Prediction is hard . . .

. . .especially when it comes to the future. Marcia Angell takes a shot at it anyway  . (I try not to link to the Puffington Host, but that's where this is so what can I do? Do not rely on the site as a source for health advice or scientific information!)

Dr. Angell wishes the Supreme Court had thrown out the Affordable Care Act because a) she thinks it's going to be a train wreck and b) if they'd thrown it out, we all would have been "energized" and gotten the universal, comprehensive, single payer health care we actually need.

As I have been saying, yes, it won't work without additional reforms and what will be a very tough political struggle to move the development of the system along the right path. But why that's supposed to be more difficult than blowing the whole thing up and magically passing a single payer plan is mysterious indeed. Angell worries, as do I, that costs will simply continue to soar and that even with subsidies too many people will decide they can't afford insurance and will just pay the penalty. The problems of adverse selection will just get worse and meanwhile, the rates paid by Medicare and especially Medicaid will be so low that lots of people just won't be able to find doctors, while people who do have private insurance will have crappy plans with unaffordable co-pays and deductibles so they won't even be able to use them.

Okay, that could well happen if everybody just hits the champagne and then goes home, like I said the other day. But let's you and I and Dr. Angell all agree not to do that. We have now an opportunity for Barack Obama and non-wingnut politicians and even the occasional, rare journalist to explain to people how the market for health insurance works and why it fails; what the act actually does and how it isn't going to force your doctor to fill out a form in triplicate and get permission from a mid-level civil servant in Bethesda before writing you a prescription, nor will it put Granny on an ice floe; and what we still need to do to make the thing work properly.

Insurance companies won't like those reforms but guess what: other employers will. So will most of the physicians' organizations, that really do want the system work for their patients even if interventional radiologists won't make a million dollars a year. So will lots of people who are actually knowledgeable. The Koch brothers, by the way, don't actually give a shit one way or the other, they just want to use this as a blunt weapon with which to cudgel Barack Obama and Democrats, as a means to their entirely unrelated ends. The only people who are truly against the Affordable Care Act and the payment and delivery system reforms we still need are health insurance companies, and to some extent perhaps drug companies and medical device makers, and ignorant far right ideologues who would have been for it if a Republican president had signed it.

I still think we have a chance. But waving a magic wand and passing single payer? Not going to happen.

Let me elaborate

I made a couple of broad assertions in the previous post, I realize most readers won't know exactly what I was talking about.

In the first place, the law regulates insurance markets so that insurers must offer a basic package of benefits, and cannot engage in medical underwriting -- that is, they must sell a given policy to anyone who wants to buy it, and they have to charge the same price regardless of the person's state of health or health history. There is an exception in that they can adjust prices for age, but obviously that only goes up to age 65 at which point everybody gets Medicare so it's not a horrible problem. They are also required to pay out a minimum percentage of the premium in benefits.

That means the only way for them to maximize their profits is to get more customers, and if they want to compete on price, they have to find ways of delivering those minimum benefits for less money. That means they have to work with providers to find efficiencies, which allies their interests with some lesser-known provisions of the ACA. These create incentives and investment to experiment with new ways of organizing and financing health care delivery. The basic idea is that providers get paid for results, not for doing more stuff.

There are a lot of complexities involved, but the current buzzwords are Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH). These are somewhat overlapping concepts but the first puts more emphasis on how providers are reimbursed, and the second on how they are organized. An ACO, however organized, gets paid mostly on a capitated basis -- i.e. they are responsible for you as a patient, and they get paid an annual fee to take care of you, no matter what they do. But they are accountable in that they get paid more or less depending on various quality measures. Note that they are only accountable for the services within their organization, in other words if you get hit by a bus your trauma surgery may be paid for separately, if that's not part of the original deal.

A PCMH is probably compensated as an ACO, and an ACO probably tries to be something like a PCMH, but they aren't exactly synonymous. A PCMH means that one organization provides all, or at least most, of the services you are likely to need, i.e. your primary care doc is there and works under the same umbrella with specialists and ancillary services like physical therapy and social workers. They have a lot of extra services such as easy accessibility of a nurse if you need to talk about stuff, health educators, people to come to your home if you have complicated comorbidity or are losing your marbles who will work with you and any significant others to set up a plan for self-management, transportation vouchers if you need them to get to appointments, etc. All of this is paid for, presumably, by the money saved by keeping you out of the hospital or avoiding complications of diabetes or whatever.

