Yep, you're probably nuts

My friend Gary G. discusses the upcoming, brand new, shiny DSM-V in the NYT. I believe I may have noted here once or twice that the psychiatric diagnoses aren't real entities. If a diagnostician makes the judgment that you have two from column A and three from column B of whatever subjectively rated symptoms are on the list, you get a disease label. But whether any two people with that label have the same disease, or any disease at all, is completely unknowable.

If Gary had more space, I expect he also would also have mentioned that applying disease labels to psychological traits or states is necessary in order to get insurance companies to pay for drugs, prescribers' time, and counselors. I will also extend his remarks (I'm sure he won't mind) to say that applying a disease framework has other important consequences.

Despite the complete lack of evidence (in fact plenty of evidence to the contrary) that psychiatric diseases are caused by "chemical imbalances" that are "corrected" by psychiatric medications, many people, including the psychiatrists who prescribe them, continue to believe that they are. And the disease framework is essential scaffolding to the deep cultural proclivity to respond to distress by finding a defect in the sufferer and trying to fix it by pumping in a chemical or some similar technical intervention. Perhaps we could look for the cause of suffering outside of the sufferer, and try to fix that; or decide that sometimes, it makes sense to suffer and that some good can come from it.

But no, all problems are medical.

Oh yeah -- Elsevier

I have spewed my malice at the greedy scientific publishing company a few days ago. My wrath has its response: A petition and boycott (to whatever extent you can manage) of Elsevier. I'm totally down with it.

Once again my passion to tread the boards is awakened

Believe it or not, I majored in theater (excuse me, theahtuh) in college and did quite a bit of acting in my youth. Got sidetracked by politics and science and whatnot but I do kind of miss it -- especially since I think I've figured it out and would be much better at it.

Anyway, I've been helping a colleague who is trying to train pharmacists to use Motivational Interviewing techniques to get people to take their pills. Actually it's more complicated than that but no sense getting into it. My mission is to role play a patient who is trying to control his blood pressure by losing weight and exercising and eating right and who believes he is succeeding based on his self-monitoring of his blood pressure at home.

Again, without going into further details or objections, this experience has driven home for me how very difficult it is for health care providers, of whatever particular stripe, to resist being Daddy. They typically see their job as getting us to do what they want us to do. That's okay, it's understandable, the whole point is they are experts and they're supposed to know what's good for us, otherwise why are they paid?

But there are major problems. If they don't actually know what's going on with us, they might just be wrong about what's good for us. However, if all they do is lecture us and threaten us with death if we don't carry out their orders, we are likely not to tell them what's actually going on because a) who wants to listen to that and b) nobody likes to be pushed around. In this case, the pharmacists saw it as their job to get me to take the pills, not to control my blood pressure. And they undermined my efforts to do it the natural way by insisting that hardly anybody could succeed at that so why don't I give up and take the pills? Having me not take the pills and keep losing weight would have been a defeat.

Now, admittedly, few people do succeed long term at weight loss and other behavioral risk modifications. That's why doctors give up very quickly and prescribe diabetes, hypertension, and cholesterol-lowering medications. On the other hand, half the people don't take the pills either. But they won't have an honest discussion with the doctor about that if all they'll get is flack.

Having played this part, I totally feel that way on behalf of my character. Supposedly the subjects have been trained and they're going to call me back and try again. I'll let you know how it goes.

I've never quite wanted to go there . . .

But, it looks like we're there anyway so let's talk about it. You may have heard tell of this new paper in Psychological Science, the essential point of which is that lower IQ is associated with prejudice and conservative ideology. I've sorta kinda danced around this in discussing the prevalence of liberalism in academia and the canard about "liberal elites," but it isn't really a very good debate strategy to accuse your interlocutors of not being the brightest bulbs on the tree.

So let's cut to the chase. The association of lower cognitive ability with social conservatism, endorsement of intergroup inequality, and authoritarianism is well known. It is not by any means a new discovery. This is a fact: people with higher measured IQs and better grades in school are more likely to be liberal, tolerant of difference, and open to social change. The authors of this study cite plenty of research going back a decade or more.

What this study adds is actually fairly modest. Using large, longitudinal data sets, they found that British children with lower cognitive ability were more likely to grow up to be adults to be racists; and that this can be explained in large part by their having more endorsement of right-wing authoritarian ideology. A separate analysis of U.S. children had similar findings with regard to anti-homosexual prejudice. "In psychological terms, the relation between g [a hypothesized general intelligence] and prejudice may stem from the propensity of individuals with lower cognitive ability to endorse more right-wing conservative ideologies because such ideologies offer a psychological sense of stability and order."

Put more simply, confronting the real complexity of the world is taxing for many individuals. It is easier for them to contemplate the world in simplistic terms, while they are disturbed by diversity, disorder and change.

While I have no doubt of this, it does not seem to be a finding that can usefully be imported into political discourse. Telling people that they are stupid, or that their beliefs are a marker of limited intelligence, won't win you very many arguments. So I'm not sure what we can really do with this information.

