Just a cost of doing business

Sidney Wolfe, who was head of Ralph Nader's health research group back when I was a 21 year old office assistant for Mr. Nader and is still at it, provides an interesting analysis to BMJ. Why, you may well ask, is an American activist reporting research on enforcement actions against drug companies by U.S. authorities publishing his results in a British journal? That's an interesting question. I'm sure it's irrelevant that New England Journal of Medicine takes in a million dollars or more a year in advertising from drug companies.

Anyway, as background, when the government fines a drug company for ripping off the government or poisoning patients, it makes them sign what's called a Corporate Integrity Agreement (yes, a CIA) which supposedly subjects them to special monitoring for some period of years. Dr. Wolfe finds that in spite of hundreds of millions of dollars in penalties and serial CIAs, drug companies keep on doing the same evil over and over again.

From 1991 through 2012, drug companies have paid $30.2 billion in civil and criminal penalties to the federal and state governments. GlaxoSmithKline has paid the most: $7.56 billion. Pfizer comes in second at about $3 billion.

For example, GSK paid $87 million in 2003 for ripping off Medicaid, and signed a CIA supposedly lasting till 2008. Didn't do any good, apparently. GSK paid another $150 million in 2005, again for ripping off the government, and signed a new CIA lasting through 2010. Whoops! Another $150 million in criminal penalties, and $600 million in civil penalties, for ripping off the government, this time by selling adulterated drugs. Then in 2012, GSK paid $3 billion in criminal and civil penalties for various nefarious schemes including off-label promotion, paying kickbacks to doctors for prescribing, and concealing evidence of the risks of one of its products.

So why does this keep happening? Well, GSK's profit in 2012 was $7.7 billion, more than the entire amount of the penalties they have paid in 20 years. Wolfe:

We are forced to conclude that neither the current level of penalties nor corporate integrity agreements are effective and that there is a pathological lack of corporate integrity in many drug companies.

Yep. If you are morally depraved, it's just a financial calculation. If you make more money by stealing and murdering and paying the fine than you would by honesty, go ahead and murder and steal. 

American Exceptionalism

I hope everyone is enjoying their holidays, to whatever extent you have them. I'm actually at work today but I'm all by myself. Just some things I needed to get done. Anyway . . .

Like a whole lot of nonplussed observers, I find the American habit -- nay, the ironclad requirement of acceptable public discourse -- of insisting that the United States is uniquely great, the best at everything, and exempt from the moral standards that apply to other nations not only epistemologically warped, but factually preposterous. Even our exceptional wealth, derived first from the exploitation of a sparsely populated by well-resourced continent, then enhanced by our triumph in World War II and post-war hegemony, is well on the way to depletion.

But that's the least of it. Even at the height of our national wealth and power, our welfare as a people was exceptional only for our failures. Throughout the post-war era, despite our greater total wealth, we have had less equality, more want, and worse health than western Europeans, and now even more countries are catching up to us and exceeding us in measures of social welfare. The military empire is financially unsustainable and brings us no evident benefit, yet we seem determined to squander everything it takes to maintain it. Our physical infrastructure is rotting before our eyes and out leadership in scientific and technological innovation eroding. As everyone knows, the material standard of living of most of the population has been declining for two decades, as whatever increased wealth we generate is hoovered up by the very wealthy. And yet our political discourse is dominated by an axiomatic belief that the greatest threat to our future is the possibility that we will spend the resources needed to fix these problems.

The issue of health care costs is one I think about professionally, so I'll present it as an exemplar of our broader malaise. Spending half again to twice as much as comparable nations on health care gets us worse health, which is I suppose the major theme of this blog. But why does this happen?

1. Inequitable access. For all we spend on people lucky enough to have health care coverage, there is a good 15 to 30% of the population, depending on who you count and what you consider inadequate, that can't obtain the full benefit because they can't pay for it. That doesn't happen anywhere else among the wealthy countries. It's one thing about us that is exceptional.
2. Overpayment. All the other countries have, one way or another, bargaining power with the suppliers of medical goods and services that keeps prices low. Note that this does not, as free market fundamentalists claim contrary to all evidence, result in inadequate supply or lower quality. Because of the way medical markets work, which I won't go into right now but will be happy to discuss (yet again) on request, an unregulated market results in overpriced inputs. We also have powerful vested interests, such as certain medical specialties, that essentially extract rents.
3. Overuse. About 1/3 of medical intervention is unnecessary, useless or harmful. Again, that doesn't happen in countries with rational health care systems.

And, taking a step back in the causal chain, why are we so dysfunctional? It's because of our political culture which enables rentiers and thieves to win in the legislature. They have much of the public bamboozled into thinking that solving national problems and producing some modicum of justice will, by some unexplained mechanism, make people not be "free"; and that it will mean stealing from them to benefit the unworthy. Racism has a lot to do with this, and so does our frontier history and our puritan heritage and a whole lot else I'm sure.

But if the medical-industrial complex continues to rob the public as it is doing, and medical costs grow in the future as many fear they will, national and local government will find it increasingly difficult to pay for education, physical infrastructure, sustainable energy and other critical investments, and social welfare. Our economy will be hollowed out, and our future bleak. Yes, it would be good to stop squandering money on useless military hardware and soldiers with nothing good to do, but that is actually a much smaller problem on a purely cost basis.

What is to be done? Many say the Republicans have become too extreme to be credible, yet they continue to win elections. The consensus prediction is that they keep the House and maybe even grab the Senate next November. There is no penalty for lying to the public, the corporate media just transmit it, and even amplify it by running with whatever conventional narrative the liars manage to establish. Oceans of unaccountable, anonymous money will continue to drown the electorate.

What is to be done? I have always believed we need to organize. Old models of organization, through labor unions and traditional issue based and identity politics, aren't working well any more. We need to innovate. I will continue to think about this, I hope you will too.

Recommended Reading

Sorry for erratic blogging of late, family responsibilities have intervened. Anyway . . .

Your Intertubes have somewhat degraded the world of print magazines, obviously, and made it harder for good writers and thinkers to get paid for all that verbiage production. But it also means there's a lot of good free stuff out there and I commend your attention to Democracy: A Journal of Ideas.

There's a lot that's worth your attention this month but I'm going to assign Hanauer and Beinhocker with a critical look at capitalist ideology. (Oh nooo! Are they commies?) This is not actually at all original, it's an accessible review of your basic social democratic thinking. However, it is sad that this very compelling and human-centered view of the economic world is pushed to the furthest margins in our mass discourse.

The essential critique of GDP as a measure of economic health is one I've made here. I should probably get over the fetish of not repeating myself because that's buried somewhere in the archives and forgotten. But here's a money quote from H&B:

How can it be that great wealth is created on Wall Street with products like credit-default swaps that destroyed the wealth of ordinary Americans—and yet we count this activity as growth? Likewise, fortunes are made manufacturing food products that make Americans fatter, sicker, and shorter-lived. And yet we count this as growth too—including the massive extra costs of health care. Global warming creates more frequent hurricanes, which destroy cities and lives. Yet the economic activity to repair the damage ends up getting counted as growth as well.

Yep. More and more money flowing through the pipes is not what makes for a better human condition. We need to radically wrench the discourse away from this deeply evil idea. Or we are doomed.

If this is really true, words are inadequate

Dahr Jamail takes a walk on the dark side of climate science -- that minority, but a substantial and credible minority, of scientists who are staring into the abyss. These are the ones who foresee strong positive feedback effects on climate as melting permafrost causes massive releases of methane into the atmosphere. They believe it is possible that global average temperatures will jump by 3 or 4 degrees centigrade on the time scale of a couple of decades. They foresee acceleration of the ongoing mass extinction, and the destruction of life support for the vast majority of the human species. Seriously folks, they're talking about remnant populations in the arctic and Antarctica.

And no, these people are not on the fringe. The point is, the forecasts we generally see are consensus forecasts -- they're somewhere down the middle, in fact somewhat conservative.

How about this prediction? Climate change will not be an important issue in the 2014 or 2016 political seasons. We aren't going to pull our collective heads out of the sand until it's so hot our eyebrows burn off. This must be our relentless focus, our most important political demand. Stop burning fossil fuel.

Situational Ethics and Eric Snowden

I haven't said much about the national surveillance state and the man who showed it to us because I haven't felt I had much to add to the most excellent commentary of many others. But now that the NSA is undertaking a PR blitz, aided and abetted by the formerly journalistic enterprise 60 Minutes, I finally feel moved to toss in my tuppence.

First, Glenn Greenwald talked with ABC News and had something surprising to say:

[Snowden] was very concerned that the government would find out what it was that he was planning on doing before he got a chance to meet with us and turn over the materials. I remember at the time thinking that he was probably a little paranoid in thinking there was this massive surveillance state that would be monitoring what it was that we were doing. Then once I did get the documents, and was able to read through them, and report on them, I realized that actually it was a byproduct of my ignorance, not his paranoia -- that we really do live in a kind of a surveillance state and he was quite right to be that worried.