Finally, there are research dollars invested through the Patient Centered Outcomes Research Institute (PCORI) to figure out what treatments work best for which patients, what the tradeoffs are of alternatives, and how to explain it to you so you can make informed choices on your own behalf; and the Center for Medicare and Medicaid Innovation which supports experiments in the organization and financing of health care as described above and tries to figure out how to deliver better results for less money.

In order to make all this work we need additional infrastructure such as electronic medical records, and decision support and informational tools for docs and patients. It's in there.

Now, actually getting individual health care providers, and institutions such as group practices, hospitals, and integrated medical systems, to take this stuff up and make it work is a long road to travel. We need to learn more about how to do it and we'll need to write new rules and regulations. Yes, there is an essential role for government in the health care industry to make this work, and it will gore many a fat ox. The political obstacle course will be as challenging as ever. But at least we've stepped onto it and jumped the first hurdle.

I'll try to say more about all this as we go along, and will be happy to answer any questions.

Celebrate briefly . . .

Good. Now sober up. If we are to make progress toward solving the critical failings in our health care non-system, we need to deal with the problem of universal access, and we need to tame the perverse market forces that suck up money while hurting patients.

The Affordable Care Act doesn't actually accomplish either of those goals -- especially with states free to refuse to participate in the Medicaid expansion, which I suspect Texas and Mississippi will do, at least for as long as they can hold out. But the Act does create a regulatory framework which makes it possible to make progress toward those goals.

If the court had overturned it -- as four of the justices wanted to do, in its entirety -- we would have faced utter chaos, economically, systemically, and politically. The price of insurance would have soared, fewer and fewer people would have been able to afford it, tertiary care hospitals and emerging integrated care networks would have faced ruin. At least now we can try to take some steps forward.

But this is not the end, or even very much progress. It just makes it possible to fight on.

What's it going to take?

I mean come on now. What has to happen to chase the global warming denialists back to the 9th circle of hell from which they came?

Would the west erupting in an unprecedented conflagration amid relentless record high temperatures convince people?

How about record lows in the extent and volume of arctic sea ice, year after year?

The ongoing collapse of the ice shelves along the Antarctic peninsula?

The earliest date that four tropical cyclones have formed in the Atlantic since records began, including a hurricane that formed at 40 degrees lattitude in mid-June?

The Midwest swinging wildly between destructive floods and exterminating drought?

What's it gonna take? Maybe we'll find out very soon, but evidently we're going to have to find out the hard way.

What Michael Tomasky Said . . .

Specifically, what he said here. It is simply baffling to me how BHO, democrats, and advocates for health care reform generally have utterly failed to defend, or even explain, the affordable care act. The act, according to pollsters, is unpopular. The people know they're supposed to hate it, but they don't know why. They don't even know what's in it.

When you ask them about specific stuff that is in it, they generally like each of the pieces, usually by a lot. What they mostly don't like is stuff that isn't in it. It is not a government takeover of health care. It does not include death panels, or rationing. It will not put a bureaucrat between you and your doctor. It will not restrict your choice of insurance plans. On the contrary, it will do exactly what Mitt Romney says he wants you to be able to do -- it will make it much easier, if you don't like your insurance company, to fire them and get a different one.

It will make it possible for people who cannot under any circumstances buy affordable insurance now get insurance and get their medical needs taken care of. It will make insurance companies take less of your premiums for profit and marketing and executive salaries and paying people to figure out how to deny you coverage or specific benefits; and put more of your money back into your health care. It will make it easier to compare insurance plans and pick the one you like. It will guarantee you a minimum standard of benefits. If you have a low or moderate income, it will give you a subsidy to make insurance affordable. And on the whole, in total, in the long run, it will create the kind of system we need to actually save money. (Alright, what I want is a single payer system that will do that for real, and now, but this is Earth One.) And so on.

