All's Not Quiet on the Less-is-more Front

Coming next year -- yes, the wheels of science grind slow, but they grind fine -- the Preventing Overdiagnosis Conference. Overdiagnosis means that people who have some condition that will never harm them get a disease label and, almost inevitably, treatment. Said treatment is at the very least costly, quite likely harmful, and the person must live with an unsettling and possibly even stigmatizing consciousness of being sick, or "at risk."

Overdiagnosis comes from screening that can't discriminate well between dangerous and harmless lesions. Examples are mammography for breast cancer, and PSA for prostate cancer. Those have been much belabored here. It also happens when the threshold for declaring that a "disease" exists is set too low, so that on average the costs of treatment outweigh the benefits. We may have done this with high blood pressure, diabetes, and kidney disease. And it happens when we define diseases that may not even exist, or for which the cure right now is worse than the disease. I'm tempted to put Attention Deficit-Hyperactivity Disorder in that category, and probably pediatric bipolar disorder. That would be a controversial position but I'm not alone.

The fact is that the incidence of cancer has been rising for decades, but the death rate has not fallen much. That is pretty much prima facie proof of overdiagnosis. Lots of old folks are put on dialysis who really don't need it, and they actually die sooner than people who are not. (Renal function declines as we get older, but the rate of decline is much slower than it is in people who really have kidney disease.)

Many people have been found to be using inhaled corticosteroids, for asthma, and antidepressants, who do not actually meet diagnostic criteria for those diseases. I'm not sure whether "overdiagnosis" is the right word in these instances, because they often don't even have a diagnosis in their medical record. They just have a prescription.

Now here's the thing. This is wasting something like 20-30% of all the money spent on health care in this country. Money that could be spent providing access to actually needed health care for people who don't have it. But when we try to do something about it, we get mobs screaming about death panels and pointy headed bureaucrats coming between us and our doctors. We need to ignore those people, and fix this problem.

Observational studies, part 1

Continuing with this series -- which I'm sure Steve Novella would agree is worth doing -- we'll step away from experimental designs for a bit to discuss observational studies.

Most epidemiological research is not based on experiments -- in which we deliberately take some action (called an "intervention") to see what happens. It's just highly structured observation of the world as it is. The simplest case is a cross-sectional study in which some number of subjects -- in our field, that ordinarily means people -- are observed in the same manner. They may be given a questionnaire; or have some biological measurements taken, such as their height, weight and age; or both.

Public opinion surveys and electoral polls are also examples of this kind of study. Most people have some idea behind the mathematics that allows Gallup to predict the votes of millions of people by talking to a few hundred, but let's review very quickly. (You can read my more extensive entries on this subject here, here, here, here, here, and here.)

If you have a way to pick people at random from all the people you are interested in -- that's called the people who constitute your "universe" -- such as eligible voters, then you can use certain mathematical techniques to figure out how similar your sample is likely to be to that "universe." Specifically, you can calculate a probability that the percentage of people in the universe who have a given characteristic is different from the percentage of people in your sample by any given amount. (See the links above if you want more info about how this works.) When they talk about the "margin of error" of a poll what they normally mean is that 95% of the time, the real number in the universe will be inside it. That 95% is arbitrary, but it's taken on sacred status. The most likely real number is the actual number in the poll; we could report the 67% confidence interval or any other interval we wanted to. But 95% it is.

But there is a lot that can go wrong with polls, or any study of this sort, other than just happening to talk to an unrepresentative sample. We could have a bad sampling "frame" -- the classic example is, we think we're picking at random from all the likely voters, but we're only talking to people with telephones, and Dewey Beats Truman! Nowadays almost everybody has a phone so that isn't really a problem, but maybe some kinds of people don't generally want to talk to us. That's called selection bias. Or maybe some kinds of answers are stigmatized, which is why few people will tell a pollster they wouldn't vote for a black person.  That's called socially responsible response bias. (Atheists, however, are another matter.) Or maybe you asked the question in a way that pushes people toward a particular answer.

In epidemiological studies, we're often interested in whether past events or exposures are associated with current health problems. For example, are people's diets associated with, oh, high blood pressure, or whatever. Here you have problems with recall. Can you tell me what you ate for lunch last Wednesday?

There is a great deal more that I could say about this but I'll just leave you with one essential point. Even if we do everything very rigorously and our observations really are representative of the population of interest, associations in any cross sectional study cannot prove causation. People who eat a lot of mangoes may have lower blood pressure than people who do not for reasons having nothing to do with mangoes. Maybe they are of different ethnicity, different socio-economic status, live in different places, have other dietary differences we didn't measure, exercise more -- who knows. We can try to control for all those factors but we can't control for anything we forgot to ask about. If we want to make causal inferences, we have to do something else.

More on evidence

Continuing my latest adventure in wonkery, the quick review of the evidentiary basis of causal inference . . .

The plural of anecdote is "anecdotes," not "data," it is true -- however, anecdotes are data.