I don't know if you were familiar with Greenwald's work before Snowden gave him the goods, but I read him regularly for years, ever since he was an independent blogger. And believe me, if Glenn Greenwald did not believe that we were under massive, secret surveillance just about nobody outside of the elect had a clue. And the courts were useless. The courts consistently found that nobody had standing to sue to find out what was going on because nobody could prove that they had been targeted, since it was all a secret. And members of Congress, who knew something about it but who had in fact been lied to about many matters, were forbidden by law to disclose what they knew publicly. So there was no oversight and no accountability, and no possibility of it. Anthony Romero of the ACLU explains this in more detail.

Snowden violated the law, and a specific oath. And he did not accept the penalty for his lawbreaking as is specified in much civil disobedience doctrine, although he has certainly paid a very high price. But this is not a standard set up for civil disobedience either. Jim Crow was not a secret, war is not a secret, and the penalty for sitting down at a lunch counter or throwing blood on a missile is not life-destroying. (Nelson Mandela was an armed insurrectionist, which is not civil disobedience, and he did not willingly accept his penalty, he got caught, with the help of the CIA. Whole different kettle of fish.)

Snowden discovered massive, almost unimaginable violations of the fundamental principles of democracy and individual rights around which there is a very broad, non-partisan and trans-ideological consensus in the United States. The atrocities he revealed would never have been known to the people who were paying for them, form whose benefit it is ostensibly being done, and who believed they enjoyed fundamental rights of protection from such practices, had Snowden not acted as he did. And the only reason this was all secret is because the perpetrators -- including two presidents -- knew damn well that the people would never tolerate it.

So he had no other ethically defensible choice. He had unparalleled courage to do what the truth demanded. Absolutely, he should be given amnesty and the opportunity to rejoin our society as a respected citizen -- and a hero.

"Antidepressants"

I put the title of this post in quotation marks because I believe that even the name of these chemicals is misleading. Alan Frances, who led development of the DSM-IV, pretty much stands by that work but he really, really doesn't like the DSM-V. (I don't particularly like either one of them, but Frances is reasonably up-front about the limitations of psychiatric nosology, and his contribution to the debate over the DSM-V has been largely helpful.) Anyway, in the linked essay Frances and Christopher Dowrick offer the astonishing factoid that 11% of the U.S. population over the age of 11 currently takes an anti-depressant.

Wow. These are drugs that have numerous serious side effects, are essentially addictive for many people in the sense that they can't stop taking them without experiencing intolerable symptoms, and they don't actually treat any known disease. Yep, I meant that. There is absolutely no evidence -- in fact compelling evidence to the contrary -- that a shortage of serotonin in the brain does not cause, and is not even associated with, the collection of symptoms labeled "depressive disorder." The way they get approval for these drugs is to ask people some questions -- from, for example, the Beck Depression Inventory -- feed them antidepressants, and then see if there is a "statistically significant" difference in the amount of change in how they answer the questions, compared to people who take a placebo.

Sample questions (pick the answer that best applies to you)

0 I am not particularly discouraged about the future.
1 I feel discouraged about the future.
2 I feel I have nothing to look forward to.
3 I feel the future is hopeless and that things cannot improve.

0 I don't feel I am being punished.
1 I feel I may be punished.
2 I expect to be punished.
3 I feel I am being punished.

It doesn't matter if you're say, serving a life sentence, or living in Aleppo, if you get a high score on this test you have a disease called depression. It turns out that for people diagnosed with major depressive disorder, clinical trials tend to show that about 15% of them have a response in how they answer these questions that exceeds the response to placebo. Or so it seems based on the data we've been able to see. Selective publication and data massaging are ubiquitous in this field.

Anyway, as Frances and friend tell us, according to the DSM-V if your spouse or parent or child  died two weeks ago, and you're still feeling sad, you have a disease. And you should take pills. That is a) nuts and b) evil. There is indeed terrible suffering that comes upon some people, not necessarily in reaction to any particular unhappy event, and that won't lift. We don't understand why, and for some of these people, antidepressants may give some relief. Others, not. But . . .

A lot of suffering is just the human condition. It comes with the big brain, the curse of consciousness, and the indifference of the universe. Let's all try to love and succor each other. But stop taking the damn pills. Thank you.

And while we're on the subject of the FDA . . .

Steven Nissen in BMJ has a rant that could strip paint, or strip the bark off of both the FDA and GlaxoSmithKline. After all these years, I'm still getting used to the apparently universal psychopathy of pharmaceutical executives. This one makes Charles Manson look like a sweetie pie.

Specifically, in case you didn't know, in 1999 Glaxo got approval for rosiglitazone, a drug to treat diabetes. The approval was based on a so-called secondary endpoint, specifically that it lowers blood sugar. However, even before approval publicly known studies showed that people who took it appeared to have an increased risk of adverse cardiovascular events such as heart attacks. The FDA went ahead and approved it anyway, but the Europeans required a post-marketing study called RECORD.

Under the brand name Avandia, rosiglitazone made huge bucks for GSK, but meanwhile, secretly, the company did a meta-analysis that found that yes, it raised the risk of cardiovascular events substantially. They told the FDA, but both parties kept this information secret from the public.

Nissen got access to the data from rosiglitazone trials through a lawsuit, and he found that the drug increased the risk of death by about 64%. At this point, Nissen writes, "FDA officials were infuriated with me for challenging the drug's safety." When the RECORD trial was published in 2009, it didn't show the increased risk, and the FDA convened an advisory panel which Nissen says was intended to "exonerate" the drug. But the study was garbage. The new Deputy Commissioner appointed by Obama held honest hearings, and the panel voted to remove the drug from the market or tightly restrict its use.  The New York Times later found that GSK had known since 1999 that an alteranative drug was safer, and concealed the information. But the FDA kept trying to reanalyze the data to prove that rosiglitazone was safe after all.

Now let's be clear here. We're talking about killing people for profit, with the collaboration of a federal agency. The common term for killing people for profit is felony murder. That is not very nice. But drug companies have been caught doing it again and again. Sometimes they pay fines, sometimes they just pocket the money and laugh in our faces. These are the "makers," the "job creators," the "builders." That's where we live.

Sorry FDA, not good enough

As you probably already know or would soon even if you hadn't visited here, the FDA has finally issued regulations on feeding antibiotics to livestock. Yes, in three years "farmers" (read: owners of buildings stuffed full of pigs and cows confined in small spaces, gorging on corn and garbage, and discharging millions of gallons of shit into lagoons) won't be able to go to the local feedstore and buy antibiotics by the 80 pound bag.

No, they'll need a prescription from a veterinarian based on the assertion that they're "preventing disease." Big whoop. They'll get one.

Some consumer health advocates were skeptical that the new rules would reduce the amount of antibiotics consumed by animals. They say that a loophole will allow animal producers to keep using the same low doses of antibiotics by contending they are needed to keep animals from getting sick, and evading the new ban on use for growth promotion.

Yep, that will happen. 

Invisible Murder

My colleague Doug Brugge offers a primer on what happens to people who live within 400 meters of major highways. To expand on this a bit, there are a whole lot of pollutants that come out of tailpipes but among the most important health hazards, now that we've put various kinds of emission control devices on cars, are so-called ultrafine particles (UFPs), which are less than 2.5 microns in diameter. That's really, really small. They are completely invisible, and odorless. You could breathe in millions of them with every breath and not know it.

They go right through the lungs into the blood stream and enter cells. They appear to cause generalized inflammatory responses, atherosclerosis, and to be acute triggers of heart attacks. As Doug tells us, the WHO says that something like 3.2 million deaths worldwide are caused by ambient particulate matter, and they're responsible for more lost years of life and healthy life than lots of risks we worry about more, including physical inactivity, high serum cholesterol, and occupational injuries.

But the risk is very localized. They're very highly concentrated close to major highways -- not so much urban arteries, which was counter-intuitive for me. But the point is the vehicles are going fast on the highway, so a lot more fuel is going through the engines than is the case in urban streets no matter how congested. But get 300 or 400 meters away from the interstate, and the level goes down to background.

About 4% of Americans live within 150 meters of a major highway, which is already bad news. I would very much want to be quite a bit farther away than that. So wanna guess who those folks are? This CDC report tells us.  Anyway, you know the answer:

The greatest disparities were observed for race/ethnicity, nativity, and language spoken at home; the populations with the highest estimated percentage living within 150 meters of a major highway included members of racial and ethnic minority communities, foreign-born persons, and persons who speak a language other than English at home (Table). The estimated percentage of the population living within 150 meters of a major highway ranged from a low of 2.6% for American Indians/Alaska Natives and 3.1% for non-Hispanic whites to a high of 5.0% for Hispanics and 5.4% for Asians/Pacific Islanders. Likewise, the estimated proportion of the population living near a major highway was 5.1% for foreign-born persons, 5.1% for persons who speak Spanish at home, and 4.9% for persons who speak another non-English language at home.