Yes, apparently the majority of people don't like the individual mandate but it might help if somebody explained it to them. Right now, people who don't have insurance, if they get really sick or hit by a bus, show up at the ER and we all have to pay their medical bills. This is about personal responsibility -- the purpose is to put a stop to freeloading. That's conservative, and libertarian, and darn well right wing.

So why can't people stand up in front of a TV camera and just say all this? There is some kind of weird collective aphasia in the Democratic Party.

Speaking of evil bastards . . .

I found in my mailbox a letter from some people who call themselves "Lifeline Screening." They are going to be in my area for one day only, and for $60 they'll do an ultrasound screening of my carotid arteries. They'll also do various other screening tests if I fork over even more dough.

As they explain, my insurance will not pay for this, which is too bad because, if I want to know "Who needs to be screened?" the answer is, "[A]nyone over 50 who wants to be proactive about his or her health." They go on to tell me that my risk of stroke doubles each decade after age 55, but "my doctor won't order these screenings -- and insurance won't pay for them -- unless you have symptoms."

Wow, my doctor isn't look out for my best interests! Neither is my insurance company. It's a good thing these folks came long to save my life.

Oh wait a minute. Here's what the U.S. Preventive Services Task Force has to say:

The USPSTF recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population. (This is a grade "D" recommendation)

And why might this be. Does the USPSTF, along with my doctor and my insurance company, want me to die or be paralyzed from a stroke? Actually no, they don't. Here's some of what else they have to say:

Good evidence indicates that although stroke is a leading cause of death and disability in the United States, a relatively small proportion of all disabling, unheralded strokes is due to CAS. [I.e., carotid artery stenosis, the problem for which these people propose to screen me.]

Benefits of Detection and Early Intervention. Good evidence indicates that in selected, high-risk trial participants with asymptomatic severe CAS, carotid endarterectomy by selected surgeons reduces the 5-year absolute incidence of all strokes or perioperative death by approximately 5%. These benefits would be less among asymptomatic people in the general population. For the general primary care population, the benefits are judged to be no greater than small.
Harms of Detection and Early Intervention. Good evidence indicates that both the testing strategy and the treatment with carotid endarterectomy can cause harms. A testing strategy that includes angiography will itself cause some strokes. A testing strategy that does not include angiography will cause some strokes by leading to carotid endarterectomy in people who do not have severe CAS. In excellent centers, carotid endarterectomy is associated with a 30-day stroke or mortality rate of about 3%; some areas have higher rates. These harms are judged to be no less than small.

In other words, LifeLine Screening is a scam. They are grifters. Keep your wallet in your pocket.

An interesting review

As part of the New England Journal of Medicine's 200th birthday celebration, David S. Jones and colleagues review what I will summarize as the social context of medicine since the journal was founded. The mix of actual physical problems that people bring to doctors has changed considerably over that time, but so has the way in which they are classified, interpreted, and responded to.

The authors present, without much comment, the pervasiveness of racist and eugenic ideology in the profession in years gone by, particularly late 19th and early 20th Century. Also of interest are the problems of disease labeling -- which again, they present but don't discuss in any depth -- and the question of the importance of medical intervention versus social determinants and public health measures in creating population health.

For all its continued faults and limitations, medicine has gotten better over the years. Sure, there are still racist and arrogant doctors, but the normative ethics of the profession have evolved to very clearly demand respect for the worth, dignity and autonomy of every patient. Medical practice is not yet fully based in evidence and science, but it's one hell of a lot better than it was just 50 years ago. When I was in graduate school there was still a legitimate argument about whether medicine contributed more than bupkis, or maybe anything at all (viz. Ivan Illich) to the health and welfare of the population. No more. We waste a lot of money on overdiagnosis and overtreatment, but the net contribution of medical intervention to our health is huge.

And that''s why the problem of universal access is urgent. Medicine has gotten a lot more expensive, so that lots of people can't afford it; but it's also gotten a lot more worthwhile, so that denying it to people is equivalent to letting them starve or freeze to death. But, unlike food and shelter, the need for medical care that any given person has at any given moment varies radically, essentially infinitely, and generally for no fault of their own.