Slow Apocalypse Now

Our political system is determined to ignore the immense dangers of global climate change, but if James Murray and David King are right, they will have a harder time ignoring peak oil, because it's already here.

As they point out, in spite of the sharp jump in petroleum prices since 2005, global production has not increased. We're stuck at 75 million barrels a day globally, and the rate of production just doesn't respond to prices. Supply is totally inelastic, which is why the price has been so volatile. And forget about the Canadian tar sands and Brazilian offshore oil and all that saving us -- they can't even make up for the ongoing depletion of existing oil fields. To meet the The US Energy Information Administration projection of a 30% increase in production by 2030, they write:

If realistic declines of 5% per year continue, we would need new fields yielding more than 64 million barrels per day — roughly equivalent to today's total production. In our view, this is very unlikely to happen.

Non-conventional oil won't make up the difference. Production of oil derived from Canada's tar sands — sometimes called the 'oil junkie's last fix' — is expected to reach just 4.7 million barrels per day by 2035.

In fact, they don't think oil production will increase at all. It will likely decline. And the current bubble in natural gas production is almost over. Those fracking fields? They only last a few years.

The consequences for our civilization are, frankly, appalling. You might feel you can take some comfort that carbon emissions probably won't meet worse case scenarios, but they will continue, and the planet will continue to warm, even as struggles over petroleum resources grow more desperate and, quite likely, more violent. The reason is that we just aren't doing anything serious about this. The economy runs on fossil fuel and it can't grow or even keep going without it.

Taxes on billionaires, regulatory uncertainty, and Kenyan Muslim socialist health care aren't what's stopping us. It's peak oil.

Vocabulary

Reporters routinely refer to Mitt Romney as a "venture capitalist" and to Bain Capital as a "venture capital firm." Neither is correct. Venture capitalists underwrite high risk new enterprises, usually with innovative technology or business models. Most of their bets don't pay off but they hope to reap spectacular payoffs from the few that do, in other words they're looking for the next Google or Amazon. Romney has never been a venture capitalist. He and his pals bought existing companies, usually old and tired ones, and made money however they could -- sometimes by chopping them up and selling off the pieces, sometimes by breaking their existing deals with workers and suppliers, sometimes by shutting down less profitable parts and buffing up the balance sheets. That's not venture capital.

A headline on the CNN web site a few days ago said that six NATO "peacekeepers" had been killed in a helicopter crash in Afghanistan. There are no NATO peacekeepers in Afghanistan. The NATO forces in Afghanistan are combatants.

The NPR newsreader yesterday morning, referring to the prosecution of ex-CIA agent John Kiriakou for leaking classified information, said that the Obama administration has cracked down particularly hard on "breaches of national security." They've cracked down hard on leaks of information, alright, but whether those constitute breaches of "national security" is a matter of opinion, at best. Kiriakou revealed information about the torture of Abu Zubaydah. Is our national security harmed because we know that?

Of course, Politifact will never label any of these statements as lies, or even half truths. They're just the ordinary perversion of discourse.

Common Sense

You may feel that all taxation is theft, and that the nanny state should not be trying to influence us to do what's good for us, and that the corporations who sell us flavored sugar water are people. Okay, fine. But let's inject some facts into the discussion and see where that leads us.

As these folks point out in Health Affairs, Americans consume on average 45 gallons of sugary beverages every year. (That's soda, sugar sweetened tea, fruit punch (with minimal fruit, of course) "sports" drinks -- which are nothing of the sort -- all of that. It's all the same. Sugar, water and flavoring.) A 20 ounce drink contains 17 teaspoons of sugar. Those 45 gallons add up to 70,000 empty calories per person. So what, you say? Women who consume just one of these per day have been found to have an 83-98% increased risk of diabetes. It's partly because it makes them fat, and it's partly because it causes a glycemic spike. Put another way: that shit is poison.

So, these people figured out, based on estimates of how price would affect demand, that putting a one penny per ounce tax on these drinks nationwide would result in a reduction in the obesity rate of 1.5%, which means 867,000 fewer obese adults. It would reduce the incidence of diabetes over 10 years by 2.6%. This is even assuming that people would make up 40% of the calories by eating or drinking other stuff. If they didn't do that, we'd save $20 billion in medical costs. That would also mean 95,000 fewer cases of heart disease, 8,000 fewer strokes, and more than $17 billion in medical expenses averted.

Now, there are all sorts of caveats and reservations and what ifs behind all this, but the basic conclusion is clear. The price of these beverages does not reflect their cost to society -- the "externalities" of the transaction. We haven't even mentioned the cost to individuals of poor health, disability, and premature death. But those medical expenses are mostly paid by Medicare, which means you are paying.

So under which situation do you have more freedom? The situation where you can still choose not to poison yourself and save the extra 20 cents on a drink, while not having to pay as much for other people's health care not to mention your own? Or the situation we have now, where corporations are aggressively marketing poison to children and nobody is doing anything about it, but you have to pay the cost?

