You're an ignorant idiot

Well, okay, not you or me, but most people think they understand shit much better than they really do. Psychologists can't just say that, they need a fancy term for it, so they call it the Illusion of Explanatory Depth. For example, do you know how a toilet works?* Or a zipper? (How does it unzip, anyway?)**

In the linked essay, my colleague Steve Sloman and Phillip Fernbach discuss it in relation to politics and public policy.

I'll forgive the false balance since they were getting themselves published in the New York Times, but the basic idea is, if you ask people if they say, understand Obamacare and know why they hate it, they'll say definitely, they know all about it. If you ask them to justify their position they'll say something like it's sushulism, it's a government take-over of health care, it will kill people (Michelle Bachmann says that's already happening), etc.

So just ask them this: explain Obamacare. What does the legislation actually do? Much of the time, they'll stare at you bug-eyed and their jaw will go up and down and they'll say "Muh, muh, muh." They know they're supposed to hate it, but they don't know what it is. Steve finds that after that, their views tend to moderate.

I'm afraid I don't really know what the liberal equivalent is. If somebody cares to nominate a conservative policy that liberals don't like because they don't know what's actually in it, I'll listen. Meanwhile I think this is pretty much a one-way street.

* Hint: It's a siphon. Look at the back of the base, you'll see the profile of the drain pipe. Its top is above the water level in the bowl. Take it from there.

**  Hint: You have to know what's inside the slider.

Okay, I've been flacked

Got another one of those e-mails from publicists that pour into my in-box, due to the world dominating influence of Stayin' Alive. This is that one in a million that doesn't go to instant oblivion. Ken Murray, M.D. discusses the deaths of physicians in an on-line publication that purports to be the Saturday Evening Post. I don't know what this effort has to do with the original magazine that featured those famous Norman Rockwell covers, but be that as it may.

Dr. Murray's first point, which is actually quite well known but probably not by the general public, is that physicians are very unlikely to want heroic measures to extend their lives. And it's because they've seen plenty of futile and tortuous "care" administered to others. They know enough not to want it for themselves. He writes, "To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask."

But the real question he ponders is why, given that they know this, they do it anyway. In fact, they very often do it even when people have given orders that they don't want it. It has been shown in published studies that Do Not Resuscitate Orders, and other components of living wills, are quite frequently ignored. And even where families are left to make decisions, they don't often offer "do nothing, let nature take its course" as an option. He thinks that it has little to do with the chance to make money and more to do with cultural pressure and fear of legal peril. Maybe so.

As you will recall, the effort to include Medicare payment for counseling about end-of-life options in the Affordable Care Act was scuttled because of mindless fools, including a particularly vacuum-headed example from Alaska, started shrieking nonsense about death panels.  Well, please think about it anyway.

Ideology is weird

As NPR's Julie Rovner explains here, all those Republican governors who were yelling "Big gummint" and refusing to accept the Medicaid expansion just might change their minds and follow the example of Arkansas. It turns out Republicans just might go along with letting the federal government cover more of their citizens if the money is used to buy the people private insurance.

Now, I don't think anybody can come up with a good reason why that's perfectly okay, whereas having the state Medicaid program pay their bills is not. Oh yeah -- it means the private insurance company gets to take a cut of the money. But as far as Ayn Rand and Grover Norquist are concerned, it's still money stolen from the makers for the benefit of the moochers. Or rather, from the trust fund babies for the benefit of the toilet scrubbers and line cooks, as far as reality is concerned, which rather seems the other way around.

The real difference is, of course, that insurance execs will get bigger bonuses, a portion of which they will donate to Republican candidates. Ain't democracy wonderful.

Science marches on

As I believe I have mentioned before, I'm a lifelong (well, since age 13) subscriber to Scientific American. They've been trying to dumb it down a bit of late, but it's still a great way to keep up with what's going on in disciplines from my own. You can't read the actual magazine without a subscription, but the free stuff they do offer is here.

So, comes now Brian Switek in the latest issue with the most important and vexing mystery facing science. How did dinosaurs do it? And by "it," I mean what you think "it" means.

The most substantial clue is that the living birds which are closest to the base of the lineage possess a male member. (I assume I don't have to tell you that birds are in fact dinosaurs.) You may not have known that most birds do not -- they just kind of rub up together. I didn't know that in fact. Anyway, crocodilians, the lineage most closely related to the dinosaurs/slash birds, are similarly endowed. Ergo, dinosaurs had wieners.

But, as you already know, some of them were really, really big, and they had big fat tails that would be hard to get out of the way. It turns out, based on computer simulations (yes, some cheetoh-dusted Dr. Pepper swillers actually did this) that the females could have supported the weight of the males in the standard posture of four-legged mammals. (There is a business in the nearby town called Doggie Style Pet Grooming. Really.) However, there are two problems. One is the tail. This could have been a manageable problem assuming the male threw only one leg over the female and approached somewhat from the side.

However, as you probably recall from your youthful obsessions, many dinosaurs had elaborate plates and spikes along their spines which would have turned any amorous male into a eunuch. One possibility is that the female lay down on her side. It occurs to me that they might even have addressed more hominum, as Melville said of the whales.