 Poor people, immigrants. There are a whole lot of reasons why poor people are less healthy and don't live as long, and no it's not because they're irresponsible, lazy moochers. It's because their conditions of life are unfavorable. That's called injustice.

Apocalypse maybe?

I can't remember the guy's name and I can't figure out a way to use your favorite on-line search engine to track it down, but many suns ago -- 20 years or so -- he was a highly controversial microbiologist who claimed it was a certainty -- not if but when -- that the global human population would be decimated by a global pandemic, or maybe several, of emerging infectious diseases.

The controversy was not so much over whether this was true -- a lot of people in the public health field, of various disciplines, tended to think so. The controversy was because he gave the impression he thought this would be a good thing. The human population is already unsustainable and becoming more so. Either we have megadeath by microbe, or by ecosystem collapse, and the former seemed preferable.

I'm not rooting for either eventuality, but I do think we need to stop having so many babies, and fast. Actually the global fertility rate has declined sharply in recent decades but not enough. Nine billion people -- the consensus number expected by demographers -- by 2050 -- all aspiring to the current levels of consumption of Europeans and North Americans -- are not a thing that can possibly work.

But what about doom by emerging infectious disease? CDC certainly worries about it and publishes an open access journal on the subject. HIV is an example of an EID that would indeed have done what the anonymous prophet predicted if it were more easily transmitted. Fortunately it's hard to catch, but it has everything else you need to wipe out much of the species -- long incubation period, so people can be walking around spreading it for a long time before they collapse on the cot -- no vaccine, no recovery, and totally deadly. Despite its wimpiness in getting from one person to another, it spread all over the world very quickly thanks to the shrinking of the planet by air travel.

We've had other episodes -- SARS, which fizzled out, novel influenza which turned out to be, meh. Actually I would say that the flu pandemic hoax of 2009-2010 -- and that's what it was, basically -- shows that yes, there are a lot of people kind of secretly wanting something dramatic to happen. The fact is that global interconnectedness, the very large human population which creates a lot of vessels where bugs can evolve and DNA recombine, and human contact with every sort of animal, does create a real risk of a new Black Death, this time globally, not just in one continent. But it's really totally imponderable. Nobody can say what the probability is that the exactly correctly nasty microbe will appear; and if it does, we'll figure it out quickly and maybe find a way to fight it before the worst happens. So yes, it's possible but I'm going to say not our biggest worry. I'm going to say that.

You kiddies really need to know this

With the outpouring of love for Nelson Mandela from across the political spectrum, you youngsters probably have a very wrong idea about history. Mandela spent 27 years in prison because the CIA handed him over to the South African security service.

The United States was a committed ally and supporter of the apartheid regime in South Africa until 1986, when Congress passed the Comprehensive Anti-Apartheid Act by overriding Ronald Reagan's veto. Reagan did not fully enforce the sanctions in the act although his successor George Bush I finally did so. Mandela was released from prison in 1991, two years after Bush took office.

Before then, Republicans labeled Mandela and the African National Congress terrorists.

Just so you know. 

Update:  Here's a fuller story from Bill Berkowitz.

Anecdotal, but it's very true . . .

Erratic blogging right now because my mother is in the hospital and I'm having to cope with various related problems. She has now been officially "admitted" but she's actually been inside the hospital, on a ward, in a bed, with IV and nurses and the whole thing since Saturday night, and yet not "admitted" until yesterday.

What does this mean? It means it's a scam, basically. Here's a somewhat explanation and here's a more formal study from some of my colleagues. Basically, three issues. 1) Hospitals are now penalized by Medicare if hospital patients are re-admitted within 30 days. If they never "admitted" you in the first place, you can't be re-admitted. 2) If you're on "observational status," you aren't an inpatient. That means that instead of being paid the flat Medicare Part A rate for a hospital episode, they can charge for all kinds of specific services and it comes to more money -- often out of pocket from the unsuspecting  victim patient. 3) Medicare can deny payment for a hospital episode altogether if they decide it wasn't actually necessary. The hospitals are trying to avoid this danger.

Problems are not only the possibility of higher out of pocket costs to patients, but compromised care. When she changed from observational status to admitted, my mother had to be moved to a different ward. That's how the hospital is organized. Ergo, different nurses and doctors. Not only is continuity compromised, but for elderly people this can be confusing and stressful.

We need a better way. With Accountable Care Organizations and capitated payment, none of this will happen. After all, it costs somebody more in the end, even if the hospital finds it more economically prudent to do things this way. If a system of care -- primary care, specialists, hospital -- gets one fee to take care of a person, they'll do it the right way. Long story made very short here, but we'll talk more about it.

Meanwhile, if you or your loved one ends up in the hospital, ask if you/they are on "observational status." If so, yell and scream. If they're really in the hospital, and getting inpatient services, insist that they be admitted. Don't take no for an answer.

About that statin controversy

I'm not a cardiologist or an epidemiologist and I don't like to make authoritative noises when I'm really just faking it. However, the recent brouhaha over new guidelines for the use of statins  promulgated by the American College of Cardiology and American Heart Association touches on many issues I do think about with some pretense of expertise, so I feel compelled to comment insofar as I can.

For those who haven't been keeping up, formerly doctors were urged to prescribe these medications with a goal of lowering Low Density Lipoprotein (LDL), the so-called "bad cholesterol." The goal of  prescribing was to get  LDL as low as possible, all the way down to 70. The new guidelines no longer call for trying to meet any particular cholesterol target; rather, the indication for prescribing is a score on a risk algorithm to predict the probability of heart attack or stroke within 10 years.

The controversy centered around three main issues. First, the risk score calculator was said by many to be inaccurate, and to overestimate risk. The whole idea of a risk cutoff in the first place is to try to balance the potential benefits of taking statins against the potential risks and costs. Obviously they cost a bit of money, although they're quite inexpensive on a per-dose basis now that many different generics are available. There are some possible side effects, including an increased risk for diabetes which would largely defeat the purpose. And a lot of people nowadays already take a lot of pills -- nowadays it's commonplace for people to have 5 or 10 prescriptions. When people have that many pills to take, a lot can go wrong, including a low likelihood that they'll take all of them as prescribed. That means statins could crowd out other medications that might be more important for some people. There's also a psychological burden. And we don't really know much of anything about possible interactions between statins and other drugs.

Another problem is that abandonment of the cholesterol target seems perverse. If statins work by reducing LDL, then isn't that the reason for prescribing them and shouldn't LDL levels be our measure of whether they are working? This is a dirty little secret of statins - it isn't clear that's the mechanism by which they reduce risk of cardiovascular disease at all. Adding other medications that further reduce LDL has not been found to provide added benefit. Many people suspect that it's actually an anti-inflammatory effect, or some other unknown mechanism, that's doing the job. But if we don't even know how they work or exactly what they are doing to our bodies, shouldn't we be more cautious?

Finally there are the usual complaints about potential conflicts of interest among the panel members, some of whom have received drug industry money.

I don't have the time or probably the expertise to evaluate all the arguments about how to balance these considerations in the face of uncertainty, but John Ioannidis comes to the rescue. If I can summarize what he seems to be saying, the fact is that nobody has an ironclad case either way. The panel worked through immense amounts of data and in the end, they had to make a best judgment, which might be wrong in either direction. It's obviously worth a lot to reduce the population risk of stroke and heart attack by even a couple of percentage points per year. Many people, including me, have a predisposition to perceive overtreatment but undertreatment is bad too.

What Ioannidis says is that what we need is what we don't have -- large scale randomized controlled trials in representative populations that can definitively answer the risk/benefit question. That would take multi-megabucks over ten or more years. Sadly, people get dug in on their own answers to unanswered questions and waste time yelling at each other when they ought to be looking for definitive evidence. That seems to be the situation here.

This is no doubt a highly unsatisfying blog post but that's the way it is.

One of life's enduring mysteries

Yesterday one of the headlines on CNN was "Mike Tyson tells Piers Obamacare is bad."

Yup, if I have one go-to person on health care policy, it's Mike Tyson. Nobody has a more distinguished career in policy analysis than Iron Mike, and there's nobody I'd rather have bite my ear off.

So, what explains the utter, screaming stupidity of the corporate media? Do they give candidates for editorial positions an IQ test and if it exceeds room temperature, toss out their resumes?

Alternatively, are they not actually blithering idiots, but on a mission to degrade the public discourse and stupefy the population? If so, why? Whose idea is it to replace the brains of the U.S. population with mush? What is the ultimate goal of the conspiracy?

Just wondering.

I basically have respect for the medical profession but this is ridiculous

Using data from the National Ambulatory Medical Care surveys (there are two because on covers outpatient practices and the other ambulatory care delivered in hospitals, mostly EDs), Drs. Barnett and Linder (no link because you need a subscription to JAMA Internal Medicine) give us some disturbing news.

Only 10% of people with sore throats have an infection that is treatable by antibiotics. And almost all of them have group A streptococcus. Good news about good ol' group A strep -- it's not antibiotic resistant, in fact it's 100% susceptible to good ol' penicillin, which by now isn't good for much else, and is also very cheap.