But, the term anecdote connotes a story that is only casually observed, perhaps retold. Both single case studies and so-called within subjects design studies can provide useful information and can even support causal inference under very specific circumstances, although it is unlikely to be conclusive; but we must very carefully observe and document what we do. That's why these aren't considered "anecdotes." The reason we often see highly dismissive responses to such studies is that they are often overinterpreted, their limitations insufficiently acknowledged. Indeed they are quite commonly used by charlatans such as homeopaths to promote quackery. But let's hang on to the baby as we pour out the bathwater.

To review, if an outcome is extremely improbable, and we try a novel intervention even once and then observe the extremely improbable outcome, we can reasonably have a strong suspicion that the intervention was indeed related to the outcome. If we have an a priori plausible explanation for how the intervention produced the outcome, so much the better. So, if surviving a fall from thousands of feet is highly improbable, and a person using a parachute survives such a fall unscathed, we don't need to see it work more than once to believe that there's something to this parachute thing.

On the other hand, a single trial would not convince us that parachutes work 100% of the time, or even most of the time. We'd need a lot of experience before we were confident we knew how effective parachutes are, under what circumstances, and what can go wrong. What we would not need, however, is a randomized controlled trial, because we are already highly confident that falling 5,000 feet without a parachute is almost inevitably fatal.

And that's the principle on which a within subjects design can be useful. If we're already confident that a particular outcome in a defined population is improbable given the existing or natural state of affairs, then a before-and-after test of an intervention can give us meaningful information about whether it is likely to be effective. If remission of metastatic cancer is extremely rare, if we give 5 people a novel treatment and 3 of them remit, we don't need a formal control group to believe we're on to something.

This sort of inference depends on the assumption that people are biologically pretty similar. After all, a chemistry experiment doesn't ordinarily need a control group at all because every atom of a given isotope of carbon, in the same state of ionization, is identical. The reason we have much more difficulty making causal inferences in health research is because people are so complex and so variable; because measurement of outcomes is often not straightforward; and because out interventions, unlike mixing chemicals in a beaker, typically have multiple components and multiple effects.

And so, the example with metastatic cancer is quite unusual. If an outcome, unlike remission of metastatic cancer, is not extremely rare, is not completely straightforward to observe, or may respond to multiple components of the intervention such as placebo effect, a within subjects trial is much more problematic. Sure, if the trial results in a rate of outcome which is markedly different from what we would have expected, it can be at the very least suggestive, but there are many pitfalls.

Here are a few:

Selection bias: People are convinced that Alcoholics Anonymous works because alcoholics who regularly attend AA meetings have a higher rate of sustained abstinence than alcoholics who do not. But maybe people who are motivated to remain abstinent are more likely to attend meetings. In fact there is no good evidence to show that AA is effective at all, for basically this reason. Should we really expect the desired outcome to be at the ordinary background rate in the population selected for the trial, or is just selection, rather than the intervention, that produces the observed effect?

History: Before and after designs are often used for interventions that target social problems, perhaps at a community level. But the trouble here is that a whole lot else is going on at the same time, in addition to the intervention. While you're doing outreach education to reduce the risk of STIs in teenagers, a whole lot else may be changing: sexual mores, condom availability, the likelihood of exposure due to other factors such as enhanced availability of treatment, you name it.

Non-specific effects of the intervention: We may attribute the observed outcome to the magic potion we had you ingest, but maybe it was the effect on your expectations, the fact that it made you mildly nauseous so you skipped your usual seven vodka-and-ginger ales, or just the fact that somebody paid attention to you, that made the difference. Notice that this category includes, but is not strictly limited to, what we call placebo effects.

So, uncontrolled, before-and-after trials, can give us some useful information but they can also often be misleading. So-called Phase One trials of drugs are of this nature. A small number of people are given an experimental drug just to see if there are any obvious, immediate ill effects; so we can figure out it's "pharmacokinetics," in other words how much of the stuff gets into the blood stream or target tissues and how long it lasts; and to see if anything else dramatic and exciting happens. If the latter, we don't jump to any conclusions. We still need to go no to controlled trials before the drug can get approved.

New Windham County Post

I'll be getting back into it. Sorry for the long hiatus.

Evidence

A couple of questions from commenters have inspired me to produce a bit of a primer on the kinds of evidence we use in health research. It seems to me that a lot of the political controversy over health policy and official recommendations is fueled by limited understanding of the use of evidence to make causal inferences. As I set out on this project I really have no idea how long it will take. We'll just see what happens.

Categories of evidence are commonly organized in a hierarchy, with some kinds said to be stronger or more compelling than others. I don't exactly look at it that way. Different kinds of evidence are useful in different situations and lead us to different kinds of conclusions. Just as important, how we regard any kind of evidence must depend on the prior plausibility of what it seems to show. If there is already very strong evidence for or against some conclusion, then any new evidence that contradicts what already seems highly probable is less compelling, and we should be much more diligent in looking for flaws in the study or concluding that chance alone is responsible for the observations.