That is why I find it beyond outrageous that the rich, ignorant clowns that the rich, ignorant Bushes appointed to the Supreme Court are going to invent some preposterous legal rationale just to deprive a Democratic president of a policy accomplishment that Republicans supported eight years ago. If they put together 5 votes to do that, the legitimacy of the court will be destroyed along with our constitutional republic. Evil bastards.

The shallowness of profundity

I don't know how many of you kids are old enough to remember postmodernism, but basically it was an academic movement that claimed, in essence, that objective reality was a form of oppression. Obviously, once you and your pals agree that there is no such thing as a criticizable truth claim, you can pretty much spout any old gobbledygook you want to, and get a tenured professorship in return.

Some clever geeks wrote a computer program that generates postmodernist essays that are just as good as the ones generated by humans. You get a new one every time you go there, so I'll give you a snippet of the truly awesome one I just got:

If one examines postpatriarchialist socialism, one is faced with a choice: either accept prepatriarchialist conceptual theory or conclude that the collective is capable of social comment. Brophy[1] implies that the works of Rushdie are reminiscent of Koons. In a sense, the subject is interpolated into a neostructuralist paradigm of discourse that includes truth as a paradox.

Riding in the wake of postmodernism comes the New Age pseudo-philosopher and quack doctor Deepak Chopra, and guess what! He's been replaced by a computer too. His latest message to me is "The unpredictable creates deep facts." Now that's heavy.

Blowback . . .

Possibly the worst ever. And it's really disturbing how the corporate media have buried this story -- of course the editors and reporters don't have much judgment about what really matters. Pakistani Taliban leader Hafiz Gul Bahadur has announced a ban on polio vaccination in North Waziristan until the CIA aerial drone attacks in the region stop. UNICEF was about to launch a vaccination drive tomorrow.

I've written about this quite a bit here before but just to review, we are very close to eradicating polio from the earth. This would be the second infectious disease of humans, after smallpox, to be eliminated. I'm just old enough to have had a classmate who walked with braces and canes, and a little girl in my neighborhood who couldn't walk at all, because of polio. Even less lucky people were dependent on ventilators, or dead.

Polio still exists in three countries -- Pakistan, Afghanistan, and Nigeria. If we keep at it, we can wipe it out in a couple more years. But if we fail, we could have a global catastrophe. Most children, in places where there is no exposure liability, are no longer protected against polio. If the disease gets loose on a large scale, we'll have to start vaccinating everybody, everywhere, and in the meantime there will be lot of people paralyzed and killed.

Yes, these attacks kill combatants, but they kill lots of other people too. And they make more enemies than they kill. Now maybe they'll end up killing thousands of children. Way to earn that Nobel Peace Prize.

A meaningless distinction

That would be the question of whether Anders Breivik is insane. Like Ted Kackzynski, he very much wants you to know that he is perfectly sane, although maybe you don't happen to agree with his philosophical and political wisdom. In TK's case, the result at stake was whether he would be injected with lethal poisons or locked up for the rest of his life. In AB's case, it is precisely where he will be locked up. I suppose these questions matter, but the criterion is just silly.

Nobody actually knows what "schizophrenia" is in the first place, or even whether it is a single entity. Very likely it is not, and one way to tell is that anyone who wants to claim that either Breivik or TK has schizophrenia has to claim that he has a special kind in which many of the characteristic symptoms of the disease are absent. But really, who cares? If you don't want to call either of them schizophrenic you can give them some other disease label by virtue of their deviant behavior -- let's say sociopathy -- and inflated opinion of their own importance -- say narcissism. But it appears that the diseases of sociopathy and narcissism don't get you off the criminal hook, while schizophrenia does. Why is that?

If you want to label them as delusional you would have to claim that believing that industrial civilization has been disastrous for humanity, or that Norwegian culture is being degraded by immigrants, is delusional, but that would cover a whole lot of people who are neither criminals nor likely to be considered insane. Alternatively, you could claim that the belief that mailing out bombs or shooting participants in a political party youth camp would help bring about a desired political outcome is  delusional, but that would mean that anybody who engages in similar actions is ipso facto delusional, which means that nobody who does such things can be culpable.