So most people presenting with a sore throat shouldn't get any antibiotics, and those who do, should get penicillin. Guess what? About 60% of people get antibiotics, and the vast majority of them do not get penicillin but other, more expensive antibiotics. This is ridiculous.

It's not only that this contributes to resistant bacteria. Taking antibiotics is bad for you! You should only take them if you really need them because a) there can be side effects of the antibiotics themselves and b) they wipe out your beneficial endosymbionts, in other words all that good stuff living in your digestive tract and elsewhere. You can wind up with diarrhea, and opportunistic infections such as thrush or something really nasty like C. dificile. (I had it when I was hospitalized, and believe me, es muy difícil.) We're learning more and more now about the importance of our microbiome, as it's called. Having your good bugs trashed can cause all kind of previously unsuspected bad results, including obesity. And it's wasting hundreds of millions of dollars every year.

Why do doctors do this? Beats the hell out of me. How hard is it to tell somebody, sorry, antibiotics won't do you any good, go with the chicken soup? Aaaarrrggh.

Sometimes there just aren't any reasons

As a Connecticutian (or whatever we're supposed to be called) I can't help but feel affected by the Sandy Hook disaster. And that's the word I purposefully chose for it. The State's Attorney yesterday released his report on the shooting, with this report in the Hartford Courant conveying the gist of it.

Sadly, and I know this is probably adding to the pain of parents and others who knew and loved the victims, there doesn't seem to be much we can take away from this as far as practical lessons or philosophical consolation. Yes, Adam Lanza's mother didn't have her head screwed on right, in failing to aggressively get him the help be obviously needed and probably more strangely, by making it her personal mission to make sure he had access to guns and target practice. But it's hard to think of any public policy or change in the law that would usefully address such a situation -- which is extremely rare in any case.

The report makes it clear that Lanza was deeply disturbed even as a young child, his head full of violent fantasies. Over the years he drew more and more inward, in his solitary world constantly gnawing on anger and imagining ultimate revenge on -- what? We'll never know. There is no known history of abuse or trauma. His brain just failed to wire correctly.

I've said before that the wetware is extremely powerful, unimaginably complex, and when it goes wrong, it can go spectacularly wrong. I think we make a category error by trying to classify this event in moral terms. It was the equivalent of a meteorite hitting the school. Perhaps some will feel a bit of satisfaction by casting blame on the deceased Ms. Lanza, but even there I am inclined just to say that she didn't grasp what was happening. The gun thing was a desperate attempt to connect with her son around the one thing they seemed to have in common.

And she could not imagine, let alone know, what was happening inside his cranium. It made no sense, it had no explicable cause, it didn't mean anything. It was just neurons that somehow got hooked up in a way that produced the awful result. Sadly, that's about all I can say.

The ruling narrative vs.the truth

Usually a huge disconnect there, whatever the subject. Let's consider the Affordable Care Act, shall we? You know,the trainwreck that has cost Barack Obama the trust and affection of the American people?

You might consider this a bit of self-pleading; it's from the president's Council of Economic Advisers. But hey, reporters are supposed to pay attention to them as well as to Republican senators, right? The sustainability picture for health care really is improving.

Health care cost inflation is the lowest in 50 years. The CBO has reduced its forecast of Medicare and Medicaid costs in 2020 by 10%. And a lot of this has to do with the ACA - not the part everybody talks about, where most people have insurance. That hasn't even happened yet. But the ACA changed the way Medicare pays hospitals and reimburses providers -- you know, those "cuts" the Republicans used to scare elderly voters into putting the current crop of wingnuts in Congress. That doesn't hurt beneficiaries at all -- in fact it helps them. For one thing, hospitals have an incentive to keep people healthy and at home, instead of getting paid for failure when people have to be readmitted.

The slowdown in health care cost growth is more than just an artifact of the 2007-2009 recession: something has changed. The fact that the health cost slowdown has persisted so long even as the economy is recovering , the fact that it is reflected in health care prices – not just utilization or coverage, and the fact that it has also shown up in Medicare – which is more insulated from economic trends, all imply that the current slowdown is the result of more than just the recession and its aftermath. Rather, the slowdown appears to reflect “structural” changes in the United States health care system, a conclusion consistent with a substantial body of recent research.

 

• The ACA is contributing to the recent slow growth in health care price and spending and is improving quality of care. ACA provisions that reduce Medicare overpayments to private insurers and medical providers are contributing to the recent slow growth in health care prices and spending In addition, ACA reforms that aim to improve the quality of care are reducing hospital readmission rates and increasing provider participation in payment models designed to promote high-quality, integrated care.

This whole story is being completely ignored, not only by the corporate media, but by Democratic politicians who should be explaining this to the people and engaging in a full throated defense of the achievements of health care reform. Why isn't that happening?

.

How bad can it get?

I have a confession: I somewhat self-censor myself because I don't want to be Debby Downer. That may seem a bit terrifying because I probably don't come off here as a cockeyed optimist.

So, here's the straight dope. I am not entirely sure that our American polity, our Republic, our civil society, is going to hold together. And I don't just mean a time of turmoil like the '60s or the '30s. I'm not in favor of riots but a good dose of civic unrest wouldn't do us any harm right now. No, I'm talking about the country being governable, about what's left of broad based political participation in a political regime granted consensus legitimacy evaporating. To be replaced by . . .

Dunno. Fascism, secession, or just plain chaos are all possible. Here Peter Turchin sees things falling apart consistent with a historical cycle in which concentration of wealth reaches a destabilizing maximum. The mechanism he focuses on is only a small part of the story, in my view, although there is probably something to it. Basically, there aren't enough high status social resources and formal offices to go around among the elites, so the ruling class fractures and its factions exploit popular unrest in their competition with each other. Or, a governing faction gets wise and makes needed reforms to save capitalism and the state, as in the 1930s. If that doesn't happen, you get Naziism, Communism, civil war, or a failed state.

While we do have to pay attention to the ruling class, the loss of legitimacy among the common people, increasingly left out of the fruits of economic growth and economic advance is just as important in the story. And in this particular instance, we're up against some real physical limits that haven't previously existed for modern civilization, although such limits have destroyed earlier empires. Then as now elites aren't confronting them because they are trapped in their short-term view of their own self-interest.

Anyway, projections of the solvency of the Social Security Trust Fund in 2050 don't mean shit right now. That's my point. If nothing focuses the mind like a hanging, we should probably be focused by now. But we aren't.

Update on Previous Post

I have to link to The Guardian because as of this writing, it is completely unmentioned on the web sites of CNN, CBS, and ABC. (11:00 am ET)

Representatives of most of the world's poor countries have walked out of increasingly fractious climate negotiations after the EU, Australia, the US and other developed countries insisted that the question of who should pay compensation for extreme climate events be discussed only after 2015. The orchestrated move by the G77 and China bloc of 132 countries came during talks about "loss and damage" – how countries should respond to climate impacts that are difficult or impossible to adapt to, such as typhoon Haiyan.

We are well and totally screwed.

Update: As of 11:40 am, CNN is reporting that Chi Chi Rodriguez has been hit in the groin by a golf ball.

If you get your info from the corporate media . . .

you probably know that George Zimmerman has undergone his monthly arrest. Maria Bartiromo is moving to Fox (why even have to pretend to be a journalist?). Virginia State Senator Creigh Deed was stabbed, Rob Ford clotheslined a 5 foot tall Toronto City Councilor. Obamacare is a Trainwreck! It's a disaster! We're all going to die! (If you read some liberal blogs you will also learn that in fact, more and more people are signing up for it and, just like Cervantes told you, they're getting the web site fixed and come January 1, it will be a fait acompli. Nonetheless, it is true that we are all going to die.)

What you probably don't know is that right now, as I write this, and has been true for the past week, the Annual Conference of Parties to the United Nations Framework Convention on Climate Change has been happening in Warsaw. You might think it's kind of important, I suppose, but as far as CNN, ABC, and CBS are concerned, it's a secret. That's why I've had to refer you to Climate Progress, which is kind of like Wikileaks, I guess, in that they tell you stuff Americans aren't supposed to know.

There are important issues under discussion in Warsaw. No, it's not going to result in an international agreement to save civilization and, in addition, Miami Beach. It is, however, intended to set up for an agreement to be signed in 2015. Many important issues are under discussion including raising $100 billion, which used to be a lot of money; issues of justice and reparation for damage caused by climate change (and that's very deep stuff); and how the responsibilities for reducing carbon emissions and mitigating harm are to be distributed among the nations that were industrialized early, and those that are less developed.

These are difficult questions. The U.S., as the largest source of carbon emissions to date, is obviously very much affected by them. As perplexing and divisive as it may be for us to work through these problems, it is essential for Americans to be engaged in them. The U.S. must be a constructive participant in these talks, and actively engage in the plans and goals that result, if all this talk about what Social Security and Medicare will be like in 2050 even to matter. But we aren't. It isn't even on the front page of the CNN web site. Although Jonathan Edwards' new law practice is. Along with the question of whether a Kmart ad is too "racy" and the story of a 400 pound high school football player. At least we know what's important.