This is different from confirmation bias, which is a feature of human cognition in which we tend to ignore or explain away evidence that contradicts what we already believe. We should certainly take surprising findings seriously, but we should subject them to careful scrutiny. If they do compel us to re-examine our prior beliefs, we should certainly do so. I will address these issues a bit more formally as we go along.

Alright. As most people know, conventionally anecdote is presented as the least convincing kind of evidence. An famous example of anecdotal evidence is the putative association between vaccination and autism. Parents see their child receive a shot, and some time not long after they start to see developmental regression and symptoms of autism. Unfortunately, some parents have an unshakeable conviction after this experience that the vaccine caused the autism. As I'm sure most readers already know, this is a common fallacy called post hoc ergo property hoc, because if you say it in Latin you must be really smart. I think if we started naming it in English we would still be just as smart, so I'll call it after this, therefore because of it.

While overwhelming, really incontrovertible evidence of much greater force has shown that vaccination does not cause autism, it is wrong to say that anecdotal evidence is worthless in general or should be ignored. A famous example is the efficacy of parachutes. Since we know that falling from 10,000 feet is invariably fatal, seeing a person do so with the aid of a parachute and land unharmed, even once, is extremely compelling evidence for the efficacy of parachutes. Not only has something obviously extraordinary happened, we can immediately see how it apparently works: by air resistance. The scenario makes perfect sense: it has high prior plausibility. Seeing it happen once wouldn't necessarily make me confident enough to strap on a parachute and jump out of an airplane; but it would make me believe that if the equipment were sufficiently reliable, and weather and other conditions similar to those pertaining to the observation, the parachute would be highly likely to work.

To return to the case of autism, suppose no child had ever been vaccinated and no child had ever been autistic - or at least that autism was extremely rare. If the first child ever to be vaccinated subsequently became autistic, we would properly have a very high index of suspicion that the events might be associated. If we could think of a highly plausible biological mechanism, our suspicion would be even stronger. Neither of these requirements holds in the real case, however.

Moving along, although it is often said that the plural of anecdote is not data, this is certainly false. Data is a synonym for information, and the more anecdotes, the more information. In fact the plural of anecdote can be organized formally into a kind of study called a within subjects design. I'll talk about that in the next installment.

The world turned upside down

I would not have predicted this, even five years ago. Hell, even last year. WaPo poll says 54% of voters think gay marriage should be legal -- and that's using the word marriage, not civil unions. What's more, 39% "strongly" agree, compared with 30% who strongly disagree.

For sure, the culture changes over time. But the stigma of homosexuality was so profound, so widespread, so ancient, that such a seismic collapse seemed inconceivable. The first legal recognition of slavery in what was to become the United States occurred in Virginia in 1654. It took more than 200 years and a horrific war for slavery to end in the United States, and another 100 years before African Americans received full legal recognition of equality. (Of course, that's still only on paper, as the composition of our prison populations attests.)

It will be a few more years, to be sure, until lesbians and gay men achieve legal equality, but just think -- when the Mattachine Society was founded in 1950, its membership was secret and the name referred to a French tradition of performers who never appeared unmasked. Homosexuality was a crime in much of the United States until 2003. The new poll shows a nearly 20 percentage point  increase in support for gay marriage in just a few years.

The Republican party successfully used gay marriage as a wedge issue to drive voters to the polls in its favor right through the 2004 election. Believe it or not, in the face of this tectonic shift, support for gay marriage among Republicans has actually declined. But it won't work in the party's favor any more.

Astonishing.

Like I've been saying . . .

The U.S. Preventive Services Task Force has held its ground on prostate cancer screening. They are against screening, for men of any age. And yes, the howls of outrage are echoing through the hospital and clinic halls, notably from the American Urological Association. Now I wonder why the AUA is "outraged"?

Ah. I have a thought. They make money by treating prostate cancer, and they make even more money by treating the incontinence and erectile dysfunction that results from the treatment. Here's what the USPSTF says, and it's not outrageous:

1. The number of men who would have died of prostate cancer within 10 or 14 years (the follow-up time of the available studies), but who will not because they are screened, is possibly zero and no more than 1 out of 1,000. 
2. 80% of positive PSA tests are false positives, but these false positive tests are followed by biopsies which in 1/3 of cases result in pain, fever, bleeding, infection or other problems that require further medical intervention. 
3. 90% of men with positive biopsies will get treatment with surgery, radiation, or drugs to suppress their androgen. Five out of 1,000 will die within a month of surgery, and from 10 to 70 more will have severe complications. Twenty to 30% of them will have incontinence and/or erectile dysfunction.
4. However, many of them -- probably most of them -- would never have died from prostate cancer even without treatment, because most of the "cancers" found on biopsy would never have progressed to cause disease.

