance, you might ask your own guy in a dress about this.

Wednesday, April 20, 2011

Opposite World

This isn't really an original observation but it's worth reminding ourselves periodically that the essential nature of conservative political rhetoric in the United States is inversion of the truth.

A key to the Republican electoral success in 2010 was a massive campaign of TV advertising claiming that Democrats wanted to drastically cut Medicare and deny life saving procedures to old and sick people. Now that their claim to be the protectors of Medicare has gained them control of the House, they propose to do away with Medicare altogether. They don't even want to bother with the death panels, they just want to let poor old people die on the sidewalk in front of the hospital.

Ed Brayton quotes from Glenn Greenwald's new book (no more direct link is yet available it seems). Conservatives crave strong, masculine leaders, so they pretend that their draft dodging chicken hawk politicians are actually macho war heroes -- viz. the draft evading George W. Bush landing on an aircraft carrier with a sock stuffed in his crotch -- while deriding actual war heroes like Max Cleland and John Kerry as weak and effeminate.

Conservatives seized on public outrage about the taxpayer bailout of Wall Street grifters (signed into law by George W. Bush, as we are expected to forget) as additional leverage to win the House, and of course the first thing they did was to block meaningful reform of financial regulations and make sure that the Wall Street grifters had nothing to fear from Congress.

They claim to be champions of liberty and small government, and of course they are the ones who want to regulate our sex lives and force their religion on everybody else. They seize on the resentments and anxieties of the imperiled working class to insist that rich people shouldn't pay taxes, and that future economic security depends on taking away the very government benefits and services that give them a chance for a decent old age and an education for their children. They claim that Christian values demand that we not guarantee health care for everybody -- that Jesus wants you to be on your own.

What I don't really understand is why this standard procedure of proclaiming the precise opposite of the truth is so consistently successful. Of course the corporate media enables it by declining to assess truth claims, but are people really that stupid? Well, I suppose they must be.

Tuesday, April 19, 2011

That'd be the butt, Bob . . .

As a classic example of answering the wrong question. (Go here if you don't know what it means, or don't bother if you'd rather not know.)

It hardly seems worth my while to discuss the unanimous vote of the Republicans in the House to do away with Medicare. If you're reading this blog you probably know what I'm likely to say, right? And there are others with much more visible platforms from which to say it. But I do perhaps have a tweak or two to offer.

First, here's James Fallows, making the point that without Medicare, many old people would face ruinous health care costs that would wipe out their estates. That's true, although the implied universality isn't quite right. Some people are lucky enough to die suddenly, without a costly terminal illness. But there's certainly no justice in that random selection.

However, the fact is that this already happens to a lot of people. Medicare does not pay for long-term care -- past six months in a nursing home, people have to spend down their estates and become impoverished, then Medicaid takes over. If you happen not to need long term care, but do need expensive medical care that Medicare does cover, then essentially the taxpayers are chipping in to protect your estate for your heirs. If it just so happens that you develop a long-term terminal illness -- dementia being the archetypal example -- your heirs don't get that benefit.

That doesn't seem particularly just either. To me, what this really invites us to think about is the basic problem of people entitlement to inherit their parents' left-over retirement savings.

The real reason to keep Medicare is not the protection of heirs, as Fallows suggests, but because it is the most cost-effective and just way to provide health care to the elderly that we currently have, and because it could be made even more cost effective and just with some policy changes -- including precisely the policy changes that Republicans decry as "death panels." They don't even want to bother with the death panels, obviously, they just want to let poor people die.

However, Fallows seems to be basing his argument on your right to inherit. That seems to be the wrong question.

Monday, April 18, 2011

But they're junkies, they deserve to die

Those wacky Canadians are at it again, providing injection drug users with a safe place to inject under medical supervision. Whaddya know, overdose deaths in the area went down by 35%, with no ODs occurring in the facility. Also, clean needles, no HIV and Hepatitis C transmission, no needles left on the street, opportunities to offer people substance abuse treatment and other services, and for staff to observe any urgent problems . . .

Sounds great, but the federal government of Canada is against it -- it's operating under British Columbia license. And you can just imagine trying to do this in the U.S. Drug addiction is a moral issue, after all, and this is just coddling people who engage in immoral behavior. Drug addiction is nothing that a year or two in the jug won't cure, right?

Sunday, April 17, 2011


I hope I am paraphrasing Stephen Pinker correctly. In How the Mind Works, he proposes that the great conundrums of the nature and origin of consciousness, free will and moral responsibility, and the infinitely recursive problem of how we know anything might have solutions. . . . But, the solutions are forever inaccessible to humans because our brains have not evolved to comprehend the answers.