Should the Redskins change their name?

Enough of this sanctimonious political correctness. The Washington Redskins proudly bear their name as a symbol of something very important in our national heritage -- i.e., racism.. I think the NFL owners should continue to show solidarity and support the 'Skins and their owner Daniel Snyder by changing the names of some of the other teams.

The New York Giants should be named the Hymies. And the jets can be the Dagos. The San Francisco '49ers, obviously, will be the Poofters. And the Arizona Cardinals, the Wetbacks. And of course, the Detroit Tigers will be the Jigaboos. The Miami Spics. Problem solved. Why can't anybody else see the obvious?

Catholic Bishops: all the moral authority of a tapeworm

I'm a sociologist, and one focus of my study is how people understand their lifeworlds and their well being. So I ought to be good at understanding major social institutions and the basis of their attraction, like for example the Catholic Church. But I just don't get why this atavistic, intellectually ludicrous and morally depraved enterprise doesn't wither and blow away.

Here's the Bishop of Springfield, Illinois organizing an exorcism to drive Satan from the body politic, "in reparation for the sin of same-sex marriage." For all of the new Pope's conciliatory words, when he was still Jorge Bergoglio he said that gay marriage in Argentina was "a 'move' of the father of lies who wishes to confuse and deceive the children of God." So Bishop Paprocki will perform an exorcism as the governor signs the same sex marriage bill.

Here's the idea, as I understand it. God is beneficent, all knowing, and all powerful. God created the universe and people (the latter "in his own image"). He put the people in a garden in which he also placed two trees, from which he instructed them not to eat. Despite his being all powerful and all knowing, another being, in the form of a talking snake, succeeded in getting the people to eat an apple, which he didn't know about at the time because he was apparently distracted elsewhere. So God cursed the people for their sin of doing what he presumably knew they were going to do and which they did because they were of the nature which he made them.

Some time later (it used to be about 4,000 years later, but since the Bishops now say they accept scientific accounts of human antiquity it's impossible to say when all this shit supposedly happened nor is it in any way coherent) God impregnated a woman with his son, who was also himself, who he then deliberately had tortured to death to pay for the sin of eating the apple, but he wasn't really dead he just rose up into the sky. That means God will no longer have to torture everybody in hell forever, just the people who don't believe this crap.

Nowadays some of the people who God made in his own image are marrying people of the same sex, which God does not want them to do, but it's happening because some other dude -- maybe the same entity as the snake, it's not clear -- is making it possible. God can't do anything about that himself, but if a bunch of old men in fancy silk dresses chant and wave incense around and ring bells and snuff out candles, maybe the snake thing will slither away after all.

The old men will do this during their breaks from raping children, of course.

The 12th Century is so over. Get used to it.

Hey Indeedy . . .

Donald Berwick was Obama's nominee to be head of the Center for Medicare and Medicaid Services but served only during a recess appointment because the Republicans in the Senate called him a socialist. (He had praised the British National Health Service, among other evidences of Commie sympathies.) He has an essay in today's JAMA, which I think you probably can't read because you don't have the magic cookie. He says stuff I've said here before, but better, beginning with:

It could be exciting. The ambitious nation that rallied to create the Marshall Plan, get to the moon first, and birth Medicare and Medicaid decides to move toward the health care it needs: universal, responsive, and affordable. But that task does not unite the nation; it rends it into political tatters.

But why? What's his diagnosis? As he points out, we're spending twice what other affluent countries are spending, and getting less. They give quality care to everybody, with better patient safety, better outcomes and more investment in prevention. Here are his explanations:

Vested interests: We pay more than any other country, which means that people and institutions are on the receiving end of all that money. They happily invest some of it in lobbying and political contributions to keep the gravy train flowing.

Diffuse interests: The majority of ordinary people who would benefit from sensible reforms aren't organized or powerful. I will add that they are also misled.

Abdication of professional responsibility: The American Medical Association opposed Medicare and every other proposal to provide government-sponsored insurance throughout most of its history. The AMA has changed on that point but doctors still don't advocate for universal, comprehensive health care, single payer or otherwise. They're more interested in keeping their incomes high.

Public distrust of science: Don't get me started. It's easy to convince people that evidence-based guidelines discouraging overtreatment and overdiagnosis are a conspiracy to "ration" health care and murder grandma, because they think science is an elitist conspiracy against the people. Thank the Koch brothers.

Contempt for the poor: If people can't afford health care, it's obviously their own fault.

There's a bit more but those are the high points. Look, the Affordable Care Act isn't the greatest policymaking ever, by a lot. It was cobbled together so as to keep the insurance companies and hospitals and AMA from torpedoing it. But it will make things a bit better, and creates a base for substantial progress in the long term.

Bill Clinton needs to shut up and butt out. The Democratic panic and instinct to retreat in this situation is just pathetic. Stand up, stand your ground, wait out the tempest. In six months, it will be a fait acompli, and there will be no going back. 

Don't Panic

By the end of this week the federroble gummint has  promised to announce progress in enrollment in health insurance through the Affordable Care Act. Via my inbox, a preview from Avalere Health -- it's going to be a very small number, maybe just 50,000.

You already know how the corporate media will play this -- there seems to be a law that you have to say "trainwreck." Republicans will yell and scream that we have to repeal this disastrous mistake, and Democrats will start panicking and filing legislation to delay the individual mandate.

Pish tosh. Avalere also points out that enrollment in Medicare Part D - the Bush administration prescription drug benefit that is now taken for granted - was almost as slow. In fact, 2/3 of the people who ultimately voluntarily enrolled did so after coverage began, and fewer than 10% had enrolled one month before open enrollment ended. In other words, if we have the same experience, the Affordable Care Act will look like a big success by March, but it will look like a miserable failure in December.

Yeah, the bad web site has slowed things down a bit, but basically, people are procrastinators. The problems with the web site will be long forgotten by November of 2014.

It's complicated . . .

That would not be any particular romantic or other personal relationship, but rather the Affordable Care Act and the bizarre non-system it is jury-rigged to somewhat improve. It is a true fact, which the prez failed to make clear (or probably didn't really grok himself) that some of those people who are getting cancellation notices are actually relatively affluent individuals who intentionally chose cheap catastrophic coverage because they figure they can afford to pay out of pocket for routine medical expenses. That single class of people will now have to pay more for more comprehensive policies, and won't get enough subsidy for it to end up cheaper, or perhaps no subsidy at all.

I wish I could have explained even that little piece of the whole story more simply. Now, whether any particular one of those people ends up better or worse off depends on whether they are hit by a bus or something next year. If they are, before their catastrophic coverage kicks in the deductible from the old policy would have been more than the premium for the new one. (Still complicated, sorry.) But, they probably won't be and in any case, they feel as though their choices has been restricted.

True enough. It's also true when you pay into Social Security and Medicare and pay your regular income taxes of course. And Randroids don't like that. But it's nothing new and it isn't tyranny. Let's be up front here: there is a redistributive element to the Affordable Care Act. It's intended to make the working poor, childless unemployed people, and moderate income people better off, and somebody has to pay for that. There's a modest tax on medical devices, a tax on very high end insurance policies, reductions in Medicare spending that come out of hospital incomes (basically), limits on insurance company expenses and profits (which are somebodies' income), and oh yeah, some relatively well-to-do people will buy insurance with benefits they don't need or want and that will help subsidize needier people.

In other words, like every public policy ever promulgated, there are winners and losers. In this case, the losers are people who can afford it, for the most part. (Not clear whether some lower level jobs in the insurance industry will be lost since they aren't allowed to do medical underwriting any more. But more customers should mean it's a wash, at worst.) But to be clear, the howling over Obamacare isn't really because it's a trainwreck, or communism, or tyranny -- it's because a small number of relatively well off small business owners and trust fund babies will have to spend a few bucks they were planning on spending elsewhere. You can object to that if you like, but that's really what the issue is.

yes, we are idiots

I checked out one of your major broadcast network evening news shows last night. Item 1: Obamacareyaddayaddayadda. Item 2: Miami Dolphins 300 pound lineman is allegedly bullied. Item 2: IPCC issues new report. Commercial.