So it's a no-brainer. Men who have been through this are convinced that it saved their lives, because who wants to admit that they went through all that for nothing? The doctors who treat them don't want to admit that they have been paid big bucks to harm people all these years either. And all the celebrities who made PSAs to promote PSA don't want to think they've been tools either.

By the way, there's no evidence that screening just by digital rectal exam is worth it either. I'm certainly not going for it.

Yet one more study showing that reality has a liberal bias

Yeah yeah, it's getting old. Analysis of data from the General Social Survey (an ongoing project of the National Opinion Research Center, and no, it is not a government agency) shows that since 1974, trust in science among conservatives has fallen by 25% -- and it's specifically among people with college degrees no less. Conservatives used to have the most trust in science, now they have the least.


Why? Because scientific truth is inconsistent with conservative ideology. That is all.

I can't believe this is even controversial

The presidential campaign this year is essentially a contest between semi-sanity and florid psychosis. Apart from the side shows about whether Mitt's tenure at Bain Capital produced a net gain or loss of jobs, and whether Obama is a "real" American, the substantive issues at stake are principally:

1. Should the government regulate banking and finance, or does removing the oppressive hand of the state liberate capitalists to create wealth and jobs?

Mitt -- what planet do you live on? Have we already forgotten what happened in 2008? Here's a view from the land of bangers and mash that would be a voice crying in the wilderness here. The "Free Market" you worship is a fiction. Markets in complex societies are not forces of nature, they are creations of the state. They cannot exist without continuous, fundamental government intervention. The only question is how they will be regulated, on whose behalf. You want to regulate markets for the benefit of a fraction of one percent of the very wealthiest people. And no, they are not job creators nor will increasing their wealth at the expense of the rest of us somehow make us better off in the end. That is utterly preposterous. Astonishingly, half of the voters seem to believe it.

2. Should government take action to protect the planetary environment? Or is environmentalism a scam to suck up grant funding and impose socialist tyranny?

The truth is starting to penetrate even people coal country.  But here's the really bad news: We may be facing an immediate planetary emergency as methane outgasses from the melting arctic. The most terrifying crisis in human history -- at least since our ancestors passed through an unexplained population bottleneck 2 million years ago -- is not even an issue in the campaign. Never mentioned.

3. Should we forbid women to control their own reproduction because God says so?

Actually, it isn't God, it's a few depraved, ostensibly celibate old men wearing medieval costumes, and some con artists sucking up millions of dollars from suckers. God apparently didn't get around to saying this until approximately the late 19th Century,  because there is not one word about abortion or contraception anywhere in the Bible, Old Testament or New. This ought to be embarrassing to the preacherly grifters, who can find verses in Leviticus telling us to stone homosexuals to death. (Somehow they skipped the ones about driving people with rashes into the desert to die).

And yet, Republicans can actually win elections with this crap. If it happens in November, we are doomed.

The World's Most Popular Fallacy

Or at least I think it probably qualifies. That would be conflating association with causation, and it's a plague (hah!) in public health research. Today's entry is the so-called "good cholesterol" hypothesis. Or at least, it should have been considered a hypothesis all this time, but instead people have treated it as a finding.

The linked article may be a bit esoteric. It has gotten some coverage in the lay media, but I'll offer my own summary. Most people have heard that "high cholesterol" is a risk factor for heart disease and strokes, but that there are actually two kinds, called Low Density Lipoprotein, LDL, and the high density HDL. There's a lot more LDL than HDL in your blood, so the LDL level determines most of your total cholesterol, but higher levels of HDL are actually associated, in observational studies, with reduced risk for heart disease.

Randomized controlled trials of statin drugs, which lower LDL, have shown that they do indeed reduce the risk of atherosclerosis, and consequent heart disease and ischemic stroke, at least for people who have already had heart attacks or are at high risk. (Their value in people at average or even just above average risk is controversial.) So that adds to the evidence that high LDL causes the bad outcomes. (I must caution that it doesn't actually prove it. Statins could simultaneously lower LDL and do something else that reduces risk. But it adds to the plausibility of a direct causal association.) So naturally, drug companies have been working on pills that will raise HDL in hopes of making billions.

I have always been skeptical. (Yeah, that's easy for me to say now, but it's true.) HDL is higher in people who engage in lots of aerobic exercise, for one thing, and it's lower in people who smoke. Observational studies try to isolate its effect by controlling for consequences of exercise -- leanness and lower blood pressure, slower heart rate -- exercise itself, smoking, and all that good stuff. But that's really hard to do. HDL could just be a marker that goes along for the ride with the true protective factors.

So these researchers whose work is published in The Lancet used certain genotypes as what's called an "instrumental variable" -- some characteristic that people happen to have that effectively randomizes them in a sort of natural experiment. Some people have genes that predispose them to higher HDL. It turns out that having these genotypes is not protective against heart disease. As a check on the concept, having genes that predispose to higher LDL is indeed associated with higher risk.