Freedom. It doesn't mean what Ron Paul thinks it means.

False consciousness

It's not exactly a news flash that we're living in a new gilded age. As human civilization reaches ever greater heights of accumulated wealth and power, it concentrates in fewer and fewer hands. This essay in the NYT by Chrystia Freeland puts our present plight in the perspective of economic history. The technological revolution in the developed world eliminates many of the white collar and pink collar jobs that kept the middle class afloat despite de-industrialization. At the same time, the industrial revolution in the formerly poor countries, combined with the rise of global transportation and information infrastructure, has allowed many of the remaining jobs that would have been stuck here to move to those emerging economies.

While our working and professional classes have suffered from this double whammy, our politics has turned in precisely the wrong direction. Market forces have created the decline of the middle class and the grotesque inequality we now endure; yet the public has turned against the activist government it desperately needs to correct the problem. The wealthy don't care about "creating jobs," and certainly not for people in the United States. On the contrary, it is precisely their decisions over the past 30 years which are to blame.

I won't go into the whole argument here about the fiction of the Free Market, I've been there before. But assuming readers are with me on this -- that we need to tax the rich and invest the money so as to give our people, not to mention our planet, a future -- the question is why so many Americans of modest means have been convinced to vote against their own interests and to direct their rage and precisely the wrong targets.

Or I might better say, non-existent targets. Who or what are the "liberal elites"? Elites are not liberal. Mitt Romney, Newt Gingrich, and the Koch brothers are elites. They are also not liberal. But they are the very people who are screwing you.

College professors do tend to be more liberal than average -- I maintain that's because reality has a liberal bias -- and we are kind of elite in that it takes a lot of luck and effort to get one of these jobs and keep it, but believe me we a) aren't rich and b) aren't running things. All we do is blather. You can dislike my philosophy and values if you like, but I'm not causing you any problems and I certainly don't have any way of forcing you to think the way I do.

I don't know if doctors and lawyers and other professionals particularly tend to be liberal but again, they only way they get to be elites in any sense other than a bit of social status is if they become fabulously wealthy, and those examples, I'm pretty sure, are not generally liberal. (Viz. Bill Frist.)

Nevertheless, the right wing propaganda machine has managed to channel people's cultural resentments and insecurities against this mythical "establishment," and thereby insulate the real establishment from popular wrath. That Newt Gingrich, the ultimate Washington insider and wealthy grifter could become a populist champion is truly bizarre. But there you have it -- the real, shadowy establishment will spend a billion dollars this year on television advertising to drive that transparently ludicrous lie deep into the collective consciousness. They just might succeed.

The most corrupt Congress ever?

I don't know for sure, Mark Twain famously said that "It could probably be shown by facts and figures that there is no distinctly native American criminal class except Congress." But this latest attempt to sell us out to our corporate overlords particularly frosts my pumpkin because, as long-time readers know, I'm obsessed with open access publishing.

Science, especially science that is funded by the taxpayers, as most basic medical research is, belongs to all humanity. But right now, subscriptions to scientific journals cost hundreds of dollars which means that people without library privileges at universities can't read them. Universities in the poor countries can't afford them which means nobody there can read them. Even here in the U.S., academic libraries -- including the library at my institution which is one of the wealthiest universities on earth -- are being forced to prune their subscriptions. And guess what? The biggest academic publishers are for-profit corporations.

So, in 2008, NIH made it mandatory that research it financed become free to access through the National Library of Medicine 12 months after publication. Remember -- you paid for it. So comes now the Research Works Act, heavily promoted by the Association of American Publishers -- the scholarly and professional publisher's lobby -- to reverse the policy and put government funded research back behind the paywall. Elsevier, the biggest academic publisher, and the AAP have spent $6.3 million lobbying over the past three years, writes Keith Epstein in the new BMJ. (Ironically, behind the paywall -- they make their research articles open access, but not their news and commentary. Yeah, I have a beef with that.) By the way, Elsevier is highly profitable -- their profit margin, even in the recession, is 36%. And the publishers have, of course, contributed heavily to the campaigns of the Act's sponsors, Darell Issa (natch, one of the worst tools in congress) and Carolyn Maloney of New York, who really ought to know better.

You know what to do -- let your Congresscritter know that you oppose the Research Works Act. The scientific knowledge that you pay for belongs to you.

They aren't in business for their health . . .

. . . or yours, necessarily. Mike Mitka, in the new JAMA, discusses recent findings on what happens when physicians have a financial interest in medical imaging services. (I think you aren't allowed to read it because you are mere commoners, so I've linked to the extract.)

It is common for orthopedists to invest in MRI scanners and such, and it has long been observed based on insurance data (what we in the biz call "claims" data) that they tend to send more of their patients to have pictures taken of their insides when they get a piece of the action. However, the docs who do this claim that their patients just happen to be sicker or in more pain than other doctors' patients. I agree that doesn't seem highly plausible, but they say it anyway. Mitka reports on research done at Duke that finds a group of orthopedic surgeons who had an interest in MRI scanners had 86% more negative scans than a group with no such interest. Put another way, 42% of patients from the financial interest group had negative scans compared with 23% from the group without a financial interest.