What sayeth said IPCC report? Oh, just stuff like this:

• Warming of the climate system is unequivocal, and since the 1950s, many of the observed changes are unprecedented over decades to millennia. The atmosphere and ocean have warmed, the amounts of snow and ice have diminished, sea level has risen, and the concentrations of greenhouse gases have increased.
• Each of the last three decades has been successively warmer at the Earth’s surface than any preceding decade since 1850. In the Northern Hemisphere, 1983–2012 was likely the warmest 30-year period of the last 1400 years (medium confidence).
• Ocean warming dominates the increase in energy stored in the climate system, accounting for more than 90% of the energy accumulated between 1971 and 2010 (high confidence). It is virtually certain that the upper ocean (0−700 m) warmed from 1971 to 2010, and it likely warmed between the 1870s and 1971.
• Over the last two decades, the Greenland and Antarctic ice sheets have been losing mass, glaciers have continued to shrink almost worldwide, and Arctic sea ice and Northern Hemisphere spring snow cover have continued to decrease in extent (high confidence).
• The rate of sea level rise since the mid-19th century has been larger than the mean rate during the previous two millennia (high confidence). Over the period 1901–2010, global mean sea level rose by 0.19 [0.17 to 0.21] m.
• The atmospheric concentrations of carbon dioxide (CO2), methane, and nitrous oxide have increased to levels unprecedented in at least the last 800,000 years. CO2 concentrations have increased by 40% since pre-industrial times, primarily from fossil fuel emissions and secondarily from net land use change emissions. The ocean has absorbed about 30% of the emitted anthropogenic carbon dioxide, causing ocean acidification.

And? Oh, just Stuff like this:

Thousands of people in vulnerable areas of the Philippines are being relocated as one of the strongest tropical cyclones ever observed spins toward the country. With sustained winds of 315 kph (195 mph) and gusts as strong as 380 kph (235 mph), Super Typhoon Haiyan was churning across the Western Pacific toward the central Philippines. . . . As it moves across heavily populated areas of the central Philippines, Haiyan's high winds and torrential rain are expected to affect millions of people. The storm system had a diameter of about 800 kilometers (500 miles) as of early Thursday afternoon.

But you know, we can't interfere with the right of the Koch brothers to increase their inherited fortune without limit, because Freedom.

The real meaning of Republicanism

This essay in NEJM is, unfortunately, off-limits to the common rabble as far as I know, but doctors Michael Stillman and Monalisa Tailor explain what these people who are fighting to their last breath to prevent people from having health insurance are really doing. Fair use excerpt:

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer. The year before, he'd had similar symptoms and visited a primary care physician, who had taken a cursory history, told Mr. Davis he'd need insurance to be adequately evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and ineligible for Kentucky Medicaid, however, he'd simply used enemas until he was unable to defecate. By the time of his emergency department evaluation, he had a fully obstructed colon and widespread disease and chose to forgo treatment. Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation. As his wife sobbed next to him in our examination room, he recounted his months of weight loss, the unbearable pain of his bowel movements, and his gnawing suspicion that he had cancer. “If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

They go on to tell of a woman with a lung nodule who couldn't afford a PET scan -- so the surgeon refused to operate; and other horror stories. Research has found that 45,000 Americans die every year because they can't afford health insurance -- and note that these are nearly all people under 65. But the disinformation campaign has been effective: " During our appointment with Mr. Davis, he worried aloud that under the ACA, “the government would tax him for not having insurance.” He was unaware (as many of our poor and uninsured patients may be) that under that law's final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to comprehensive and affordable care."

These conservative billionaires who fund the astroturf "Tea Party" and Sens. Cruz and Rubio and all their co-conspirators are evil, repulsive, psychopathic bastards. That anybody will vote for these disgusting creeps proves that our political culture is profoundly diseased. 

Guest lecture

Here's some of what I will be saying today. The students have read two histories of the controversy over leaded gasoline and its ultimate banning. (One is Kevin Drum's famous Mother Jones article, the other an academic essay by Herbert Needleman, a scientist who was a pioneer in recognizing the harm caused by low levels of exposure to lead.) A major part of this story is of course that a powerful industry for decades dishonestly attacked science and scientists, including Needleman, in the completely amoral pursuit of economic self-interest, at incalculable human cost. This plot has been reproduced endlessly -- tobacco, acid rain, pesticides, global warming, you name it.

But you need to understand not only that this happens, but why it works. The fact is, risk assessment is hard, and inevitably freighted with uncertainty. And even after you manage to narrow down those uncertainties, there are still value conflicts about the implications of our knowledge.

In order to understand an environmental risk, you need to go through four steps:

Hazard identification

Dose-response assessment

Exposure assessment

Risk Characterization

Hazard identification means that relevant people -- those who can cause the next steps to be taken  -- recognize that some chemical or other phenomenon present in the human environment might be dangerous and we ought to study it. The fact is that most of the chemicals commonly used in consumer products or emitted into the air, water and soil have not been studied much, if at all, for their potential harm to humans and other living things. Until Needleman and others came along, this was basically true of lead. We knew it was toxic at high doses, but assumed to be harmless at the levels of exposure people experienced from gasoline and paint.

Dose-response assessment means figuring out what the consequences are of exposure to the chemical at the continuum of plausible levels and patterns. This is very difficult because, obviously, you can't experiment on people. We do experiment on animals, notably mice, but let me give you the news: mice aren't people and there are plenty of well known cases in which exposure harmless to mice are dangerous to people, and vice versa. Epidemiological data is very difficult to interpret, for reasons I have discussed here before. Basically, it's difficult to separate out the exposure of interest from everything else that goes along with it, e.g. exposure to lead from gasoline depended on where you lived and spent your time so maybe the observed effects aren't because of lead at all. A corollary is that you can't easily measure people's exposure. In the case of lead, because it persists in the body, you can measure the concentration in blood, which helps. But there will still be arguments over acute vs. chronic exposure, and yes, there are confounders that go along with blood lead levels as well as imputed exposures. And you have to know what effects to look for. If you aren't measuring the relevant endpoints, you won't see them, obviously.

Exposure assessment means figuring out who is exposed to how much of the stuff and by what routes. This is also very difficult because chemicals travel through the environment along complicated paths that are affected by all sorts of influences -- wind, rain, temperature, the food chain, human behaviors, on and on. And chronicity of exposure matters as much as amount.

Finally, risk characterization means putting it all together: somehow multiplying the dose response by people's actual exposure to say "Ultrafine particle pollution from highways is causing 180,000 heart attacks each year in North America," or something like that. (I just made up the number but it does apparently cause cardiovascular disease and also triggers myocardial infarctions.) However, that's not the only consequence of UFP pollution and you need to somehow translate all of the harms of an exposure into a common currency that can be compared with the benefits. In other words, we aren't going to give up cars, trucks and buses even though we know they cause harms. We need some method of weighing harms against benefits. And of dealing with uncertainties while we do this.

Hence, people argue. That's never going to stop but at least we can develop a common understanding of the available information. Or at least it would be nice if we could.

A righteous rant

This one from British doc Iona Heath. (I'm not 100% sure you can read this, I can't test the site without my magic cookie.) Anyway, she reminds me of Ivan Illich's famous book Medical Nemesis. Illich, writing back in 1982, argued that medicine, on balance, did more harm than good. Heath doesn't go that far, and neither do I, although in 1982 Illich had a defensible case. Medical intervention has become more effective since then, as the longer survival of people with heart disease, which I discussed a couple of days ago, demonstrates. However . . .

In addition to the downside that those longer lives are often spent in a condition of sickness and disability, medicine inflicts harms directly. First of all, money wasted on ineffective, futile or harmful medical intervention is money taken from some better use. And that includes improving the social and physical conditions of people's lives in ways that will keep us all healthier in the first place. It also includes putting disease labels on people who have no symptoms and whose only "disease" is some lab test that is outside of an arbitrarily defined range of normality.

Those people then have to live with anxiety and the sense that they aren't really healthy after all. They may take pills that cost them money and have adverse effects. They may undergo biopsies, or surgery, go back for repeated physician visits just to be told the results of yet more and more lab tests. As Heath writes:

[W]e have, for the first time in history, separated our notions of disease from the human experience of suffering and have created an epidemic of disease without symptoms, defined only by aberrant biometrics. An ever greater proportion of healthcare resources are directed towards reducing these numbers to some fictitious state of normality. In the process, those who are perfectly well are not only assigned labels that in themselves can be shown to compromise health but are also exposed to treatments with significant adverse effects. . . . . If nothing else, this serves to distract attention from the government’s failure to meet its own responsibilities for health protection through fiscal and legislative measures, such as promoting greater socioeconomic equity, nurturing vulnerable families, and such policies as minimum pricing for alcohol, and plain packaging for cigarettes.

Extending the range of what is considered abnormal clearly expands markets for pharmaceutical and other interventions, and thereby the possibilities of maximising commercial profit. . . . As more and more people previously considered normal are included within the definition of, for example, hypertension, diabetes, or breast cancer, outcomes improve: rates of hypertensive stroke or diabetic foot amputation or breast cancer mortality seem to fall. In this way, extending the definitions of disease and lowering the thresholds for preventive interventions create the illusion of improved population outcomes, while there is no difference at all in the outcomes for affected individuals. Clinicians, health policy makers, and politicians have found it difficult to resist these seductive illusions of progress.

 We are chasing a mirage. Health is not a biological state read off of an elaborate construct of structured biological measurements. It is a condition to which medicine can contribute sometimes, in some circumstances, but too much medicine is bad medicine. Somehow our culture cannot encompass that.

There's a right way and a wrong way to do things . . .

