What I'm doing right now

Just in case people are curious about what I do for a living, here are my recent and current activities.

1. I just got a paper accepted and revised the page proofs. It's a focus group study of people living with HIV about their experience communicating with their doctors about adherence to antiretroviral medications. It's an open access journal so as soon as it's on-line I'll give y'all a link.

2. I revised and resubmitted another paper, about a new system I developed for coding and analyzing clinical encounters. The system is also part of the basis for . . .

3. An award from the Patient Centered Outcomes Research Institute to study how features of clinical communication in chronic kidney disease and heart disease are related to patients' understanding and recall of the information they get and the treatment decisions that are made in a visit. Right now we're finishing up the interview guides and protocols and waiting for IRB* approval.

4. I finished drafting a paper on racial and ethnic differences in patient-provider communication in HIV care, based on our system for coding and analyzing interactions, and sent it to a co-author.

5. I'm in the middle of a study called Explanatory Models and Decision Heuristics in HIV Care. I did a whole bunch of semi-structured interviews with people living with HIV, to find out what they understand and believe about HIV and HIV treatment, and how that affects whether they take their pills and so on. Now my mission is to develop a structured survey that can be given in waiting rooms to find out what conversations people really need to have with their docs and/or nurses. (It turns out, BTW, that people who tried this with kidney disease found out that 1/3 of people living with chronic kidney disease  do not know that the kidneys make urine. Really.)

6. I'm supposed to be analyzing data from another survey I was involved in, concerning people's perception of risk from near-highway pollution. Need to get cracking.

7. I'm working on a proposal about communication between providers and families, and how well families follow medication and infection control protocols, for kids who have hematopoetic stem cell transplants (AKA bone marrow transplants, although they don't literally transplant bone marrow.)

8. Two more papers I'm supposed to be writing . . . will get a round tuit.

I probably forgot a couple of things. In fact I know I did. Anyhow if anyone has questions about any of the above, or would like to learn more, let me know.

* Institutional Review Board. They're supposed to protect the rights and interests of human research subjects, but they can often be a source of petty bureaucratic annoyance.

Some worthwhile propaganda

Check out Science works for us, a web site created by a consortium of research universities to explain why threatened cuts in federal funding for scientific research will be bad for the economy, and bad for you. (They even have a map you can click on to see what will happen to funding that comes to your state.)

Yeah yeah, federal spending on scientific research is soshulism. Here's the problem Sen. Paul: knowledge is a public good. That means that even according to the bogus Economics 101 theory you embrace, it won't be produced in sufficient quantity by private enterprise. Of course, you don't believe in scientific conclusions anyway, you prefer that we remain ignorant.

If congress doesn't act affirmatively before January 1, federal funding for scientific research will be reduced immediately by 8%. It's already the lowest it's been in a decade, in real dollars. Funding for research (and that includes the military, BTW) is only 2% of the federal budget, but it generates huge profits for society, part of which is returned to the treasury in taxes.

Making these cuts will be absolutely nuts. Write or call your representatives in congress and tell them to make sure it doesn't happen.

The varieties of crankery

Okay, the most obvious reason why people sell bunkum is just that -- to obtain money. Pat Robinson has managed to get very wealthy by conning the rubes, but every preacher is out to make a living. True, you don't have to be a creationist to get people to put money in the plate but having your own special truth to which those smart people who laugh at you are hostile builds tribalism and loyalty and helps shake out your pockets.

The same motive applies to homeopaths and naturopaths and chiropractors. They couldn't get into medical school or didn't want to make the serious effort it requires, but this way they get to pretend they are doctors and get a fee.

Most con artists start believing their own bullshit -- it makes them more effective a the con and lets them live with a clear conscience. So they also get to believe they are actually helping sick people or saving souls. It makes the money even sweeter. So these cases are not hard to explain.

Climate change denial is rather similar -- it's mostly financed by the fossil fuel industry and associated tycoons. Just follow the money.