A meta-analysis (pooling data from various studies) of claims data finds that physicians who do such "self-referral" do more than twice as many imaging tests as physicians who refer out to an independent radiologist, in all sorts of conditions.

I tell you all this because it is just one more way in which the mythical "free market" does not work in health care. It is what we call provider induced demand. Patients don't decide whether they need an MRI, doctors do. And if doctors are getting paid to do them, they'll do more of them, whether you really need it or not. And no, it wouldn't work to have you pay out of pocket because you have no idea whether you need an MRI or not and chances are, you wouldn't get one if you really did need it.

The solution is to make sure that doctors make these decisions untainted by financial interest, one way or the other. In other words, this just doesn't work as a market transaction. There are lots of other reasons why it doesn't but this one ought to be obvious even to Ron Paul (although I doubt that it is).

The most straightforward, best and smartest solution is universal, comprehensive, single payer national health care. That's what we need.

Here we go again

Yet another prominent, highly productive "scientist" has been caught making it all up. This time it's Dipak Das, who was director of the Cardiovascular Research Center at UCONN. His research focused on resveratrol, which you have probably heard of -- it's a compound found in red wine that has been thought to have anti-aging properties, although unfortunately it's not looking so great lately. This doesn't help, so if you have been using the whole resveratrol thing to rationalize getting schlozzed every afternoon, you'll need another excuse.

Anyhow, if you're interested (and you probably aren't), you can look at the university's investigative report here. The whole thing is (literally) 60,000 pages long but it's summarized up front. Basically, the university concludes that he was photoshopping his western blots. (That's a method for detecting specific proteins in samples.) His entire program of research was evidently fraudulent. They're stripping him of tenure and firing him. Oh yeah, they're giving up $890,000 in NIH funding. And there are more than 100 published papers which are now either shown to be fraudulent or suspect.

This and other recent cases are not starving post-docs desperately trying to compete for the few available faculty spots. You could understand that even if it's sad and bad. (Plenty of Ph.D.s are driving cabs these days.) These are very senior people with fancy titles and big time salaries, and plenty of money with which to do honest science. The moral depravity of this conduct is just astonishing. It's not just stealing money, and obstructing scientific progress. It's harming patients, maybe even killing people; and it's potentially ruining the careers of the students, fellows, post-docs and junior faculty who worked under him, not to mention the more diffuse damage to the institution and everyone connected with it. The swath of destruction is just incredible. I simply cannot believe that anything like that could happen where I work but I'm sure that's what people thought in all the places where this has happened.

So, comes now the obvious question. Why? I honestly cannot tell you. Sure, when you set out on an investigation you may have hypotheses that you cherish, that if proven true will open up a road you really want to go down. But it's nonsensical to think of a rejected hypothesis as a failure. You hear that language all the time -- the experiment "failed" -- but that's completely wrong. The experiment showed what it showed. Ruling out a hypothesis is just as much a contribution to knowledge as confirming it. Okay, that didn't work, try something else.

One problem that probably does contribute is publication bias. For reasons which are not entirely clear to me, it's usually harder to get negative results published. That never made any sense, and it is starting to change, but it's still there. Another problem is that it may be harder to get the next round of funding if you can't build directly on previous work. Proposal reviewers like it if your work so far leads logically to the proposal they are seeing now, and that may be harder to argue if you've had negative results. However, in my own work at least, I've had no problem making lemonade out of my negative results, it just takes the imagination to see their implications.

So I can only conclude that this behavior must have started way back, before the guy made it big, and it's actually been the basis of his whole career. It came to be the thing to do, in for a dime, in for a dollar. Think Bernie Madoff. Anyway, it is just enraging.

Oh yeah, I forgot to mention the damage to the reputation of science itself. With one of the two major political parties in the U.S. running against science as an institution and a philosophy of knowledge, we really can't afford that.

All the roots grow deeper when it's dry

I grew up in the Sixties -- which lasted from 1964 to 1974. To place myself more precisely, I graduated from high school in 1972, so I missed the SDS and the stolen FBI files and all that stuff at Swarthmore but still got swept up in enough momentum to spend my 20s and early 30s as a full time activist. Yeah, I was an ACORN organizer, among other $80 a week movement jobs. Poor people voting and demanding decent services in their neighborhoods and jobs and housing is not actually contrary to American values, by the way. Martin Luther King and the civil rights and poor people's movements were obviously a major inspiration for me.

In spite of the inexplicably popular presidency of Ronald Reagan, we still maintained that vision of a more just and humane future. It was just going to take a little longer than we had expected.