This cautionary tale is important for several reasons, but the most important practical lesson is that we need to be much more cautious about approving drugs based on so-called "surrogate end points." We need to prove that they do what we really want them to do, which is to make us healthier or keep us healthier, or at least make us feel better. Changing some technical indicator that we think has something to do with being healthier isn't good enough.  

The Great Dying

That's a commonly used label for the Permian Extinction, 252 million years ago, in which 95% of living species went extinct. There is controversy over the underlying cause, but it does appear that marine life with carbonaceous skeletons -- molluscs and corals, mostly -- were wiped out due to higher ocean temperatures and more dissolved carbon dioxide, which made the water more acidic.

Oh yeah, the same thing is happening today, plus a lot of other huge changes that are causing another Great Dying. You've probably heard about this report from the World Wildlife Fund, which says that humans are consuming the earth's resources faster than they can be replaced. They don't even emphasize CO2 emissions, which seem to have triggered the Permian Extinction, but plenty of people are on that case, obviously.

The collapse of resources essential to human life will mean the collapse of the human population and, no doubt, catastrophic consequences for the social order. True, back in the '60s there were predictions that this would have happened by now, and it hasn't. A major reason is the so-called Green Revolution, which transformed agriculture with massive fossil fuel inputs. Don't be fooled by advertising or nostalgia: farming has nothing to do with nature and there is nothing less like nature than farm country. That just means that we bought time by doubling down on the mechanism that got us to the looming resource crises of that era: extracting the remains of ancient vegetation from beneath the earth and burning it for fuel.

That is what made it possible for the human population to expand from a few million to what will soon be more than 10 billion. It is the indispensable basis of our entire civilization and way of life, even for poor farmers and urban slum dwellers, although affluent people consume far more of fossil fuel and the abundance of products it makes possible.

We can't continue to live this way. It's over. But politics, in the U.S. and just about everywhere else, is not about the fundamental issues we face. Not at all. They are ignored. I don't care if you're liberal or conservative, Tea Party or Occupier, you are living in denial. What you are arguing about does matter, but it won't matter much longer if we keep on as we are. Wake up.

This is apparently supposed to be a secret in the U.S.

Eminence grise Arnold Relman, former editor of the New England Journal of Medicine, has published an essay in a British journal, that you aren't allowed to read if you aren't on a university faculty, about why the U.S. health care system is heading over the cliff and how to get it back on the highway. Great move Dr. Relman! That should have a big impact on the debate here in the United States, which I believe is why you might write such an essay.

We actually see a lot of this -- leading scientists taking to the pages of The Guardian to rebut climate change denial that appears in the Wall Street Journal  comes to mind. I suppose it's just not possible to get liberal arguments published in the United States.

Anyway, Relman basically makes three points: the concept of the "free market" does not work in health care; therefore we need universal, comprehensive, single payer national health care; and we need to reorganize the system into multi-specialty group practices with physicians paid salaries and some form of capitated payment.

It's the latter point which goes a step further than single payer advocates necessarily go. I've already become something of a broken record on the first two here but let me make a couple of quick summary points. Relman points to provider induced demand as the key failure of "the market" in health care but actually there are many others. These include the unpredictability of any given individual's need for health care -- unlike your need for food, clothing and shelter which is roughly similar for everyone; the very serious negative externalities when people don't get health care that they need, such as loss of economic productivity, transmission of infectious disease, and failure to care for dependents; and the erosive effects on society and culture of mass-scale abandonment of desperate people.

Relman also points to the inefficiency of private insurance and the massive waste it entails in the form of profits, marketing and administrative costs. But he does not see moving to a single payer system as sufficient in itself to solve our problems. Provider induced demand will continue to generate waste and even harm patients as long as doctors and hospitals are paid more to do more, and as long as drug and device manufacturers continue to bribe them, and manipulate both doctors and patients into wasteful spending. Salaried physicians in so-called Accountable Care Organizations are the solution for Relman. Maybe that is a good idea, but I should point out that they have done pretty well in Canada with fee-for-service primary care, while in the UK, physicians are paid salaries but they operate independent small practices for the most part.

Anyway, Relman notes that many physicians are already moving to multi-specialty group practices because there are advantages over being in business for yourself. These include reasonable hours, having administrative staff to worry about all that nonsense, more economic security, and having colleagues with varying expertise to collaborate with. He hopes that if this trend continues, it will become politically easier to make policy changes. But he also doesn't necessarily expect it. He thinks we'll likely have a catastrophic failure of the system, after which, eventually, after Grover Norquist and Paul Ryan are sent off on an ice floe, we might be able to fix things.

We shall see.

Terridiots

It's no surprise the corporate media loves the new undiebomber story. First, they don't have to do any work. Some official talks to them anonymously and they write down what he says. Is it necessarily exactly true, or the whole truth? Don't bother to ask, that's not your job. Plus which, it's a really cool spy story, and they get to be all worried about whether we are safe.