It's just good luck that brains that evolved to solve the problems of existence and reproduction on the African savanna, in the particular way ours did, are also equipped to undertake scientific inquiry, including studying human brains. The mechanistic problems of the neural processes that produce sensation and behavior are solvable by us, at least in principle. (Although they are enormously complex and we might not have the time and resources to get anything like a complete picture.) But why consciousness emerges -- why, for example, we experience pain instead of merely having a behavioral aversion to painful stimuli -- is not one our brains are equipped to solve.

As for the epistemological problem, we know the way we know because that's how we came to be. Whether our picture of the world is valid or accurate according to some other way of knowing, well, it's a silly question. If you are really just a brain floating in a vat and all your life is an illusion, so be it. Who cares? Certainly not you.

Religion survives in part because many people aren't satisfied with these dead ends and it feels as though religion supplies answers. Of course it doesn't. If God gave us consciousness, free will, and apprehension of the world, where did God come from and why and how did he do it? There's no answer there either, only censorship of thought.

As for me, I'll keep pondering the deep questions. You never know. I might think of something.

Thursday, April 14, 2011

Some of my best friends are doctors . . .

But honestly, what is wrong with these people? These folks tried an intervention to improve infection control in ICUs. It didn't work, but it's not necessarily because it wasn't a good idea -- it's because the providers didn't follow the protocol.

In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts.

Now come on. Almost one third of the time they didn't even wash their hands after contact with a person who was believed to harbor antibiotic resistant bacteria! Yank their damn licenses. I don't know what else to do at this point. WTF?

Wednesday, April 13, 2011

For the first time ever, MoDo is not a waste of time

She took a day off from mocking Democratic politicians for being effeminate to tell you to speak up when you don't think doctors are being conscientious about infection control. Which, outrageously, they often are not.

Not only that, she diagnoses the real problem, which is the cultural authority of physicians, the deference people automatically pay to them, and maybe the fear that if we offend their hypersensitive egos they won't give us first class attention. It would be a huge win if people would just speak up if they aren't happy with what a doctor says, does, or doesn't do; aren't satisfied with an answer; or don't intend to do or are not doing what the doctor has prescribed. Go ahead and have those conversations. If physicians don't like it, they'll just have to get over it. It's their chance to explain to you what you didn't understand correctly, if that was the problem; or to come up with a recommendation that is acceptable to the physician and which you are also more inclined to follow, which is obviously better than what the physician thinks is a perfect recommendation to do something you aren't going to do. Everybody, including the doctor, will be happier in the end.

And, if they're screwing up, say by not washing their hands, they need to hear about it.

While we're on the subject of infection control, kind of, DON'T USE PRODUCTS CONTAINING TRICLOSAN! Madison Avenue types market all kinds of products, from soap to socks, that contain this antibacterial agent, by claiming, falsely, that it will protect you and your family from germs. Au contraire. It creates cross-resistance with antibiotics, and doesn't disinfect any better than ordinary soap. And -- according to a column in today's JAMA (off limits to the rabble, as usual), exposure to triclosan can actually be harmful to the immune system. Children exposed to high levels are apparently more likely to develop allergies and asthma. It also alters hormone regulation and may be a carcinogen. So don't use it! Ever!

Update: As commenters noted, the verdict in the case of Kristen LaBrie, who did not give her son prescribed chemotherapy, was guilty. First, it astonishes me that they could get 12 people to agree to this. She must have had really lousy representation. And I'm with my readers: the blame here is on a health care system that failed her and her son. The prosecutors have chosen to attack a victim. That's legal malpractice and a serious abuse of office, in my view.

Tuesday, April 12, 2011

Malicious Prosecution

I am just aghast at the actions of the Essex County, Massachusetts District Attorney who is prosecuting a mother for attempted murder because she failed to administer chemotherapy to her young son, who later died of lymphoma.

That probably sounds pretty awful but here are the facts. She was single, trying to cope by herself with the demanding caregiving regimen for a severely sick child. She observed that the chemotherapy made him much sicker, and she was afraid it would kill him. So she stopped it. She had no support, the doctors weren't communicating with her, she believed he was rid of the cancer, she had nobody to talk to or advise her, so she made a wrong decision. That's all. It's tragic but exactly who is to blame here?

Recently I've been educating myself about pediatric lymphatic cancers. Children who fail chemotherapy are given hematopoeitic stem cell transplants (HSCT) as a last resort therapy. (These are popularly called bone marrow transplants but that is imprecise. It is the stem cells that produce blood cells, not the marrow per se, that is infused.) First they destroy the child's stem cells, then they replace them with donor cells. This means the child's immune system is completely destroyed; it takes up to two years for it to fully reconstitute as the various types of white blood cells start to be produced one by one.