So looking back on the past 40 years this MLK day, what do I see? That the fundamental trajectory of the era would be plutocratic ascendancy, reactionary religious revival and resurgent militarism is astonishing, preposterous, nearly inexplicable. Here we are trying desperately to hold on to the basic social infrastructure forged over 50 years, from FDR to LBJ. Even voting rights and basic values of secularism are in retreat; and the hardest times and greatest economic inequality since the Great Depression have produced, not a mass movement for justice and equality, but an uprising of moderate income people on behalf of wealth and privilege. Our hard won scientific understanding of the biosphere and our relationship with it has been simply rejected, by political consensus, and we are destroying the very world that enables our existence to satisfy the immediate greed of the wealthiest.

The title of this post is a song by David Wilcox.

It looked so easy, we change the weather
We would turn this world ourselves, our world so small.
But slower rhythms still unheard of
Said that every blessed summer someday has to fall.

Prosperity will have its seasons
Even when it's here it's going by.
When it's gone we pretend we know the reasons,
And all the roots grow deeper when it's dry.

Sympathy for the devil

Or rather, for some minor demons who might prefer to be cherubs but they are what they are. That would be our modern class of journalists.

Yes,it seems utterly ridiculous for the purported representative of the readership at the New York Times to be asking whether reporters should bother to point it out when politicians lie. But it compels us to ask how the culture of journalism could end up in a place where that actually seems problematic to its practitioners.

They must inhabit and transmit the political culture, and the fundamental problem of our age is that we have had a breakdown of epistemological consensus. To me, it is a fact that burning fossil fuel increases the atmospheric concentration of CO2 and makes the climate warmer; it is a fact that increased federal deficit spending counteracts recessions and that the stimulus package of 2009, however inadequate, saved millions of jobs; it is a fact that Barack Obama has never "apologized for the United States" and that he has not "slashed military spending" but increased it; it is a fact that taxes have been cut, not raised, under the Obama administration; the health care reform act is not a "government takeover" of health care. And so on.

But conservatives repeatedly, relentlessly, say otherwise. Just about everything they say is objectively false (except for normative statements such as "abortion is murder," which are another category). So, if you are a reporter covering the Romney campaign, for example, every story would have the headline "Mitt Romney lies about X, Y and Z." I believe that would be objective and balanced, but half the country would see it as advocacy journalism and confirmation that the New York Times has a liberal bias. The Times doesn't want to be perceived that way, so what can they do?

Satire is obsolete

I caught this via Atrios. The New York Times "Public Editor" asks readers to weigh in on whether reporters should point out when politicians tell lies, instead of just transcribing the lies as they normally do.

Apparently he finds that an odd concept -- of course that isn't their job -- but he's been getting all this puzzling mail complaining that they don't do it, so please explain it to him.

I'll retire to Bedlam.

Where was I yesterday?

Answer: I was transferring my driver's license and motor vehicle registration from Massachusetts to Connecticut. It turns out this is approximately like getting a top security clearance. Because my passport gives my name as Cervantes, Jr., and my birth certificate lacks the "Jr." it became a federal case. I was there for 3 1/2 hours before I finally managed to avoid getting sent to Gitmo. After all that I didn't feel like doing a blog post.

Anyhow, I owe the world one so here are two essays in the new JAMA that have something to do with each other, one on patients who request interventions their physicians believe are useless or potentially harmful, the other on court involvement in disputes about end-of-life care, focusing mostly on families who refuse to pull the plug when their doctors want to (the other category being disputes between family members, a la Terry Schiavo, but that's another kettle of fish).

What both of these discussions highlight is the evolving conception of the physician's ethical obligations and the physician-patient relationship. We have experienced a major shift in cultural expectations since I first studied medical sociology some 20 years ago. On the one hand, from Talcott Parons's conception of the "sick role," in which one of the obligations of the sick person was to obey "doctor's orders," we have moved to an ideal of "patient centered" medicine in which patients make informed choices on their own behalf. (I said that's the ideal -- it isn't so much the reality. I will have a good deal to say about that down the road.)

On the other hand, while we once presumed that the physician's sole ethical responsibility was to the individual patient, given the unsustainable growth in medical spending, physicians are increasingly expected to be stewards of society's, or at least the health plan's resources. They are expected, and in some cases paid, to limit medical spending. Now, that doesn't necessarily conflict with the individual patient's interest. In fact, it's generally maintained that the obligation is to maximize both efficiency and patient welfare, and that there is no paradox because right now, much medical intervention is not justified by the balance of risk and benefit.

This is certainly true, but as these essays indicate, conflict does often arise between the ideal of appropriately limited medicine and patient autonomy. Whether they are husbanding society's resources or interpreting patients' interests according to their own calculus, physicians may conclude that beneficence conflicts with patient choice. This puts them in an uncomfortable position. Many simply acquiesce, as by prescribing antibiotics for cold symptoms or ordering imaging or other tests that patients demand, but for which no benefit is expected.

While the authors of both pieces say that physicians should take the time to have better discussions of these issues with patients and families, they don't address the reasons why this doesn't happen. There are at least two. One, they don't get paid to do it. They get paid a standard (and inadequate) amount for an office visit, whether they take extra time for a discussion or not; and they get paid to do procedures -- which is exactly the wrong incentive. Second, they don't know how to do it. Physicians are taught the biological science of medicine, but the interpersonal art gets short shrift.