But that doesn't entirely explain why lots of people who aren't making money off of these schemes become passionate believers. These frauds sell in large part because the truths they deny are inconvenient, uncomfortable to downright distressing, or take some hard work to really understand. It feels better, at least for many people, to believe the bunkum, and once they start believing, confirmation bias, tribalism and just avoiding the conclusion that you've been duped all reinforce and maintain the belief against all evidence.

That doesn't explain, for example, Peter Duesberg, the virologist who to this day maintains that HIV does not cause disease. It's cost him career advancement and the respect of his colleagues and gained him nothing, as far as I can tell. But here's what seems to have happened.

When the HIV hypothesis was first proposed, like any hypothesis it took some work to confirm. At the early stages of any emerging scientific idea, it's appropriate to question it, push back, and really make the proponents of the hypothesis prove it. Indeed, most of the time they turn out to have been wrong. If the hypothesis holds up, and the critics say fine, you have overcome my objections, they shouldn't pay any price, in fact they should gain respect. But the dynamic doesn't always work that way, either within the relevant community or the individual critic's psyche. In the process of arguing with his colleagues, Duesberg evolved from a friendly critic to an adversary, and came to see conceding that HIV causes AIDS as a personal defeat. His self-esteem just wouldn't allow it. In other words it was a case of confirmation bias run amok.

The problem is what to do about it. Presenting people with ironclad evidence and irrefutable logic that says they've been just plain wrong all along doesn't work with most folks, most of the time. It just makes them resent you and dig in even deeper. Viz. Duesberg. So we come to an impasse.

My colleague Steve Sloman has an idea. Most people have what he calls the illusion of explanatory depth: they think they have a very sound basis for their belief but it turns out they really can't explain why they believe it or defend their belief effectively if you ask them.  Don't tell them they're ignoramuses or dupes, ask them to explain it to you. They may suddenly find they can't.

Catching up wit h the news

I'll get back to the deep epistemological thoughts soon, but a couple of noteworthy studies have come out over the holidays, in the general vein of less is more.

First, I'll bet your doctor has you come in for an annual checkup, assuming you are fortunate enough to have health insurance. Don't bother. Based on a systematic review, some Danish folks whose names I won't repeat because I don't know how to make the "O" with a / through it conclude that "General health checks [i.e. checkups] did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although they increased the number of new diagnoses. Important harmful outcomes were often not studied or reported." In other words, they don't make you any healthier or make you live any longer, they just get you more diagnostic labels. And, obviously, cost money. Maybe we wouldn't have such a shortage of primary care providers if they weren't busy wasting their time and ours.

See the doctor if you have a good reason to, such as symptoms you're worried about or you need a certificate or something. And of course, if you have a chronic disease that requires ongoing management. Otherwise, find something better to do.

And yet another analysis that should prompt second thoughts about screening mammography. Basically, based on data from the U.S. cancer registry called SEER, Bleyer and Welch conclude that somewhere close to 1/3 of the cancers found by routine screening would never have caused clinically significant disease; and the vast majority of the rest could have been successfully treated even if they were diagnosed later, after a palpable lump or other symptoms appeared. The basis of this conclusion is essentially that after screening became widespread, the rate at which early stage cancers were diagnosed went way up, but diagnosis of late stage cancers went down only a tiny bit. Simple arithmetic tells you that most of those cancers diagnosed by screening would not have ended up being diagnosed at a late stage. Also, this means that something like 70,000 women a year are "overdiagnosed," i.e. they are told they have breast cancer and treated for it, even though nothing bad would ever have happened to them if the "cancer" had not been found.

Again, I'm not a real doctor and I'm not giving medical advice. Certainly if your mother or sister had breast cancer, if you've had estrogen therapy, if you have never had children, you are at higher risk and have a stronger argument for getting a screening mammogram. But make your own decision -- don't let anybody pressure you to do it.

That said, this finding is not anti-medicine. Au contraire. The death rate from breast cancer has fallen a lot in the past two decades. But that is because of better treatment. Advances have been incremental so they haven't been much noticed, but they have been substantial. The contribution from screening to the lower death rate, if any, must be quite small. And by the way, better treatment is probably why screening doesn't turn out to be so valuable after all -- catching it very early isn't as important any more.