As I was walking to my car last night I saw a big, beautiful blue helicopter marked "NYPD" land at the Providence heliport, which is near my office. The brilliant thought "WTF?" came to me. It turns out that's how New York City Police Commissioner Raymond Kelly travels -- at least when Marine One is unavailable -- and he was here to give a talk at an institute belonging to my employer.

Sadly, he was unable to speak because protesters shouted and jeered him off the stage. The photograph shows him with Providence Public Safety Commissioner Steven Paré, with whom I serve on the Commissioner of Health's Emergency Medical Services Working Group, and as you can see Steve does not look particularly happy. I wasn't there but I'm not happy either. I have previously expressed my unhappiness about this on Daily Kos and a commenter said there should be a limit to the people the university invites to speak, and how would I feel if they invited Glenn Beck or Rush Limbaugh?

Well, I'd feel just great, actually. Kelly was supposed to give brief remarks and then spend an hour in exchange with the audience. That was a world class opportunity to subject him to something he almost never gets: smart, informed people asking him tough questions and confronting him with the arguments about why his policies are counterproductive, unethical and contrary to the values we Americans claim to believe in. Reporters will never do that, but there were reporters in the room and they would have heard it. Even if they were fair and balanced, they would have had to report what those smart, informed people had to say.

Now that will never happen. Instead all we know is that east coast pointy-headed liberals won't even let the guy talk if they don't agree with him. Well, evidently that's true. It's also sad, and embarrassing, and it isn't smart or well-informed. It's FUAB. That is all.

Bad news?

Apparently so. Specifically, the bad news is that we're living longer. The linked analysis by Pandya et al is concerned specifically with heart disease. This is one area in which medical advances have unquestionably extended life. We haven't reduced the incidence of cardiovascular disease by much, but it doesn't kill people nearly as quickly as it used to. Fortunately, rates of smoking have declined, but the prevalence of obesity and diabetes is increasing. More people with heart disease, living longer, means a lot more people living with heart disease. These authors predict the prevalence will increase from about 11% for men and 8.6% for women today to 14.5% and 10.4%, respectively by 2030. And that will mean an enormous increase in disability, people living with poor quality of life, and of course Medicare spending.

What could be worse than that? If, as many predict, scientists figure out how to slow down the aging process by even just a little bit, say adding 2.2 years to life expectancy, that will be worth $7.1 trillion in benefits over 50 years, if we say a healthy year of life is worth just $100,000. But Medicare costs would increase by $3 trillion per year. (Social Security would go up by about $90 billion, which used to be a lot of money. All of this is in constant 2010 dollars.)

The problem is, are we willing to pay for that? We certainly could pay for it. We live in the wealthiest society ever. And we're all hoping to be in that old category some day. So shouldn't we decide, "This is a good way to spend our money"? Well, it doesn't look that way because rich people would have to pony up. And there seems to be a very strong correlation in this country between wealth and psychopathy.

Running on empty

The Republicans in congress seem to think that the not very functional Healthcare.gov website is their Watergate (since IRSgate, Benghazigate and FastandFuriousgate, among others, haven't panned out). And the corporate media seem to agree! Even John Stewart is piling on. The balky web site proves that the whole concept is unworkable, a trainwreck, and an embarrassment.

Well no. See, here's why this is not going to work as a campaign issue in 2014. They're fixing it. Day by day, they'll fix all the problems and then they will be done, and it will work just fine. And as Rachel Maddow explains via Ed Brayton, Social Security, Medicare and Medicare Part D all got off to rocky starts. Nobody remembers that now, and "Healthcare.gov didn't work right for a few weeks" is not going to be the basis of a a winning campaign in 2014.

People are worried, more substantively, that maybe those healthy young folks who we need to sign up will be discouraged by the crappy web site and we'll end up with adverse selection and a death spiral. Not to worry! The law is written so that we don't need them all to sign up right away. It would be a little bit wonky to explain in detail but basically, there's backup money and reinsurance built in to give us a year or more breathing space on that. Nice if a lot of them come in early, but not essential. Not a panic.

Here's a tip for Republican politicians: don't spend your air time making predictions of disaster that aren't going to come true, because reality will happen. Even the people who are getting ticked off now because their catastrophic coverage is being withdrawn will mostly end up happy when they find out they can get much better insurance, for not much more and maybe even cheaper if they qualify for subsidies. Just about everybody else, except for a few rich people like Ted Cruz who have cadillac plans (that will be taxed) will be better off. Even in Alabama! And they won't be communist slaves after all, either.

Once that actually, you know, happens, all the rhetoric of today will be gone the way of the snows of March. I mean, this is  evident to me. What am I missing?

Time Warp

Amanda Marcotte notices what seems to have been oddly under the radar lately, which is the Republican party taking up the cause of banning contraception. It went almost unnoticed that one of their fallback demands in the government shutdown was to eliminate the requirement for contraception coverage in insurance plans. Since 99% of women have used contraception, and only 8% of Americans think it's morally wrong, this does not seem to be a winning cause.

She has some good snark, too:

Clearly, no matter how much hand-waving is going on, many Republicans are trying to demonize contraception, a wildly unpopular position that frankly makes them look like lunatics. But they obviously don’t understand that this is what happens when they threaten to run the government into the ground to keep even a handful of women away from contraception or characterize one as “promiscuous” just because you don’t hate contraception.

Clearly, many Republicans live in a bubble world, constructed of right wing media and Bible-thumping bedroom communities where they get almost no exposure to the fact that some of their ideas are just plain weird. These politicians are supposed to be representatives of the people, but many of them clearly haven’t even considered the possibility that they sound like they’ve been transported here in a time machine from 1963. When I hear some Republican trying to imply that birth control pills are some kind of great controversy in America, I often wonder how their staffers hide the existence of color television from them, much less iPhones and electric cars. The modern world is clearly not the one they’re living in.

Well yeah. It does finally seem to have gotten to the point where their extremism, hypocrisy and detachment from reality are overcoming racial resentments and tribal loyalties to the point where even the Koch brothers' money can't save them. I'd like to think so anyway. Because the alternative, that these refugees from the 12th Century could actually seize state power in the U.S., is unthinkable.

Republicans is Weird

Now they're outraged that Healthcare.gov doesn't work right, demanding the head of Kathleen Sebelius and gearing up for endless hearings and hostile grillings of administration officials.

Am I missing something here? They don't want the website to work. If people sign up for insurance, it will be slavery, communism, and fascism. The only thing standing between us and the destruction of America as we know it is the fact that the web site doesn't work. If they fix it, we'll be living under the iron heel of tyranny like those enslaved Swedes and Canadians.

Well, actually it would be more like the Swiss, who are required by their sadistic overlords to blow giant wooden trumpets while wearing leather short pants with suspenders and expensive watches; and who also get to choose among various private insurance plans with subsidies for lower income people. Yes, it's a horrific vision. We will know that God has truly withdrawn his protection from America if the web site ever works.

The new luddites

The latest blooming meme -- transmitted by some very credible and buttoned-down thinkers, in many cases -- is that this time, the machines are taking our jobs and they aren't coming back. Yeah yeah, the power loom and the harvesting combine put people out of work, but the thereby wealthier economy found other jobs for them to do in the long run. But this time around, the machines aren't just physically powerful and fast, they're getting smart as well. The proposition is that we'll need fundamentally new social and economic structures to keep everybody supplied with an income and meaningful ways to spend their days.

Brad DeLong, no sidewalk raver to say the least, lays it out in telegraphic form. David Atkins sees IBM's Watson replacing oncologists as diagnosticians. I'm not sure that will happen, exactly -- people will still demand that a human make the final decision, I think, even though the human isn't really necessary or even doing anything regarding decision making. But the doctor will need to talk to the patient about Watson's conclusions and their implications. Still, the broader idea that even high level intellectual work is not safe for long seems to hold.

Tom Streithorts, in a compelling essay in the LA Review of Books, puts a positive spin on this as the problem of "post-scarcity economics." But he also considers that the end of scarcity is a big problem. If the economy produces all we need and more with little human effort, your labor -- of whatever sort it may be -- isn't worth anything. We distribute resources now by exchanging them for work, or giving them to rentiers and investors. If labor is worthless, then the 1% will have everything. Of course they won't be able to sell anything, because the rest of us won't have an income. You can see the problem.

The proponents of this claim say it's already happening, that the "natural" level of unemployment is rising. We'll never get back to 4 or 5 percent, and quite possibly we'll bounce off of 7.2% -- already misleadingly low because many people have left the labor force -- and see unemployment going up even as the economy grows. Obviously this is unsustainable, but the problem demands the precise opposite of what the conventional wisdom is saying. People won't just go out and find jobs if you cut off their food stamps and disability and Medicaid. There aren't any, and there won't be any.

I don't know for sure if this is true -- it was the dystopian vision in Vonnegut's novel Player Piano, and other visionaries have been imagining this scenario for a long time. But we need to think this through.

Apparently size does matter . . .

. . . for some people anyway. I have an excellent e-mail spam filter, and it never stops anything that should get through (I don't think, anyway). But, just for the heck of it, the other day I checked my spam folder.