Meanwhile the child has to take a complex medication regimen, including, ironically, immunosuppressives to prevent the donor cells from attacking the child's own body (which is called graft versus host disease). Because the child is highly vulnerable to infection during this time, families have to take extraordinary precautions -- meticulous hygiene, excluding visitors with contagious diseases, limited contact with pets, no houseplants, no playing outdoors, no crowds -- which means no school, no birthday parties, no restaurants or baseball games or parades. The child faces strict dietary restrictions. Caregivers must be alert to any signs of infectious disease and contact doctors if they see any.

Now just imagine -- you've been trying to nurture and comfort this child who has been horribly ill, tortured with chemotherapy and all sorts of painful and terrifying procedures in a strange city (only a few hospitals in the country do these procedures) and a weird alien environment. You yourself have been desperately afraid of losing the child. Now you have to transform yourself into a drill sergeant, and deny the person you love most in the world most of what children desire. Grandma and Aunt Tilly may well have different ideas about what is best for the child. The siblings feel neglected and also deprived in many ways. The doctors are 500 miles away and you have no support.

I expect that something has to give. Complete adherence to these demands is just impossible. I don't know that people are likely to completely understand and remember all the rules anyway, but regardless, they will have to make decisions about what is most important and where they can make an exception or relax one of the rules. Maybe they decide that a certain medication isn't really necessary, or it's okay to go to the sleepover, or to Grandma's house. Whatever.

There is a very high rate of complications and sometimes the kids end up dying of the common cold. But you don't prosecute the mother.

Monday, April 11, 2011

A new bookmark

It's a busy day for me, so let me just turn you on to a good on-line magazine, Miller-McCune. I'm surprised I haven't heard about it sooner, and that it doesn't get more attention. In particular, if the Huffington Post health coverage makes you sick, the way it does me -- Ariana just loves her some of that voodoo -- their health and health care section is totally reality based and written for people who can think critically.

I particularly draw your attention to the work of Michael Scott Moore on drug control policy, and also here.

Check it out!

Friday, April 08, 2011

Trick Question

Quick, what country exports the largest amount of oil to the U.S.? (Hint: Most of them speak a version of English.) Yep, watch out for flying hockey pucks, it's Canada. But as my old friend Ellen Cantarow tells us, that stuff isn't exactly oil after all, it's bitumen, a corrosive, sticky, nasty substance obtained from the so-called tar sands. We're already importing almost a million barrels a day of this dreck, and the projection is more like 3.5 million barrels by 2025.

It has to be diluted with natural gas and pumped through pipelines at high pressure. It corrodes the pipelines and there have been spills -- including a big ugly one near Kalamazoo. They're building more pipelines to haul more of it. And it is very carbon inefficient -- with the energy needed for extraction and refining, about 50% more C02 winds up in the atmosphere than we get from using petroleum.

Wait there's more! Who is the biggest corporate player in this depravity? Koch Industries, which according to Ellen, handles 25% of imports to the U.S. and is one of the biggest U.S. refiners. Sweet!

Thursday, April 07, 2011

I'm not going to talk about politics,

I'm not going to talk about politics, I'm not going to talk about politics. ...

Plenty of people are on the case, and anyway it's just gone beyond comment. Are we really talking seriously about repealing Medicare and Medicaid?

So, I'll bet you didn't know that today is World Health Day. Okay, that's kind of a made up thing, like National Pickle Week, but the WHO does it every year and this year, they've got an important theme, which is preserving the effectiveness of antibiotics.

You've probably heard about MRSA -- staphylococcus that is resistant to penicillin-like drugs. That problem concerns the so-called gram positive bacteria (named for a guy who invented a way of staining bacteria for viewing under a microscope). But there's another resistance problem affecting the gram-negative bacteria, called Klebsiella pneumoniae carbapenemases (KPC), which are enzymes produced by enterobacteria that confer resistance to all the beta lactam antibiotics, including penicillin-like drugs. This is a huge worry because gram negative bacteria exchange genes very readily, and because these organisms are often resistant to other antibiotics as well. Basically, we may soon be seeing a whole lot of untreatable infections.

WHO Director Margaret Chan isn't pulling any punches:

In the absence of urgent corrective and protective actions, the world is heading towards a post-antibiotic era, in which many common infections will no longer have a cure and, once again, kill unabated. The implications go beyond a resurgence of deadly infections to threaten many other life-saving and life-prolonging interventions, like cancer treatments, sophisticated surgical operations, and organ transplantations. With hospitals now the hotbeds for highly-resistant pathogens, such procedures become hazardous.