We can't solve this problem just by writing about it and exhortation. We need basic change in both the organizing and financing of medicine; and the culture of medical training and practice. That's like sweeping the beach. But we must do it.

News of the (Instructively) Weird

I caught this little item from the AP today in the Paper of Record. I'd like to just paste the whole thing but in fear of the copyright police I'll just give the lede:

Disability groups in Greece expressed anger on Monday at a government decision to expand a list of state-recognized disability categories to include pedophiles, exhibitionists and kleptomaniacs.

No, it's not The Onion, this is evidently real. It seems that in Greece, pyromaniacs, compulsive gamblers, fetishists and sadomasochists are already eligible for disability. The main advocacy organization for people with disabilities is outraged because this will dilute the pool of money available for them.

I was a student of the late Irving Kenneth Zola, a founder of the sociological study of disability and of the Self Help Movement; and I consulted for and worked with the Massachusetts Coalition of People with Disabilities, among other relevant experiences. I strongly support the basic philosophy that there is much to be gained in both productivity and justice if society can adapt -- architecturally, culturally, economically -- to be more inclusive and empowering of everyone, rather than creating a physical and social environment that many people cannot navigate and that fails to value the abilities that everyone has. After all, in one way or another we are all disabled, and will grow more so -- it's a matter of degree and of kind. (For example, watching an NBA game, I know I'm disabled.)

But, as a fairly simple matter, I fail to see how pedophilia or kleptomania or pyromania are economically disabling conditions meriting a pension. Yes, if you've been convicted of a crime you will have difficulty getting a job, but that just raises the broader question of our policy toward ex-offenders. The diagnostic label seems irrelevant. All of these are behavioral proclivities, in other words, which our modern fashion is to categorize as "diseases," which is a matter of some philosophical contention but there you are.

However, if the Greek policy strikes you as bizarre, what about schizophrenia or severe bipolar disorder? These can qualify you for disability in the U.S., as could substance abuse disorders at one time (although that has been greatly restricted). That seems to make sense, to most people. And the vast majority certainly support accommodation and assistance for people who are blind, who cannot walk, who have cognitive limitations, and other more classic categories of disability. So where is the line, exactly?

I actually am not sure. This is a bit of puzzle.

Mitt Romney Endorses Obamacare!

Actually, what the headlines are actually saying is Mitt Romney Likes to Fire People! Yes, he did say that, and people are taking it totally out of context in order to completely change the meaning, but that's fun to do! And Romney himself already said it was okay when he did it to Barack Obama! And it fits with a pre-existing narrative! So it's the thing to do.

Okay. But I'm going to put his remark in context for a really radical new approach to journalism, and take a look at what he actually said and its relationship to public policy! Now I know that's strange and unethical and would ruin my career if I were a real journalist, but just for kicks. . .

What Romney actually said is that he wants to be able to choose his health insurance plan and pick another one if he doesn't like the one he already has. What a coincidence. If he waits until 2014, when the Patient Protection and Affordable Care Act takes full effect -- unless, of course, he becomes president and gets it repealed, as he has promised to do -- he'll be able to go to his state insurance exchange. There he will easily see all the health insurance plans available to him, and their various features, and pick the one he likes! Then, if he isn't happy with his experience, he'll be free to change it! That's Obamacare! He's for it!

So, what a reporter might ask him, if the reporter was interested in public policy instead of the horse race and gotchas and gaffes, is why, since he actually likes the key feature of the bill, does he want to repeal it? But that would require the reporter to know something, and be able to think one move ahead. That's unreasonable.


BTW: When a person publishes in medical journals, a person often gets strange e-mails, like this one:

I can use telepathy, you can easy find me online, my telepathic brain scan is on [URL redacted] What I find most fascinating my telepathy is nearly identical what Schizophrenics experiences or it manifest itself exact like "Schneider's first-rank symptoms". I can exchange voice, video, smell, people can read my mind, stalk on me, people can move small move muscles on my body from distance up to few kilometer and much more and all messages from me are transmitted to big number of people so I am a Mental Radio. One of the most advanced things I can do is to talk brain to brain and it is very fascinating, works 100% all the time and it is really talk direct to brain.

And it goes on. Why am I not surprised that his telepathy is nearly identical to what schizophrenics experience? Anyway, I mention this because of the anniversary of the shootings in Tucson. The perpetrator is, from all publicly available information, as deranged as it is possible for someone to be and was very clearly inhabiting an alternate universe when he did his awful deed. So my question is, why is the DoJ so intent on prosecuting him? That just seems pointless.

Does anybody remember public policy?

I am finding the TV news shows completely unwatchable because all they ever talk about is the ridiculous crap the Republican candidates for president are saying to and about each other.