The fact is that for all of us, free will is an illusion. The brain produces behavior; and the development of the brain through the interaction of genetic endowment with the life course of physical environment and social experience produces the state of the brain that produces said behavior. Claiming that one person is culpable because of the specific -- although not actually well-defined -- state his brain happened to arrive at, while another is not because of some different brain state, is just silly. It's a category error.

Time to see if I can qualify for Irish citizenship

Honestly folks, if if one schtickdreck is openly boasting that he's going to donate $100,000,000 to get Mitt Romney elected president, we do not live in a Republic. Notice, by the way, that this man is a total idiot. His reasons are that a) Barack Obama is a socialist and we're now living under socialism and b) Barack Obama is insufficiently friendly to Israel. In other words, it is loyalty to a country other than the United States, along with paranoid ignorance, that motivates him. Many people are trying to say, don't worry about it, spending all that money isn't going to work. Sorry to have to disagree -- it'll work just fine. Remember that it doesn't just buy advertisements, it buys the corporate media that get paid to carry the advertising. And it isn't aimed at you, all smart and well-informed and capable of seeing through the bullshit and hey, you don't watch TV anyway or at least you skip the ads. It's aimed at the people on whom it does work, and there are plenty of them. Hell, some of them are even as stupid as Sheldon Adelson. Tell me why we aren't completely screwed. I'm listening.

Not that I have anything highly original to add . . .

to what most people are already thinking about the stomach churning story coming out of Happy Valley, but there are some important lessons here. Philly.com is providing comprehensive coverage of the Jerry Sandusky trial and it appears the testimony is so disturbing that the university figured this was a good time to distract attention from the trial by publicly throwing its former president under the bus, releasing e-mails showing that yes, he did know about and choose not to report allegations about Sandusky because it wouldn't be "humane." Oh yeah, his last year on the job they paid him more than $1 million because, you know, it's hard to find competent leadership.

Okay, that's not exactly a distraction, but evidently they're trying to let the public know at this moment that the institution is all reformed and they're all good guys now. Whatever.

The fact is that Penn State football was an elaborate fairy tale. The entire vast institution of the university was built around it -- the demigod Joe Paterno and the generations of mythic heroes, pure of heart, mighty of sinew, imbued with noble tradition, who yearly rallied 'round the glorious banner of PSU. It was the fairy tale that brought in the millions in contributions, gave the local community its identity, and put PSU on the map. (It happens to be a great research university but ironically, people tend to think it's just a jock school.)

So, I guess president Graham Spanier just thought he couldn't afford to wake his kingdom from the dream. When it finally came, it was much, much worse.

The worst news ever?

According to a recent Gallup poll, the proportion of Americans who believe that God created humans in their present form within the past 10,000 years has actually bumped up recently, to 46%, about where it's been for decades. This is incredibly sad. In order to believe this you need to be ignorant not only of biology, geology and physics, but of history and indeed of simple common sense.

I had long presumed that generational change would push those numbers in the right direction -- that as people who grew up ignorant died off, better educated younger generations would steadily make acceptance of evolution pervasive. That the opposite is happening is deeply disturbing. Our schools are failing utterly, and so we have no future. People can now leave school rejecting overwhelming empirical evidence for incontestable fact, choosing instead atavistic ideology that survives only as a marker of tribal identity. And that has given us our utterly dysfunctional politics, where the multiple crises that confront us are met by the opposite of rational response.

Here's a very long post  from Brad DeLong on Tom Mann and Norman Ornstein discussing their new book about the Republican Party. Quoth Ornstein:

Now, one interesting question is how much can you hold together those private factors and you begin showing things that clearly cut directly against the interests and desires of their own constituency. Most of them have no clue what the government does. And if you think about it, you know, the Tea Part has a lot of older voters who don’t understand how this will affect them. Just to pick one example, cut Medicaid by 30% and eliminate the state and local tax deduction and then think about who is in a nursing home. Now they will still be in a nursing home, there will be one nurse’s aide for every 25 patients instead of one for every three, so you will never be seen. You will ring your little bell, and four days later somebody may stop by and say "oops, let’s remove that one, we are going to need another patient for this bed."

Maybe you don't see the connection, but I do.