A few thoughts on science denial

Now that the election is over, we can finally start to talk about stuff that's real. I perceive a modest burst of assertiveness by scientists and the defenders of science. All of a sudden we're allowed to talk about climate change, Marco Rubio gets an actual hard time from the corporate media over the age of the earth, even Ross Douthat excoriates the Republican party for cozying up to creationism.

So I'm inspired once again to ponder why so many people are alienated from reason and reality. Now, this gets tricky. Obviously there are legitimate disagreements in this world, and the route we got from finding truth in ancient fables to figuring out that the universe is more than 13 billion years old, the earth about 4.5 billion years old, and the life we see around us and partake of results from the process of evolution by mutation and selection. If you haven't studied these matters in depth, it seems as though you're simply being asked to choose between justification from the authority of your preacher, or the authority of some snotty kid who got into Harvard whereas you never had the chance.

There isn't any magic ruler that tells us what's true. We can learn enough about a small part of science to convince ourselves, but to a considerable extent we do have to trust authority. The real heuristic we need is to choose between authorities. I can't prove to you the credibility of the standard model of particle physics or the pathogenesis of atrial fibrillation, although I can make a pretty good case for evolution.

I think there are a few different varieties of denialism. People cling to homeopathy for different reasons than they cling to creationism, or global warming denialism, or holocaust denialism, or AIDS denialism. We call these by the same term but they aren't quite the same phenomenon. I'll try to sort it out in the next post.

The Horror! The Horror!

As New Englanders grimly contemplate a month or more of Gronklessness*, an even more horrific prospect appears on the horizon: that president Obama might remove John Kerry from the Senate to the Cabinet, whereupon Scott Brown will rise from the grave, compelled yet again to devour human brains.

Massachusetts law requires a special election to fill a Senate vacancy. That's how Scott Brown became a senator in the first place. Massachusetts Democrats don't have any compelling candidates to fill a new vacancy. Just witness the ragtag band of Whotheheckareyous? who ran against Elizabeth Warren in the primary.

But wait, it gets worse. Possibly corrupt and definitely irresponsible lieutenant governor Tim Murray is making noises about running. In a well-financed campaign, he would be a gigantic human target.
Did I say well-financed? A zombie Scott Brown candidacy will be the opportunity for the wounded and enraged financiers of the Romney debacle to recover a shred of their dignity, and there will be no competition for their money. Massachusetts will be carpeted a foot deep in cash. Blimps advertising Scott Brown will hover over every city square and village green. They won't just buy every commercial slot on radio and TV. They'll buy the TV stations and run 24 hour Scott Brown infomercials. They'll buy the Boston Globe, Worcester Telegraph and Gazette, and Berkshire Eagle, and rename them respectively the Boston, Worcester and Berkshire ScottBrownforSenate.

Brown has already proved he can win a bye-election, he already has an organization and enthusiastic, experienced volunteers. The Democrats had the candidate they wanted on November 6 and pretty even finances, and Brown still outpolled Obama by something like ten points and made it close until near the end. He'll get a sympathy vote this time around as well.
Mr. President, please, in the name of all that is good and decent, don't do it! Sen. Kerry, think of the children!

*For those who don't follow the game where steroid abusers in plastic armor beat the crap out of each other, that's New England Patriots superhuman tight end Rob Gronkowski, out of action with a broken arm.

The issue you can't talk about

As a commenter who wandered over from Informed Comment to berate me on the previous post illustrates, and as David Atkins here laments, there are reasons - not exactly good ones, but reasons - why bloggers are wary of writing about the Israel-Palestine thing.

Nevertheless, I'll take a chance. First of all, just so you know, I was at one time professionally involved in Middle East related activism, as staffperson for an organization called the Lebanon Emergency Committee. This was a coalition formed in the Boston area following the invasion of Lebanon by Israel in 1982, in pursuit of the PLO. Yes, we wanted Israel out of Lebanon, among other objectives for both the Lebanese and the Palestinian people. Unfortunately neither has fared all that well since.