Well okay, let's assume it's all true. It strikes me that Al Qaeda in the Arabian Peninsula is seriously suffering from a lack of imagination. They are totally determined to somehow strike at the United States, but the only way to do this that meets their exacting standards for martyrdom is to have a guy blow himself up on an airplane. Since we know that's the only terrorist act they will ever attempt, we can make it fairly difficult. Hence the undiebombing technology. Scary!

However, not being a depraved terrorist, I can think of at least 16 ways to cause major carnage and disruption that are pretty much impossible to prevent, many of which do not even require that you have anything that is normally thought of as a weapon, let alone slaving away in your workshop for months to invent an undetectable suicide bomb. As a matter of fact, I could put a big fat plain old detectable bomb in my carry on luggage, wheel it up to the security checkpoint where there are 200 people in a tight mass, walk away and detonate it remotely, thereby shutting down every airport in the country until they figured out what to do to prevent me from doing it again, which they never could.

Without giving away my patentable idea, I could cause an economic catastrophe with maybe a dozen old dump trucks, or some chain saws. Do you have any idea how easy it is to derail a train? (I probably shouldn't have mentioned that.)  Anybody in the United States can buy a truckload of semi-automatic weapons, and well, use your imagination.

So, let's hope they stay obsessed with aviation. Or maybe, they are just a few wackos out in the desert and they don't have the people or the money to come to the U.S. and buy dump trucks. I vote for the latter.

Those improvident, irresponsible wastrels

That would be the half of Americans who aren't saving anything for retirement. Oh wait -- maybe it's because they can't. You need enough left over after paying for the rent and groceries and keeping your 1998 Honda Civic running to make the required minimum investment in an IRA.

So of course it makes perfect sense that the Republicans in congress want to cut food stamps, meals on wheels, child care and other programs to help poor people -- that would be working poor people, by the way -- in order to avoid cutting military spending.

Now why is military spending so important? Is it because the United States is under threat from powerful aggressors? Ha ha. It's because of that black goo deep in the earth. As Michael Klare makes clear, military tensions around the world are ramping up because it's harder and harder to get and everybody wants more and more of it. Why are there two U.S. aircraft carrier task forces in the Persian Gulf right now, along with a whole lot of guided missile cruisers and oh yeah, I bet you didn't know this, a U.S. Coast Guard station in Bahrain.

But if we keep on sucking that stuff out of the ground and burning it, as we are determined to do, nothing bad will happen except that we'll destroy civilization. It's a small price to pay.

Two Worlds

I don't usually link to the Puffington Host because it is infested with bunkum, but if you haven't already, do check out the first chapter of the latest book from The Shrill One, which happens to be available there.

Krugman describes the massive suffering and tragedy of the past few years, but as disturbing as the catastrophe itself is that he actually has to point it out. He is some sort of radical or alarmist because he bothers to notice the pain of so many people and the irrevocable losses we have suffered; and insists that we actually do something about it. The millions of young people who are graduating from college into a bleak future as far as the eye can see; the people in mid-life whose career accomplishments and savings are destroyed, along with their self-esteem; the countless people we don't even notice any more who are destitute; to the corporate media and much of political discourse, they are irrelevant. This is not the problem we need to worry about.

I have some thoughts about why this is. Do you?

Yes we are ruled by idiots

It's apparently too technical for the general public or Columbia-educated journalists to grasp, but if you follow Brad DeLong and/or The Shrill One you have probably gotten the idea that the elite consensus about the economy in Europe and the United States is completely insane.

I've been thinking about a simple, non-technical way to explain our situation that a smart politician such as, say, president Obama could use if he had the courage. The reason there aren't enough jobs is not because rich people have to pay taxes or companies are worried about "regulatory uncertainty." The reason is that companies can't sell enough stuff to expand output, and therefore to hire more people. The reason they can't sell more stuff is that there are too many people out of work or stuck in crappy jobs. That's why investors aren't putting their cash to work building up companies, they're sticking it in the equivalent of the mattress, i.e. U.S. treasury bonds that currently are providing a negative rate of interest, that is less than the rate of inflation -- which is also very low. So that cash is just sitting there.

The way to put people back to work, and therefore cause them to have money with which to buy stuff and therefore cause companies to sell more stuff and therefore hire more people, is to spend that money. You could actually spend it to pay people to dig holes and fill them in again, but even better to invest it in stuff that will also do good in the world, such as mass transit projects, fixing bridges, educating folks, modernizing the electrical grid, energy conservation and sustainable energy production, you name it.

The government has to do it this, using that money it can borrow extremely cheaply. That will also cause tax revenues to go up and make it possible to pay the debt in the future and reduce the deficit without having to do horrible damage to society.

This is the simple truth. Department of stupid questions: will we hear this simple truth discussed in the next six months?  

Are you nuts?

Very likely. CDC says 25% of Americans have a "mental illness." They also say that half of us will have a "mental illness" at some time in our lives.