G-mail only keeps the spam for 30 days, but 30 days worth turned out to be thousands of items. Ninety-five percent of which offered to enlarge my privates. One after another after another. Then the twentieth would be touting a penny stock. That was it. I deleted the entire folder and checked by 30 minutes later just to see what was happening. There were already 250 offers for anatomical enhancement.

Obviously, people wouldn't be doing this if it wasn't making them money, and we'd still be seeing Nigerian princes and Viagra if that's what was selling, Ergo, there are a helluva lot of guys out there who feel seriously defective. This could account for the gun culture and pickup trucks jacked up to six feet. Also the invasion of Iraq. In fact, come to think of it, Tom Friedman explained it just that way -- that's why he was for it, because it would make him prouder of his peter. Could this be the key to much of what ails our politics?

Hoisted from my comment . . .

On Charlie Pierce's blog  (which I heartily commend):

Some people here may view what I'm about to say as a bit contrarian, but believe me Paul Krugman agrees with me. Long-term, the cost of Medicare -- and Medicaid, and health care in general, but let's talk about medicare specifically -- is indeed a big problem, and it would be a good idea to start to get handle on it soon. (Conflating this with Social Security is indeed a scam.) Unfortunately, no politician, including BHO, is talking about the true nature of the problem and the needed solutions. No, we don't have to cut benefits, make beneficiaries pay more out of pocket, or even means test it (which would produce trivial revenues/savings). But we do need to a) pay less for drugs and overpaid medical specialists; b) stop doing unnecessary, useless and even harmless procedures (which is what Republicans call "death panels"), which requires basically changing the way we pay for health care; and c) invest more (not less as we are now discussing) in public health, social welfare and environmental protection programs that promote health, prevent disease, and will more than pay for themselves in avoided medical costs. And we need to do more comparative effectiveness and cost effectiveness research so we can figure out how to do all of the above right. That's the discussion we need to be having, but we aren't going near it.

My (unpublished) letter to the NYT

Much to my surprise, they sent me an e-mail saying they were considering publishing this, would I confirm I am the author? But of course they did not.

I am baffled as to why every journalist, including your own headline writer and reporter, are compelled to append the absurd phrase "the God particle" every time they mention the Higgs boson. The Higgs mechanism, Higgs field and Higgs boson have nothing whatever to do with God, an imaginary entity with no relevance to physics. Please stop it.

Reporters seem prone to these ridiculous verbal tics. I have written previously about "James 'Whitey" Bulger" and "Steven 'the Rifleman" Flemmi." Apparently it was illegal simply to print the men's names. Reporters also don't seem to know that they can stop using the word "alleged" after the person is convicted. Actually I don't think they know what it means or why they're supposed to say it in the first place.

Actually I'm being grumpy because I'm so disgusted with them on more substantive grounds. But you already knew that.

The real problem with health care in the U.S.

Here's a systematic analysis and a plausible tale told by Buz Cooper. In a pistachio shell:

Problem: U.S. spends more than 2X as much on health care as other affluent countries, gets worse health in return.

Buz says: :

1) Well, kinda, but U.S. is more affluent than most, so as a pct. of GDP we only spend 60% more.

My comment: Why does it follow that we should spend more on health care just because we're wealthier, if we aren't getting more for it? We don't eat six meals a day, or go to school for 30 years. If there's a "right" amount of health care we should just buy that much and spend more of our money on something else. But please go on.

 2)  The price of health care inputs is higher in the U.S. than elsewhere. Further correcting for that, we're only buying 31% more.

My comment: This is a good point, up to a point. On the other hand, given your point 1, incomes in the U.S. are higher than elsewhere so we would expect to pay higher salaries to doctors and nurses and EMTs and so on. But, on the other other hand, there's no reason why we should be paying higher prices for drugs and devices; and even in terms of our own general affluence, some medical specialties are definitely overcompensated. But either way yes, it's true that the higher spending doesn't entirely consist of higher consumption.

3)  The remaining 31% can be explained by general inequality. Poor people, of whom we have a lot compared to Europe and Canada, are less healthy and therefore need more health care.

My comment: Now you're talking. We need to spend much more, not less, on social welfare -- making sure that kids are well fed and educated; creating safe urban environments; providing affordable mass transit to connect people with jobs, and educational and cultural opportunities; providing affordable child care so parents can work safe in the knowledge that their children are well cared for; making sure decent housing is affordable for working people. And all that jazz. If we do that, we can get a huge return on our investment -- we'll save money on health care, have a stronger economy, and have healthier happier more fulfilled people. 

So why are we talking about doing the exact opposite? How did this moronic discourse come to rule our politics?

From Habermas to Cervantes

Habermas says that metaphysics is dead, epistemology is on life support, what really matters is epistemology. The philosophy of knowledge can only be pursued as the philosophy of communication. If I convince myself of a truth, and most do not agree with me, of what use is such a truth? Human reality has ineluctable elements, but it also has a huge socially constructed portion. How can we sort out the variety of claims -- of truth per se, or other kinds of validity -- and once have put them in appropriate buckets, how can we evaluate them? And how do we talk with each other about all of this?

I think these are indeed the pressing questions right now. With powerful people inhabiting inconsistent realities, we need to do better than just dismiss those wackos, or murder them, or whatever. We must figure out how to talk with each other. You go, Jurgen!

While Rome burns . . .

Of course, the wingnuts don't believe in the fire even as it scorches their own asses. BMJ today reminds us that antibiotics will stop working for us unless we stop feeding them to livestock. The Brits actually have pretty good policies about this but it doesn't matter because lots of other countries don't and antibiotic resistant pathogens cross international borders as freely as the wind. We might want to do something about this before our kids start dying of staph infections. We might.

Of course, that might actually be merciful if we don't urgently start to deal with climate change. But you know, it's a hoax. Thanks, I feel better now.

This is getting scary

I like to think that I've had a productive research career so far, that the methods I've developed are promising, and that I have a chance in the years I have left to help people take better care of themselves, work more effectively with their physicians, prevent some bad outcomes, and even save us all money in the process. But I've only been able to do this because the American people have valued medical and health services research, and been willing to pay for it. If that isn't true any more, my work is over. I'm not sure what other kind of  job I can get right now, but I need to start thinking about it. That's kind of sad.

Anyway, in case you didn't know it, the work we do is essential if we're going to provide a decent level of Medicare benefits to the growing elderly population in the coming decades. That is a legitimate concern. No, not the spending on food stamps and environmental protection and food safety and veterans benefits and Headstart and diplomacy and highways and bridges and all that stuff that the Republicans have already cut and are demanding to cut further. But the long-term fate of Medicare is a real problem.

But here's the fact: we don't have to limit benefits or make seniors pay more out of pocket or even means test Medicare. (Which maybe sounds like social justice but is a very bad idea politically and would save scarcely any money.) We can get most of the way there by getting more bang for our bucks. Figuring out how to do that is what we do. And we actually understand the problems, unlike the interchangeably ignorant Rand Paul and Paul Ryan.

Here are a couple of examples from the new JAMA. They're very wonky, and I think you'll be stopped at the abstract anyway, which is probably a blessing. Lewis Lipsitz discusses the so-called 3-Night rule, and Steven Landers discusses the future of Medicare home health benefits.

The 3-Night rule is that in order to qualify for care in a Skilled Nursing Facility (SNF), you first have to spend 3 nights in the hospital. Back when the rule was created, it usually took that long for proper assessment and stabilization of whatever acute episode the person had suffered. The rule was intended to make sure people didn't receive skilled nursing care, which is quite expensive, unnecessarily. But, nowadays, it's often the case that somebody come into the ED and they can quickly receive whatever acute services they need and could be immediately sent on to a SNF without even being admitted. However, if that happens, Medicare won't cover the bills in the SNF, which few families can afford. What often happens is that doctors end up keeping people for three nights, just so they'll qualify, but hospital care is even more expensive than SNF care. Also, being in the hospital is bad for you, especially if you're old and frail.

So why not just bag the rule? Well, a funny thing can happen. If people who are in a nursing home but not receiving skilled nursing care, the nursing home gets a relatively low reimbursement. If the person has some sort of a setback, the facility can decide to start charging the SNF rate even if the person doesn't really need skilled nursing care. If they have to send them to the hospital instead, and get a doctor's authorization, they can't get away with that. The result is that waiving the 3-Night rule so far has not consistently demonstrated cost savings. But, if you structure payment and regulation correctly, you could indeed get both cost savings and better experiences and outcomes for patients. It takes policy wonks to figure out how to do this correctly, and well-designed trials and data analysis to prove what works and what doesn't.

There are similar issues with home care: how to get people the services they need, that can keep them at home and out of the hospital or nursing home, without overpaying or inviting fraud. If we can figure out how to do these things correctly, along with many other challenges, we can make Medicare much more sustainable while taking better care of people. But that takes a) investment up front and b) honesty and wisdom from politicians who prefer to exploit fears about Medicare to scare people into voting against their own interests. I'm talking to you Paul Ryan.