The fact is, the Israeli occupation of the West Bank, and the Israeli settlements there, are in violation of international law and several United Nations resolutions. There is a vast imbalance in power between Israel and Palestine, and the Palestinian people are simply being crushed, politically and economically, by a movement of settlers, mostly from Europe, who claim that God gave them the land on which the Palestinians have lived from time immemorial, and who are slowly, relentlessly, exercising this utterly absurd claim.

That's the basic reality. Are there Palestinians who deny Israel's right to exist? Certainly. But the international consensus since at least the 1960s, to which the Fatah leadership is committed, is that there should be two states.

I personally do not believe that in the modern world, we should be promoting nation states based on religio-ethnic identity at all. However, Israel is a fact, and there's no way to go back. Justice cannot be established in the past, but only in the future. And future justice demands that Israel uproot the settlements, leave the West Bank, and let the Palestinians work out their own future. Israel possesses an absolutely overwhelming advantage of military force and economic power. The country is in no existential danger. Any claim to the contrary is nonsense.

Those are among the starting points for any sensible discussion. And by the way, my comment that so provoked our guest was to condemn Hamas for launching rockets at Israel. This post, if noticed, will attract even greater outrage, I expect, from the opposite direction. As Atkins says, you can't win.

Non-ignoramuses unite!

You have nothing to lose but Marco Rubio's brains, such as they are. The theory is that if the Republicans just nominate a Latino for president, it won't matter what their policies are or whether the rest of their candidates go around bewailing the threatened surrender of Anglo-Saxon civilization to the brown hordes, they'll finally get Latinos to vote for them.

Alas, having spent 15 years working for a Latino community based organization, I can tell you from long, intense personal observation that people whose heritage is from the predominantly Spanish speaking countries of the Americas are not typically ignorant idiots, unlike the Senator from Florida:

The senator, who has recently created buzz about a potential presidential run in 2016, said that he is not qualified to answer how old the Earth is, calling the question a "dispute among theologians."

"I'm not a scientist, man. I can tell you what recorded history says, I can tell you what the Bible says, but I think that's a dispute amongst theologians and I think it has nothing to do with the gross domestic product or economic growth of the United States," he told GQ Magazine. "I think the age of the universe has zero to do with how our economy is going to grow. I'm not a scientist. I don't think I'm qualified to answer a question like that."

Note that he is even stupider than might appear at first glance. He explicitly says that the dispute is among theologians, not between theologians and people who actually know something and have arguments to make based on evidence; and he thinks that the age of the earth and the age of the universe are the same question.

Here's a dispute for the theologians. Which is stupider, Marco Rubio or a blastocyst? Either way, they're both human infants, right?

And right on cue . . .

The first thing the Republicans do after they lose an election by appealing to white racism and patriarchy is start beating up a black woman. Real smart.

Greatest hits

I just found out that something I wrote back in 2005 went comparatively viral, but I had no idea at the time. It's still relevant, I think, although the assertion in the third paragraph about current control of government is arguably out of date.

Living on the edge, but still taking up way too much space 

Nov. 5, 2005

In my checkered youth, I was at one time a community organizer in Philadelphia. I worked in black and white neighborhoods -- and believe me, the city was completely segregated. I was an exotic sight in North Phillie, but I never felt unwelcome there. In the poor white neighborhood of Fishtown, however, I felt like an extraterrestrial.

Almost everyone in Fishtown claimed to be a conservative, and expressed scathing contempt for liberals. So what were some of their conservative ideas? This was the time of the Arab oil embargo and (gasp!) gasoline at a dollar a gallon. Many of Fishtown's rabid conservatives advocated nationalizing the oil companies. Other popular conservative ideas included government sponsored health care, a higher minimum wage, stopping the developers who were deliberately creating blight so they could buy up large tracts for upscale development, massive investments in public transportation (the Kensington Ave. trolley was a foretaste of hell), cleaning up the air pollution -- all kinds of radical right wing ideas. They were mostly Catholic and went to church, but I can't remember anybody giving a shit about abortion or keeping people on life support.