Bummer. (Uh oh, I shouldn't have said that. Maybe I'm depressed.)

The problem with this claim is that whether or not you have a "mental illness" is purely a matter of whether a committee of psychiatrists has decided that some state of affairs qualifies as a "mental illness" and some specific psychiatrist or otherwise authorized savant, such as a clinical psychologist or your family doc has decided that said state of affairs applies to you.

As you have likely heard, an effort is just winding up to create a new set of diagnostic criteria for mental illness. You can read all about it here. It's fascinating to explore. Keep in mind that as my old professor Sheldon Krimsky and his colleague Lisa Cosgrove have reported, 69% of the authors of the new DSM5 have ties to the pharmaceutical industry. And you know what happens to people who have "mental illnesses": they take pills.

Do you often argue with authority figures? Do you often actively defy or refuse to comply with requests from authority figures? Have you been spiteful or vindictive at least twice within the last six months? Are you often touchy or easily annoyed? Congratulations! You have oppositional defiant disorder. You are mentally ill.

Have you been sad for two weeks, even if you think you have a good reason? You're having a major depressive episode! Do you tend to misplace things? Do you talk too much? Are you easily distracted? Disorganized? You probably already know you have ADHD.

Even the definition of schizophrenia is based purely on whether somebody thinks you're just too weird, basically. Anders Breivik and Ted Kaczynski have both been diagnosed with schizophrenia but I read this and I have to say, "Huh?" A requirement to have schizophrenia is having at least one of delusions, hallucinations, or disorganized speech; and if you don't have two of those, you also need to have grossly abnormal psychomotor behavior (e.g., you are permanently in the fetal position); or diminished emotional expression or avolition.

Hating non-Europeans and non-Christians, or thinking that industrial civilization has been a disaster, are unpopular ideas in some circles, though not in others. Killing folks more or less at random in order to promote these ideas is teleologically inept, to be sure, also illegal. But I fail to see what is gained by applying a disease label to it.

Here's the basic problem. Psychiatrists like to say that these, and other traits they label as psychiatric diseases, have something to do with "chemical imbalances" and that they can be fixed by swallowing the right chemicals. However, they have no specific evidence for any particular chemical imbalance being related to any particular set of diagnostic characteristics. All they know is that if you drug people into a properly semi-stuperous condition,  they will be, for example, less oppositional and defiant, or less fidgety. As soon as a real chemical imbalance or functional neurological impairment is discovered and a reliable test for it is found, the problem ceases to be a mental illness and becomes a neurological condition, or perhaps even an infectious or endocrine disease.

Psychiatry, up to a point, may be necessary. But it is not properly considered scientific medicine. That's my opinion, anyway.

Town and Gown, cont.

One way universities can change is in how they do public health research, and other kinds of research with direct relevance to the communities in which they sit (and which they often dominate). As one review puts it:

Community-based participatory research in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved.

But . . .

Really doing CBPR is difficult. There are huge differences in resources, perspectives and interests between academic investigators and community representatives, whether they are professional staff of CBOs, patients or clients, community residents, people living with chronic diseases, or otherwise defined. Community based organizations are generally undercapitalized and have real difficulty investing the kinds of resources in speculative proposal development, with a potential payoff that we typically don’t see for two years or more, that we take for granted in the university. Unfortunately, despite the professed interest of NIH and the ICs in CBPR, NIH staff and proposal reviewers still have a long distance to travel  in adjusting their thinking to both the philosophical and practical demands of CBPR. The most straightforward practical mismatch between the NIH funding process and CBPR is that the specific aims and research strategy must be fully developed, with a high level of scientific rigor, before the proposal is submitted. But CBPR demands a planning and developmental process between the academy and the community during which the research problem and research strategy are shaped to meet the somewhat disparate needs of the two groups. Community representatives simply cannot engage in this process without financial support. The result is that putatively CBR projects are often actually completely developed and written before they are even presented to the community “partners.”

The philosophical difference between academic and community visions of research is complex.  Community representatives are typically interested in the specific problems and needs of their own community, obviously, but academic research, and certainly most NIH-funded research, cannot be satisfied with description of a particular instance but rather must create general knowledge which is broadly applicable. This is not usually an outright contradiction, but it can create tension. Most important, the ultimate goals of the two groups with respect to the uses of the research are different. Academic investigators have a personal interest in their careers – in publication, grants, tenure and promotion – and in the advance of science. Community representatives want their problems and needs to be understood, and addressed. Much research that is done in collaboration with community partners never results in any direct benefits to the community.

Rather than belabor these issues – and there are more -- I will just say that effective and, if I may presume, honorable, collaboration requires infrastructure. The community and the academy need ongoing institutional collaboration so they can grow to understand each other and benefit from mutual exchange of ideas, wisdom and resources to create the basis for truly equal partnership. This means an up-front investment. Which somebody with money has to make.