Headlines

With 7 billion people on the planet, there are going to be a few serious weirdos. If one in a billion kills guys and mails their body parts around, kills and eats his roommate, or eats a guy's face, you're going to have an example here and there. On the other hand, your personal chances of having it happen to you are, under my stated assumption, one in a billion. Even if it's one in 10 million, is it really more important than the collapse of planet's marine and terrestrial ecosystems and the destruction of civilization?

Just wondering. Your editorial judgment may differ.

Observational Studies, Part 2

We've been handed a teachable moment by the study reported in The Lancet finding that exposure to CT scans in childhood is associated with an increased risk of cancer later in life.
This is called a retrospective cohort study. It would be impossible to do this particular study in the United States, because of our fragmented health care system. In the UK however, they do indeed have socialized medicine. While this means that Britain must be a totalitarian dungeon, it also means that they have universal access, much lower costs, and better outcomes than we do. Also the people are more satisfied with their health care. I know, The Horror, The Horror!

It also means that it is possible to link events that befall specific people at one time in their lives with their later fate. Since everybody gets their health care from the National Health Service, the records are available for every single child who had one or more CT scans. The study (by Mark S. Pearce and colleagues) included every person who did not have a prior cancer diagnosis, who had one or more CT scans while they were younger than 22 years from the years 1985 through 2002. The UK also has a central cancer registry, so it was possible to identify all of these individuals who were subsequently diagnosed with cancer in the years 1985-2008. Again, this could not be done in the United States. Finally, they developed models for total radiation exposure to the brain and bone marrow based on which body parts were scanned and the age at which it happened. This enabled them to calculate a dose-response relationship between exposure to these tissues, and subsequent blood (leukemia) and brain cancers. Because the radiation dose to bone marrow and brain from scans of the extremities is at or near zero, this gave them what amounts to a non-exposed comparison group.

The net result is a study that is in many respects as good as a Randomized Controlled Trial (info to follow in a few days). The investigators excluded leukemias that appeared within 2 years of the scan, and brain cancers that appeared within 6 years, so as to eliminate the possibility that the scan was done because of suspicion of cancer. That means that as far as we can tell, the exposures were random with respect to cancer risk. (They would typically have been done because of a traumatic injury, or abdominal pain.) The diagnoses of cancer were made by physicians who had no idea this study would ever happen and most likely did not even know that the scans had ever taken place, so it qualifies as blinded; and in any case diagnoses of leukemia or brain cancer are pretty definitive and unlikely to be much influenced by ascertainment bias.
The results are additionally compelling because there is a very pretty, linear dose-response relationship for both categories of cancer; and because the results are similar to what has been found from other observational studies such as observation of Hiroshima survivors. So this gives very strong support for causal inference.

Caveats? A couple. I said "almost as good as an RCT" because it is possible to imagine some confounders. Actually I don't think the authors even mentioned this, but head trauma is an indication for a head scan, obviously, and could plausibly be related to later risk of brain cancer. Similarly, one can imagine that there is some as yet unrecognized relationship between causes of abdominal pain or intestinal symptoms in children and later leukemia. One could also imagine that there are certain socio-economic or environmental circumstances associated with the probability of receiving a CT scan in childhood and cancer risk. However, the linear dose-response relationship would seem to argue against these possibilities.

The good news, for those of you who are now paralyzed in fear because of that abdomen scan they gave you when you had suspected appendicitis, is that the relative risk reported in the corporate media -- 3 to 7 times for the highest doses, for leukemia and brain cancer respectively -- actually represent very low absolute risk. By 10 years after exposure, you would expect one case of leukemia and one brain tumor per every 10,000 patients. Unfortunately the elevated risk, as far as we know, continues after that, probably for life, but it still adds up very slowly. One more takeaway -- an I'm volunteering this one -- this study does support the widely used assumption that there is no safe threshold for radiation exposure, that the risk for cancer is linear and that the line goes right through zero. But -- the risk at low levels is extremely small.

Finally, obviously, this is one more cautionary tale about overutilization of medical procedures. CT scans are still well worth doing under some circumstances. They are actually much safer than, say, riding in a car every day. And wouldn't you want to know if your child had a cerebral hemorrhage that might kill her? Say, because she'd been in a car crash? But, make sure there really is a darn good reason.