Now, actual real conservatives have an iron grip over all three branches of the federal government. In public opinion polls, many more people label themselves conservative than label themselves liberal. But a majority of people also tell pollsters that they are willing to pay more taxes to protect the environment, improve the schools, and do other good things; that they want universal health care; that they want curbs on development to protect communities and the environment; that they favor keeping Roe v. Wade (that one's not even close -- 65% to 29%). 82% of Americans opposed intervention in the Terri Schiavo case by the Congress and King George. In other words that particular maneuver was less popular than legalized wife beating. And oh yeah -- the majority favor sensible regulation of gun ownership.

Now, back when I was knocking on doors in Fishtown the gay rights movement was just emerging and nobody was talking about gay marriage. I'm sure the Fishtowners would have opposed it had it come up. So score one for a position more associated with conservatism. But looking at the scoreboard, it's pretty clear that the supposedly democratically elected government is generally sharply opposed to the majority of voters on important issues of public policy.

What's going on? I confess I have left out the most important issue that the good people of Fishtown were worried about. In their own words, it was the niggers. They were all on welfare, and they were taking all the jobs. (That's right, I often got that in consecutive sentences. And by the way, I would estimate that 1/4 of the households in Fishtown consisted of single mothers on welfare, or disability pensioners.) They were going to push us into the river. They don't keep up their own communities -- why some of them moved in over in Kensington a couple of years ago and inside of a year, half the houses on the block were abandoned. (Oh yeah, that's their fault.) The nearest high school was dropping plaster on the kids heads, and there was a proposal to build a new high school in Fishtown, but the people were against it, unanimously. Why? Because black kids might have walked through the neighborhood on their way to school.

Frank Rizzo, the racist neo-Nazi mayor, was very popular in Fishtown. Now you know why.

Politics is complex. The right has cobbled together a coalition of minorities -- people who are willing to trade off issues that aren't terribly important to them for ones they really care about. Wall Street financial barons and corporate executives want low taxes on high incomes, minimal environmental and safety regulation, low wages and minimal protections for workers, and they have plenty of money to put into political campaigns. Most of them think the religious right consists of ignorant lunatics, but they're happy to scoop up the wacko vote for candidates who will favor the rich. The mass media, of course, are part of the corporate establishment and naturally favor its interests. Religious zealots may be in a minority, but they volunteer for political campaigns, give what little they have, and vote as a bloc. So that's an important part of the story.

But it is racism that makes it all possible. It is largely because of racism that we have such an underdeveloped social infrastructure compared with western Europe and Canada. Racism has divided the working class, and made the white majority mistrust social programs which they have been persuaded somehow favor the other at their expense. It is racism, and nothing else, that led to the ascendancy of the Republican Party in the states of the confederacy, once the Democrats embraced the Civil Rights Movement and resolved the contradiction between their role as the party of the Old South and the party of the urban north. It is racism, ultimately, that underlies the tendency of white Americans who hold liberal views on issues to label themselves as conservatives. Racism is still the central problem in this country. It still is. Yes it is. 

 

 

All twits considered

So I'm driving home last night and comes now Gary Loveman, operator of gambling casinos (audio link) who appears as a representative of the CEOs who met with the prez yesterday. He explains that we have to get the federal deficit under control, but if marginal tax rates are raised on the wealthy, it will destroy jobs. The mechanism is that rich people won't have as much money to gamble with, so he'll have to reduce some shifts.

Of course the interviewer doesn't challenge this. I mean, if you're the CEO of Caesar's, you're a serious person, right? I'm just a babbler on the radio, who am I to question anything you say?

At least we finally know how it is that the rich are the "job creators." They do it by gambling in Las Vegas. The Republicans had not gotten around to explaining that before.

I can tell you from personal experience . . .

. . . hospitals make money by screwing up.

I've written about this before, so first let me emphasize, no personal condolences or sympathy required, this happened many years ago and I'm fine now. Not to worry.

Without going into great detail, back when George Bush the First was bombing Iraq, I entered a Major Teaching Hospital of Harvard University through the emergency department. I had pain localized between my navel and right hip, with rebound tenderness and a fever. They told me I had acute appendicitis and they were going to take my appendix out. Eight hours after entering the operating room, I awoke severely dehydrated, in agony despite enough morphine to float William S. Burroughs for a week, and lacking my ascending colon. After opening me up they had seen, not appendicitis but rather a lesion that they decided was cancer but was actually diverticulitis. Eleven days and many travails and grievous errors and misjudgments later, I finally left the hospital.