Town and Gown

As you may have heard, my employer has agreed to fork over $31.5 million to help keep Providence from going bankrupt.

This was a very contentious situation. A few weeks ago, I came to my office to find firefighters demonstrating outside. Their pensions are at risk in the city's financial crisis and they apparently didn't think the university  was paying enough for the protection they provide.

The issues seem fairly simple on the one hand. Even with the $31.5 mil, the university pays the city about 1/4 of what it would pay in property taxes, given the immense value of its real estate. The regular folks in Providence see privileged kids from all over the country and the world getting their ticket to a life in the upper reaches of business, finance and academia that their kids have no chance for. Why should the city subsidize this enterprise when all the people see when the students come in September is New Jersey license plates?

That seems fair enough but the matter is somewhat more complicated. In the first place, that real estate wouldn't be worth whatever gazillions of dollars if it didn't happen to be Brown University. Take away the university and Providence turns into a ghost town. All those stores and restaurants on College Hill would close, the apartments would all go vacant, the price of taxable real estate would collapse. The university puts the city on the map. I'm sure all this was argued over in endless circles during the negotiations.

Still, I believe that it is both an ethical imperative, and long-term very much in the university's interest, to move aggressively to tear down the ivy-covered walls between the institution and its communities. (Metaphorically ivy-covered that is. Brown has a strict policy against ivy. If you see a wall with ivy, it's RISD. Just an odd factoid.) We need to democratize the way we do science and education. Sure, the opportunity to get a degree from Brown is always going to be limited to winners of an intense competition. We can certainly do better about the criteria, but the prize is only valuable because it's rare and that is essential to the prestige of the institution and much of its raison d'etre, which no protest from YT is ever going to change.


However, there is a lot that we can do differently. I'll have more to say on this theme.

A tough problem . . .

. . . but there are solutions, or at least ways to improve the situation. A newly recognized consequence of the epidemic of prescription opioid abuse in the U.S. is a huge increase in the number of babies born addicted. Most, though not all (for reasons not well understood) of the babies born to women who are chronic opioid users will go through withdrawal (called Neonatal Abstinence Syndrome, NAS). Doctors give them opioid replacement, such as methadone, and wean them off gradually. They end up spending typically 16 days in the hospital at a cost of over $50,000, mostly paid for by Medicaid.

Stephen Patrick et al, in the linked report, find that the incidence of NAS increased from 1.2/1,000 births in 2000 to to 3.39/1,000, in other words almost triple. Investigators have yet to sort out the direct long-term consequences for these babies -- they often have problems later but their mothers, not surprisingly, are also disproportionately likely to smoke, drink alcohol, have poor nutrition and so on, and the babies go on to have a disadvantaged social environment. They have an increased risk of low weight birth, but whether that is a direct consequence of opioids is unknown. In any case, it's a humanitarian catastrophe and oh yeah, it costs a lot of money at a time when Medicaid programs everywhere are under strain.

I've discussed this opioid epidemic here before, but just a reminder, the driving force is misuse of prescription opioids. Some people who start with prescription drugs do end up using heroin because it's cheaper; but women tend not to like needles and so the epidemic prescription opioid abuse has meant a higher proportion of women get into trouble.

The difficulty is that there are completely legitimate uses for opioid analgesics, in fact they are a great boon to humanity and some people would suffer horribly, and unnecessarily, without them. But it's difficult for doctors to tell when somebody really needs them or just wants them because she or he is addicted, or intends to sell them. But here are some ways to improve the situation:

1. Shut down pill mills. Florida had a big problem with this, clinics that exist only to write scrips for dope. The governor refused to take action for a long time (maybe he had friends in the business), so Florida also has a disproportionate problem with NAS. These operations can be identified pretty readily, and there's no reason to tolerate them except that law enforcement doesn't make it a priority. We'd do a lot more good concentrating on them than on marijuana growing and trafficking.

2. Many states have registries for opioid prescriptions. They all should have them, and doctors should be trained (and perhaps required) to check them before writing a new scrip. That way they can find outif the person has recently filled opioid prescriptions elsewhere.

3. Offer treatment on demand. Stop locking up addicts in jail, which is very expensive and doesn't do any good. Have drug courts that divert them to treatment, and actually have the treatment available (which it often is not).

4. Create more comprehensive pain programs. There are alternatives to opioid treatment that will work well for many people, but there aren't enough physicians trained in comprehensive pain management.

5. Have universal health care, including dental care. Lots of people develop chronic pain because they have untreated conditions. They show up in Emergency Rooms and they need pain relief. ER docs can't tell the people with real dental pain (or whatever) from the fakers, so they write scrips indiscriminately. If they could just have the people seen right away by a dentist, that particular tactic would instantly become obsolete.

I can think of a few more but you get the idea. This is a problem that can be solved, or at least greatly ameliorated, if we take off the ideological blinders and approach it pragmatically. And that requires a government that responds compassionately to human needs.