News update on the antibiotic resistance front

Sorry to have skipped for a couple of days, but I had a RTI -- that's a respiratory tract infection, or, to put it in English, a cold. I was at a conference in Miami, no less, and I had to at least minimally discharge my responsibilities in attending sessions where my work was discussed and presenting a poster. However, I was absolutely miserable and had no energy to do blog posts.

Do not grieve -- I'm feeling much better already. Many people in my situation go straight to their doctors and ask for antibiotics, and for reasons even I, who study physician-patient communication for a living, and not sure of, the doctors often comply with the request. This is a very bad idea because it is extremely unlikely the antibiotics will do the people any good - they have a viral infection - while misuse and overuse of antibiotics are threatening a global catastrophe.

One of many early warnings we're getting right now -- in addition to extremely drug resistant tuberculosis and methycyllin resistant staphylococcus aurea -- is drug resistant gonorrhea. This basically comes about because people receive inadequate courses of antibiotics, a function mostly of poor quality health care or over-the-counter dispensing of medications in low resource settings. The linked article from MSNBC says "Experts say the best way to reduce the risk of even greater resistance developing - beyond the urgent need to develop effective new drugs - is to treat gonorrhea with combinations of two or more types of antibiotic at the same time." That's sorta kinda true, but actually the best way is stop transmission in the first place by getting people to always use condoms. Which would also stop the HIV epidemic dead. Sigh. Not going to happen I expect. Ratzinger says it would be immoral.


On a happier note, I think you may only be able to read the first 150 words, but JAMA reporter Bridget Kuehn has the latest on FDA efforts to reduce use of antibiotics in animal feed. (I rooted around for a bit in the FDA web site but I couldn't track this down.) Unfortunately they are issuing "guidelines" for livestock producers to eliminate routine use of antibiotics in animal feed, rather than regulations. They figure, it they try to regulate, they'll get sued and it will take 20 years to work it out. So they're going with the voluntary guidelines. They are hopeful that the industry will think this is a great idea and go along with it. I'm not holding my breath but at least there is now some statement from the government that this will be in the public interest. Maybe that will help.

Meanwhile, if you come down with a cold, don't ask your doc for antibiotics.

Leavin', on a jet plane

I'm headed to Miami today for the International Conference on HIV treatment and prevention adherence. I'll let y'all know what interesting stuff I learn there.

My own little presentation has to do with differences in provider-patient interactions depending on the patient's race/ethnicity. It's not super-dramatic, but basically, there is more talk about medication adherence with Black and Latino patients, regardless of whether they have suppressed viral loads or say they are taking their pills; Black patients talk less overall; and there is less humor and empathic utterances by doctors with Black patients. This is based on my analysis of 415 recorded routine visits at 4 different clinics around the country. Don't know if it means a whole lot, or what exactly it means, but it's at least suggestive.

I'll keep you posted.

While you were being titillated . . .

. . . by the endless, wall-to-wall yet largely content-free coverage of the shocking, shocking fact that some secret service agents and military security guards like to party while they are on assignment abroad, there was in fact a summit of the Americas happening in Cartagena. The corporate media didn't bother to cover that, presumably because there was no sex involved.

Fortunately, we have Alma Guillermoprieto to reveal the secret of what happened at the summit. It seems there was an uprising by the leaders of just about all the Latin American countries against the war on drugs. This policy, launched by Richard Nixon (who was fond of wars on this and that) has pretty much been serially destroying the nations of this hemisphere. It also has done absolutely nothing to control drug abuse in the U.S. or anywhere else, although it has filled our prisons with Black and Latino men (even though white men are more likely to use illegal drugs.) It is unquestionably a colossal, horrific, atrocious failure.

However, we aren't allowed to talk about that stupid fact. Obama obviously couldn't do anything in an election year but tell them to fuggedaboudit. We're going to keep on fighting this war to the last Mexican and Honduran. Because, because, well, because it's DRUGS, that's why.

I urge you to read Guillermoprieto's piece, and then let's all get together and think of a better way.