I had insurance. However, they weren't happy with the amount the insurance company paid them. A couple of weeks later I received bills totaling more than $25,000 -- it would easily be twice as much in nominal dollars today. I told them to go pound sand and eventually they did but . . .

Hospitals get paid for doing stuff. The more stuff they do, the more money they make. Suppose you hired a roofer, who set up scaffolding incorrectly which caused a staging plank to crash through your living room window and smash thousands of dollars worth of antique glass. Would the roofer then bill you to repair the window and replace the artifacts? I think not. However, that's what hospitals do when the doctors make mistakes.

The linked article in Health Affairs reveals a major problem in efforts to control health care spending. If hospitals undertake quality improvement programs to reduce the rate of surgical errors and complications, they lose money. Not only do they have no incentive to do it, some small community hospitals might actually go broke if they didn't screw up so much.

In civilized countries such as the totalitarian dungeon to our north, hospitals are given a global budget to care for the needs of a community. It's in their interest to be competent, and efficient. So here's what we need:

We need universal, comprehensive, single payer national health care. Shout it from the rooftops.

Reality Eventuates

The Affordable Care Act, it now appears, will continue its painfully slow march toward full implementation in 2014. This has always been the essential problem: most of the good stuff that's going to happen to people won't happen until then, and that's why the opponents of the ACA have been able to rant about socialism and government takeover of health care and death panels. Once people see for themselves that nothing bad happens, game over.

However, as Timothy Jost discusses, it's going to take at least a few tweaks and also a few bucks for the ACA to really work out well. The right wing governors will have to accept the Medicaid expansion after all. Specific insurance regulations need to be promulgated (Stat!). The federal exchange needs to be set up because it appears several of the states are not going to establish exchanges out of pique. (Ideologically inconsistent, I know, to prefer federal control, but they aren't making sense about any of this to begin with.) The House Republicans will no doubt try to use extortion over the debt limit, the fiscal cliff, and federal appropriations in general to mess up the thing, whereas it actually needs some technical corrections and constructive changes.

Whether the Republicans can get away with, or think they can get away with, continuing their strategy of trying to wreck the society and the economy in the hope that the opposition will get the blame for their own vandalism, I don't know for sure. But it's looking right now like they think they can get away with it. A well-informed, honest journalistic estate dedicated to the public interest would probably stop them, but we don't have that. Look forward to the continuing hail of BS, and wish us all luck.

What frosts my pumpkin

And probably yours too. Yesterday, I had to take the day off from work to drive my mother to an appointment with a specialist physician. (Everything turned out okay.) They told her that her appointment with the doctor was at 3:00, but she should arrive at 2:30 to do all the paperwork. (So why can't they just say, "Your appointment is at 2:30"?)

So we got there at 2:30, she filled out the questionnaires, and at 3:00, they called her in to the examining suite. I then waited for 2 1/2 hours, until she finally emerged at 5:30. What the heck was going on? Answer: They did some tests, then she waited for the doctor for an hour and 40 minutes.

Now, this is a specialist. He comes to this clinic once a week, and sees only scheduled patients. He deals with no emergencies. When they book the day, they know every patient who is coming, why that person is coming, and what they are likely to have to do with that person. There is no good reason why they cannot see a person at 3:00 who is scheduled to be seen at 3:00.

The reason this happens is because of arrogance and a total lack of respect and consideration for patients. No other service industry could possibly get away with this.

We're going to fix it.

Yes, I am actually a bit less cynical today

The corporate media are, no surprise, only grudgingly conceding a Democratic victory, and pretty much universally describing the outcome of yesterday's election as essentially maintaining the status quo. It isn't.

1. The right has lost the culture wars: Gay marriage, contraception and abortion are losing issues for them now. They've lost that wedge almost everywhere. This is good news in itself, of course, but it's also an enormous clearing of the terrain for the liberal coalition.