And the way in which they are talking about said ridiculous crap is not to analyze why it is ridiculous (or not, if any of it happens to qualify as non-ridiculous), but rather simply to repeat it and speculate about how it will all resonate with Republican primary voters. Will Gingrich going negative on Romney backfire because people will think he isn't being nice? Will Ron Paul's failure to support bombing Iran make him seem soft? Is Romney parsing his support for the Massachusetts health care reform act and his abhorrence of the nearly identical federal act finely enough to convince people that there's no contradiction?

Which brings me to the real point of this post. Republicans know they're supposed to hate the Patient Protection and Affordable Care Act, but they don't know why they're supposed to hate it. Something to do with socialism and death panels, but exactly what it has to do with those things, no-one can say.

The stenographers recently reported that Rick Perry said he met a woman with cancer who implored him desperately that if the Affordable Care Act wasn't repealed soon, she'd be doomed. These news stories were correct -- Rick Perry did say that. And I'll even give the benefit of the doubt that the woman exists and said to Rick Perry what he says she said. However, this is not journalism, because what they did not bother to point out that there is no conceivable set of circumstances under which said woman could possibly be worse off with the Act than she would be without it. Yet there is no point in even asking what she might have been thinking and what the point was of Perry's anecdote.

If she doesn't already have insurance, and she does already have cancer, she will not be able to get insurance until 2014, when the Affordable Care Act takes effect. Then she will be able to buy affordable health insurance and she'll be taken care of! If she does have insurance, she will simply keep it, exactly as it is now. In fact, she might even be able to get a subsidy and pay less. Yet she's doomed, doomed! To what? Being forced to buy health insurance even though she'd prefer to die?

What is lacking so far is any clear explanation and defense of the Act by its chief exponent. I presume that as he shifts into re-election mode we'll hear more, but meanwhile the Democrats in congress need to be doing much more to tell people what's really in the Act and why it's not the work of Satan after all. No-one, it seems, is bothering to do that, ceding the floor to Rick Perry's deranged (imaginary?) interlocutor. Surely we can do better.

The un-winter

After a very rough year -- from last winter's relentless, roof crushing snow, through two consecutive tropical storms that left Connecticut in the 19th Century for a week and went on to destroy the road network in Vermont, to a bizarre October snowstorm that wiped out the electric grid for the second time in two months, we figured we were headed for climate apocalypse. Then came the winter of 2011-2012. Or rather, it didn't.

Yeah, it gets below freezing at night but, except for a two day cold spell where we had basically normal January temperatures, it's been downright balmy in the afternoons. There has been no snow since October (sic), there is no snow on the ground, and there is rain in the forecast for next week. If you'll take a look at the snow cover map you'll see that there is basically none in the lower 48 except for the lake effect region of upper New York and northern New England. (Why would anyone choose to live in Buffalo?)

This may be convenient for homeowners and municipal budgets, but it is actually bad for agriculture. Snow insulates the soil and keeps it warm. It hides the voles from the hawks, and when it melts, it saturates the soil to get spring off to a good start. I'm sure the deer and turkeys are happy, but I'd like to slow down their depredations. (Yesterday, heading to work, I discovered the biggest flock of turkeys I have ever seen in my field. There may well have been 100 of them -- dozens, anyway.)

I'm sure winter will come eventually, but at this point, it will already be short. Does this have to do with global climate change? As with all weather, sorta kinda. This year, in sharp contrast to the past two, we've had a polar oscillation that has kept the arctic air bottled up. But it is fair to say that given this pattern, we're averaging a couple of degrees warmer than we otherwise would have. And when that's the difference between snow and rain, it means bare ground and that, in turn, means warmer temperatures on sunny afternoons.

The reason I go off on all this is that as you may recall, when we had all that snow in previous years, Rush Limbaugh and James Inhofe were chortling about how ridiculous the whole anthropogenic climate change thing was. Of course that was nonsense then -- the planet as a whole went right on warming, the arctic was very unusually warm,and the temperatures in the continental U.S. were normal. It's just that there was a lot of snow. But this year, with unusually warm weather in D.C. and everywhere else from Montana to North Dakota, I hear nothing from them.

So what's it going to take to get our rotten to the core political system to function and begin to respond to the greatest crisis humanity has faced since our unexplained population bottleneck 400,000 years ago? You tell me.

Hey Indeedy

Lawyer Einer Elhauge, in NEJM, explains why the individual mandate in the Affordable Care Act is indeed constitutional. Go ahead and read it but in case you're too lazy, he throws the kitchen sink at this question.

Most broadly, once you engage in commerce, then Congress can regulate you. And it is not the case that Congress can only regulate commercial activity -- Congress can regulate any activity that affects commerce, as it did when it limit wheat growing for self-consumption back in the 30s. (Yep, it did that, and the Supreme Court said it had that power in 1942 and re-affirmed it in 2005.) In 1790, Congress required ship owners to provide medical insurance to sailors; and in 1798, it required sailors to buy it for themselves. (Really!) In 1792, Congress required every able bodied citizen to buy a firearm. Furthermore, the distinction between the mandate -- buy insurance or pay a tax penalty -- and an actual tax -- e.g. the Medicare payroll tax -- is purely semantic. It amounts to the same thing. And he goes on and on.