The actions we can, and must take are actually not all that hard, but they are urgent. Number one, most important, easiest to do in reality and apparently hardest to do politically, is top feeding antibiotics to livestock! Just outlaw it. Boom. Done. Of course this means that livestock will have to be raised more humanely, under less crowded and more hygienic conditions. It will take away our God-given right to fatten cattle and pigs while they wallow in their own feces, making the country a totalitarian dungeon. So be it.

Second, physicians must stop prescribing antibiotics inappropriately. This apparently will require some sort of intervention by payers, because they seem incapable of doing it on their own.

Third, everybody must get the message: don't ask for antibiotics, let your doctor decide if you really need them. If you do really need them, and you do start taking them, finish the entire course even though you already feel better. That is your duty to humanity.

Fourth, we need to improve infection control measures in hospitals and other health care settings. Equipment and facilities need to be designed so they are more readily cleanable. Microbes can obviously hide in every crack and crevice, so there mustn't be any. We have to get cleaner, make fewer holes in people, and enforce stricter policies on hospital visitation. Sorry.

Fifth, we can adopt better hygiene habits in our own lives. Keep washing those hands. But don't use those antibacterial cleaning products, the bugs just get resistant to them. Keep a clean house. Bleach and alcohol do disinfect and can't produce resistance, but they usually aren't really necessary.

Stay home if you're sick.

Do your part.

Wednesday, April 06, 2011

Well said, Dr. Ludwig!

JAMA truly annoys me by keeping the stuff behind the subscription wall that the general public really ought to read. (NEJM has heard my exhortations and fixed its policy.) I wish I could give you my password but I would be severely castigated, so here's a link to the first paragraph of David Ludwig's commentary, and I'll summarize the key points for you.

Back in the good old paleolithic, life might have been nasty, brutal and short, I don't know, but our ancestors actually ate pretty well, it seems. With the benefit of stone tools and fire, they were no longer limited to fruits and insects, but they could kill large animals, cook tubers and coarser parts of plants, and pretty much eat anything and everything. The agricultural revolution may have seemed like a good idea at the time, but it got people eating mostly grain which meant less protein and less of those great micronutrients from the other parts of plants, so people actually ate worse and got shorter. (There were other reasons for this as well -- check out Jared Diamond for a big discussion.

Comes now the Industrial Revolution and the advent of "ultraprocessed" foods. Ludwig gives the example of "Strawberry Splash Fruit Gushers," which "has only a trivial amount of strawberries (from concentrate)," but 7 kinds of sugar plus partially hydrogenated fat. Ultraprocessed foods ultimately derive almost entirely from corn, wheat and soy -- much of it processed through animals. It is high in energy density, low in fiber and micronutrients, has the wrong kind of fat, high glyemic index, and a lot of salt, sweetness and other flavorings to trick us into eating too much of it. E.g., 10 ounces of strawberries have 90 calories, 5 grams of fiber, vitamins, minerals, and all kinds of phytochemicals; 1 ounce of Strawberry Splash Fruit Gushers also has 90 calories, and basically none of that other stuff.

Eat that crap and you're likely to get fat, get diabetes, get heart disease, and die. But it's cheap, abundant, easy, heavily marketed, and addictive. So all of the above is happening to us.

I think I may have written about these issues one or two times previously, sorry if it gets old. But there are public policy responses to this disaster. One excellent start would even cut federal spending and reduce the deficit! That would be ending subsidies for corn and soybeans. Have I heard the Tea Party mention that one?

I didn't think so.

By coincidence . . .

PZ Myers posted a link to this cartoon which illustrates my post of April 1. Just thought I'd let you see that.

Tuesday, April 05, 2011

Let your congresscritters know

that you oppose cuts in the budget of the National Institutes of Health, which in case you didn't know the Republicans want to seriously trash. The Association of American Medical Colleges has made it easy, go here.

The more we know the less we do

This has got to be a trend. Last week it was prostate cancer screening, now coronary artery bypass grafts and pills for autism. Stuff we spend a lot of money on that doesn't work, that is.

Getting a "triple bypass" is almost seen as a rite of passage for older men, and of course parents want to do something for their autistic kids so they let doctors feed them pills, although there was never really any evidence for benefit. I've spent however many years on this blog primarily arguing that the biggest problem in medicine is that we do too much, and that we could go a long way toward solving a lot of problems -- including providing universal access, having more to spend on public health, and just plain being healthier -- if we could fix that. So is it harvest time for all like-minded people?