2. Sheldon Adelson and the Koch brothers' billions couldn't buy the election because the fundamental premises behind their propaganda barrage were rejected by the voters. Yes Virginia, there is a role for government in creating a strong economy, boosting employment, and providing a safety net for the unfortunate. Rich people should pay more to help make those things happen. The basic social infrastructure of the New Deal and the Great Society is built into the bedrock of the political culture; it is unassailable, at least in 2012.

3. The right has lost the race war: It will never be possible to win an election by marshaling white racism and resentment. The changing demographics of the country rule that out forever.

4. The right has lost  the generational battle: Their electoral base is dying and the 16-year-olds who will vote in 2014 will be overwhelmingly against them.

They only held onto the House because the 2010 wave election gave them control of legislative redistricting. That advantage will gradually fade between now and 2020 as congressional districts naturally change. The Senate is considerably more liberal. Finally, the corporate media may have finally found the right-wing lies just a little too much to include in the phony balancing act, and Fox News is no longer taken seriously. Oh yeah, the religious right's influence is also clearly withering.

This is really pretty good news. The republic may endure. Now if we can really start to do something about carbon emissions . . .

Falling 24 miles

The difference is that Graham Spanier is doing it without a parachute. The president of Penn State University for 16 years, pulling down more than half a million a year in salary, traveling in the most rarefied of elite circles, and now he faces charges of perjury, obstruction of justice, and endangering the welfare of children. Whatever the outcome of the criminal case, Spanier's reputation in his own field -- family sociology and therapy -- is forever ruined. How could he possibly not have understood the likely implications of the reports he got -- on two occasions years apart -- about behavior by Jerry Sandusky that obviously, even to a layperson, raised very disturbing probabilities?

Well, the answer is, he did understand, and it seems to me quite evident from the smoking gun e-mail in which he approves a decision not to report the allegations against Sandusky to the authorities, but only to raise them with the executive director of Sandusky's charity, the Second Mile, and let him follow up.

The only downside for us is if the message isn't `heard' and acted upon, and we then become vulnerable for not having reported it. The approach you outline is humane and a reasonable way to proceed.

Penn State is a "mandated reporter," legally required to bring credible suspicions of child abuse to the attention of authorities.

The Catholic Church, PSU, the Boy Scouts, and now the BBC with the Jimmy Savile scandal -- all of these stories are eerily parallel. The Catholic Church's history of covering up child abuse was no surprise. It was pretty much common knowledge my entire life. People told jokes about it long before the Boston Globe's expose. I personally knew a guy who was viciously abused by monks at a Catholic boarding school, and another who grew up in a Catholic orphanage and, while he was not victimized himself, knew all about what was happening to other kids.

But having the same sort of tale emerge about one powerful institution after another is, I confess, a revelation to me. It seems more the norm than the exception for people in charge of organizations that are built on image and reputation to instinctively respond to this particular crime by ignoring the victims and protecting the perpetrators.

I'm still trying to parse out exactly what this tells us about the culture. Of course the people responsible are all men, and that includes the BBC which seems to have a very male dominated power structure. I can't prove that women in charge would have acted differently. So far we don't have any evidence about that, but I think most people will consider it a factor. However, it is certainly not my instinct, as a male heterosexual, to protect men who rape children. And I would like to think that my instinct as an organizational leader would be to put the organization's virtue ahead of its reputation . And even if I were entirely cynical, I hope I would be sensible enough to realize that the damage to reputation would be far worse if I got caught out  after the cover up.

So I do find this puzzling. Raping children is, to most people, the most revolting of crimes. Yet it seems also to be the one crime that powerful men are least inclined to do anything about, if it might inconvenience the institutions that give them their power. I mean, if these people were stealing from the parishioners, scouts, Second Mile participants or kiddie show audience members, I'm pretty sure there would not have been a cover up. What gives?

Speaking of evil scum . . .

We can always whip up an evil scum post by taking a look over at the pharmaceutical industry. Two pieces in the new BMJ (I think you'll just get the first 150 words or something but the Blog Oversight Organization requires that I provide links) skim the scum for us.