This is pretty much what every dispassionate observer says -- there is no constitutional problem with the Affordable Care Act. But as we have already seen, lower courts have been divided on the question and guess what? It's Republican judges, exclusively, who have ruled against the Act. So what do you think the highly partisan, highly politicized Supreme Court majority will do? Uphold the Constitution and more than two centuries of precedent, or make an indefensible and deeply harmful decision in order to serve its political objectives?

I'm not real hopeful about this. By the way, I don't like the kludgy individual mandate, as you well know. It is not the best public policy, but we know why it happened -- to get the insurance companies on board with the legislation, because it's corporate lobbyists who run Congress. However, Congress has the constitutional power to make bad law.

There would be no constitutional problem whatsoever with universal, comprehensive single payer national health care. We know that because Medicare has already been upheld. Just extend it to everyone. We're done.

More on the mythical center

Continuing my recent musings, suppose I were to tell you that the midpoint between Honolulu and Nairobi is in Philippines Bay. (I believe it is, approximately.) Would that suggest a way to resolve the "controversy" over Barack Obama's birthplace?

Tom Englehardt, as usual, does a good job explicating the utter pointlessness of the recent adventures in Iraq and Afghanistan. (He's written the same essay about 97 times but you can never get too much of a good thing.) Now think about it. Who is the only prominent U.S. politician -- someone whose words are actually noticed by the hairhats on teevee, not a non-serious person such as Bernie Sanders -- who says this?

That would be the otherwise completely wacko Ron Paul. (And no, there are no other exceptions to Paul's wackoness. He says he wants to end the War on Drugs but he doesn't really mean it, he just wants to transfer it to state control. Ditto for all of his other libertarian pretensions. He's actually inimical to individual rights because he rejects the 14th amendment, which means that he does not believe that any of the rights enumerated in the Constitution need be respected by the states. So all of you Cheetoh-dusted Pepsi swillers can scrape the Ron Paul sticker off your parents' basement door.)

And this is the real problem with our politics. The Constitution, with its winner-take-all presidency and similarly modeled state governments, creates barren ground for third parties; while dissent on any one issue cannot bring down a government as in parliamentary systems. The result is that we perpetually have only two competing coalitions, and voters have only a choice between two complete menus, each of which is likely to contain 49% inedible swill.

I can't vote for Ron Paul's foreign policy, and the specific limitations he wants on the federal government, without getting abolishing the federal reserve and repealing the Civil Rights Act. And, now that I'm a citizen of Connecticut, I can't vote for Sen. Blumenthal's support for renewable energy investment without getting his gluttonous appetite for high tech military hardware. And you can no doubt think of your own conundrums.

There are many other big flaws in our Constitution -- not least the grossly unrepresentative Senate. The requirement that we treat it with religious reverence is preposterous. It really doesn't work very well. And we're seeing that right now, with a vengeance.

Parallel Universes

Of late there has been no point, for me at least, in watching TV news or any of the political chat shows such Ed or Rachel that I might ordinarily use to dispose of an hour so of unwanted consciousness. All they ever talk about is how the Republican candidates are likely to fare in the Iowa precinct caucuses, about which I give not a FFOARD.

This would be a pointless waste of airtime in any case, because when it's over, it will be what it will be, and 50,000 hours of speculation about it ahead of time will be completely meaningless and forgotten. But in the specific case of January 3, 2012, it's also bizarre, because there is one absolute guarantee: whoever wins will be either delusional, a cynical psychopath, or a little bit of both. The candidates are competing ruthlessly to prove that they are the most radically wrong they can possibly be about everything. The prize goes to the most profound, consistent, and unabashed ignoramus or liar.

I am quite sure, however, that Republican primary voters have a similar opinion of me and the godlesshippiecommiefaggotfreaks I hang out with. That I am a professor at an Ivy League university is an even graver insult. That this situation bodes ill for the future of our country and our planet is obvious.

What does not follow, however, is the fetishized conclusion of many a pundit that the way forward lies somewhere in the "middle" between what in my view is insanity and reason. There is no middle. There is no planet in which anthropogenic global warming is simultaneously a scientific fact and a massive conspiracy to defraud the National Science Foundation and destroy capitalism. There is no universe in which drowning the federal government in the bathtub causes economic collapse by ending necessary investment in public goods such as economically essential infrastructure, education, public health and scientific research; and simultaneously unleashes the heretofore enchained forces of the Job Creators, forced to leave us wallowing in underemployment by regulatory uncertainty and a 15% marginal tax rate. There is no universe in which allowing gay people to marry simultaneously respects individual rights and promotes social harmony; and calls down the wrath of God upon us.

There is no "center." There is no way to split the baby, even if baby splitting were a good idea in principle. We have nothing to talk about when we don't exist in the same world of facts.