More of the necessary research and meta-analysis is being done, to be sure. But this isn't just an issue of knowledge. The affirmative evidence was never really there to support population-based prostate cancer screening, or CABG surgery, or feeding pills to kids with autism, or COX-2 inhibitors, or rosiglitazone, or ...

Instead, we did all that stuff because of the financial incentives, with a little bit of cultural proclivity thrown in. Getting more and better evidence is important, but we still need to reorganize our health care system to properly take advantage of the evidence we do have, and to avoid wasting money and doing harm.

But it's a conversation we aren't even having. Instead we're talking about repealing Medicare and replacing it with vouchers to buy private insurance. Which is insane. Our entire political discourse these days is insane, in fact. The most basic truths are no-where to be found, and nobody -- most egregiously, not the president -- is articulating them. This is a well educated society, by the way. I'll retire to Bedlam, as they say.

Friday, April 01, 2011

I told you so . . .

In a population based randomized controlled trial, "After 20 years of follow-up the rate of death from prostate cancer did not differ significantly between men in the screening group and those in the control group."

If you read my previous post, you know that "significantly" doesn't mean "significantly." The 95% confidence intervals for the screened and unscreened groups overlapped, but actually the most likely interpretation is that screening did result in a slightly lower risk of ultimately dying from prostate cancer, (although of course you'll still die of something!) "To prevent one death from cancer, 1,410 men would need to be screened and 48 treated." That means 47 men who got no benefit but who underwent surgery and/or radiation therapy and risked incontinence, erectile dysfunction, and bowel symptoms. And maybe even that single beneficiary who got a slightly longer lifespan is fictitious.

No thanks.

Here's some boring wonkery . . .

. . . to give you some relief from all the April foolishness.

Xin Sun and a cast of thousands reviewed 469 clinical trials reported in both high impact and lower impact journals. Okay, here's the wonkish part. It's actually kind of important and profound, in ways that go well beyond the current context. So I'm using this as an occasion to talk about a big issue.

It is conventional in clinical science to consider results to be valid when they have an associated "p value" of .05 or less, the jargon for which is "statistical significance." The term is misleading, in both directions. Findings with p values <.05 aren't necessarily "significant" in the sense that they actually matter; and "statistical insignificance" doesn't mean that an association doesn't exist, or is trivial, it just means you haven't established it to the satisfaction of an arbitrary convention. Most people misunderstand what a p value really means. It's usually interpreted as the probability that your result is not real, but arose just by chance. If the p value is less than .05, then you would say that there's a 95% chance your result is real. But that isn't what a p value means. It is the fallacy of the transposed conditional. The p value is actually the probability of getting your results given the hypothesis, in this case the null hypothesis that there is no real association. But, obviously if you make a lot of comparisons you'll see a lot of low p values that are spurious. The true probability that the drug is effective depends not only on the results of your study, but on the probability that the drug is effective based on what you knew before you did the study. If it is extremely unlikely -- say because there is no biological plausibility -- then a p value <.05 doesn't make it likely after all. It's probably just a coincidence. That's why, in order for p values to make sense, they have to be used to test plausible hypotheses that are specified before you undertake your trial. You always have a lot of information about clinical trial subjects, so even if the results of the trial are negative overall, you can comb through your data and look for "significant" results for some group that you didn't define ahead of time - say, women, or people of a certain age range, or people with a particular severity of disease, whatever you like. Chances are, you'll find some. And guess what -- people publish results of that kind. But they're basically BS. They might constitute hypotheses worth testing, but they aren't findings.

What Sun and the gang found is that when trials are funded by drug manufacturers, that did not have significant results for the pre-specified primary outcomes, they are much more likely to report sub-group analyses than trials that aren't funded by the manufacturer. What this means is that they are trying to find a way to sell their product, even though it apparently doesn't work, by inventing some specific category of person for whom they claim it does work, when in fact they don't have credible evidence for that conclusion.

Whoo. Sorry about that. Anyway, we need to do things differently. Industry funding of clinical trials must be totally isolated from the conduct and reporting of the trials, not just because of this finding but because of a vast record of deception, spin and scandals going back decades. There are probably several plausible ways to organize medical research to bring this about. We could establish a government sponsored institute to which the drug companies would transfer the funds for clinical trials. The institute would then accept competitive proposals from researchers, and award the funds to the most credible investigators, who would carry out the trial with no contact whatsoever from the interested parties.

Doesn't look exactly like the Free Market™ of conservative corporatist fantasy. But it would be a better world.