First, Medtronic corporation, a name you will find familiar should you be a totebagger. The Senate finance committee has found that they paid -- get this, it's not a typo or an extra zero -- hundreds of millions of dollars to doctors to pretend to be the authors of articles they drafted, edited and approved praising its product InFuse. Senator Max Baucus says, "Medical journal articles should convey an accurate picture of the risks and benefits of drugs and medical devices, but patients are at serious risk when companies distort the facts the way Medtronic has." Indeed. The editors of Spine Journal weigh in: "If surgeons had known that the lead authors of the 13 original studies on InFuse had received payments ranging from $1.7 million to $64 million [sic!] from Medtronic and that its marketing employees were co-authors and co-editors, would they have been as eager to use InFuse on their patients?"

That's all well and good but BMJ fails to name the names of those "physicians." They are all cruising along with high powered appointments and continuing to publish.

Along a somewhat different pathway of scummery, BMJ editor Fiona Godlee writes an open letter to Roche board member John Bell, "regius professor of medicine at Oxford University." Since it's open, presumably she doesn't mind if I quote it at length.

Dear John

I am writing to you in your capacity as a member of the board of Roche. As you may be aware, the BMJ has been working with the Cochrane Collaboration in its efforts to get Roche to release the raw data on the effects of oseltamivir (Tamiflu) so that Cochrane can properly fulfil the UK government’s commission for a systematic review of neuraminidase inhibitors based on clinical study reports.

To remind you of the background to this, in 2009 the BMJ published the updated Cochrane review of neuraminidase inhibitors in healthy adults.1 This took the view that, since eight of the 10 randomised controlled trials on which effectiveness claims were based were never published and because the only two that had been published were funded by Roche and authored by Roche employees and external experts paid by Roche, the evidence could not be relied on. The BMJ also published an article summarising the Cochrane team’s efforts to obtain the data from these randomised controlled trials and a feature investigation exploring the underlying issues.2 3

After these articles were published, we and the Cochrane Collaboration received public assurances from Roche that the data from these 10 trials would be made available to physicians and scientists.4 Although some further data have been released to the Cochrane reviewers, the data that were promised (“full study reports”) have not been made available. . . .

The Cochrane reviewers now know that there are at least 123 trials of oseltamivir and that most (60%) of the patient data from Roche’s phase III completed treatment trials remain unpublished. We have concerns on a number of fronts: the likely overstating of effectiveness and the apparent under-reporting of potentially serious adverse effects. Meanwhile, oseltamivir has just been added to the World Health Organization’s List of Essential Medicines, alongside aspirin and β blockers.

On behalf of the Cochrane collaborators and public health decision makers around the world, I ask Roche to honour its publicly stated promise to make available the full clinical study reports. In order for the Cochrane collaborators to properly analyse these data they will need individual patient data in electronic format.

Oseltamivir has been a great commercial success for Roche. Billions of pounds of public money have been spent on it, and yet the evidence on its effectiveness and safety remains hidden from appropriate and necessary independent scrutiny. I am appealing to you, as an internationally respected scientist and clinician and a leader of clinical research in the United Kingdom, to bring your influence to bear on your colleagues on Roche’s board. As company directors, responsibility for Roche’s behaviour rests with you, as individuals and collectively. In refusing to release these data of enormous public interest, you put Roche outside the circle of responsible pharmaceutical companies. Releasing the data would do a great deal to restore confidence in the company and its board of directors.

As you may recall, during the Great Flu Pandemic Hoax of three years back, the World Health Organization and many national governments paid megabucks to stockpile the stuff. That's your money. It's you who got ripped off.

Personal note: I'm still without electrical power but I think of it as a kind of penance. My neighborhood wasn't burned to the ground or washed into the ocean, my children didn't disappear into the raging waters, I didn't lose my business and I'm not freezing or starving. I'm blogging from work where I can also take a shower and get a good meal. Not so for millions of people.

Res Ipsa Loquitur

I get a lot of e-mail. Should I go for this?

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I'm sure all my readers will be very interested.