The main reason I raise this issue is that it asks us to reflect on why we do science. I mean, who cares? What difference does it make? The answer is, we're curious. We just want to know stuff. We want to figure it out. More than that, human knowledge is a single structure. Physics, cosmology, biology, chemistry, archaeology, geology, astronomy -- all are woven together in a single tapestry of light. Everything we learn, everything we figure out, makes everything else more clear.

This is one reason why religion is so destructive. Every false belief founded on faith degrades all of understanding and assails the foundation of every other truth.

Exciting New Toy!

Until I have a chance to do a real post, please amuse yourselves with the Thomas Friedman op-ed generator. It's completely random, completely meaningless, and even better than the real thing!

Radical Discontinuity

We've certainly had our share of catastrophes lately -- think of the southeast Asian and Japanese tsunamis, Haitian earthquake, Katrina, Sandy, great floods and droughts all over, the emergence of HIV. All of these have disrupted countless lives and destroyed or radically changed communities, towns and cities. But the broad course of history flows on little affected by these events, however dramatic they are. (The Japanese tsunami has significantly weakened the Japanese nation, an important economic power, with perhaps some effect on geopolitics, but it doesn't change anything fundamental about the world order.)

To be sure, the cumulative effect of global climate change will have a radical global impact. The wise among us -- which does not seem to include our political leadership -- are working hard to understand what this is likely to be, and to find ways to avert the worst and cope with the inevitable. But I have been thinking of late that all of our hopes and worries about the future are quite likely to prove largely irrelevant on the scale of decades. Completely unpredictable events will almost certainly intercede. Arguments about the federal budget in 2050, with which we are presently obsessed, are preposterous.

In 1859, when Edwin Drake drilled his oil well in Pennsylvania, petroleum was essentially viewed as the source of kerosene, a replacement for whale oil and tallow candles. Nobody could have anticipated that it would be more important than that. As it turned out, it wasn't long before people no longer lit their homes with open flames of any kind, yet petroleum ended up changing the world more radically, in fewer years, than any innovation since language.

On the down side, I got to thinking about this because of the recent discovery in London of a mass grave from the Black Death. In parts of Europe, it killed one third or more of the population, maybe half. Historians will argue about the consequences, but it is entirely plausible to argue that it brought about the end of the Middle Ages and opened the way for the Renaissance and  Enlightenment. Suddenly, there was twice as much land, housing, livestock and tools per person. Labor was scarce and the peasantry suddenly in a much stronger relationship with the gentry. Land peonage could not endure, and the old ways started to fall away.

We might well have a global pandemic of some highly transmissible and deadly pathogen that we cannot quickly control. Public health authorities are continually insomniac over this possibility. Decimation of the human population would have unpredictable consequences in the long term, but immediately of course it would be horrific. Lots of other really bad stuff could also happen, but I'm not writing this to catalog them, that's not the oint.

On the up side, the possibility of a radically transformative technological innovation that saves us from our present multiple crises like a deus ex machina can't be ruled out. A breakthrough light, compact, energy storage technology; viable fusion energy; room temperature superconduction -- it could happen. And any of 1 million things I haven't thought of. In other words, the one safe prediction is that the future won't be anything like people are predicting.

Public Opinion Polling

I just saw Al Sharpton (I don't call him "Reverend" because I don't revere him) report that 53% of Americans think "The Iraq war was a mistake."

Had I been among those polled, I would not have answered that it was a mistake. Obviously, they did it on purpose. It was a crime against humanity. It was a monstrous evil perpetrated against people in Iraq and the United States, first and foremost, but everyone and every living thing on the planet to some degree. It was a world historical crime with the complicity of, among others who you might think you admire including Hillary Clinton, Christopher Hitchens, Mary McGrory and the entire editorial staff of the New York Times, Washington Post, and Boston Globe. Whatever it was, it was not a mistake.

I am really sorry to be a downer . . .

but, the new BMJ demands that I bum you out.

Britain's Chief Medical Officer -- kind of like our Surgeon General, except that she actually gets  out of bed in the morning -- issues a report on antibiotic resistance. Yes, I write about this from time to time and hear and there you will hear someone cry with alarm, and yet nobody does a damn thing about it.

It seems that after the Good Lord intelligently designed microorganisms that can kill us and make us sick, He forgot to prevent them from evolving. Yes, yes I know, he's a total doofus. Anyway, they've been doing that ever since we even more intelligently designed antibiotics that can kill them, and now they're starting to escape en masse. There have been no new classes of antibiotics developed since 1987, and nothing is in sight.

What happens if we lose antibiotics? We won't just go back to a world where a sore throat or a cut finger can kill you. As Smith and Coast point out, we'll also lose the ability to do surgery. No more joint replacements, no more cancer resection. No more health care as we know it.

And why aren't drug companies reinvesting some of those trillions in profits into developing new antimicrobials? Easy. That's not where the big bucks are. They can sell you a ten day course of an antibiotic, or get you to take statins or antidepressants for the rest of your life. They are much more interested in the latter.

And why are we still feeding antibiotics to livestock? Because our politicians want the money from the pharmaceutical industry and agribusiness, just like they want the money from the fossil fuel industry, more than they want humanity to survive into the next century. Other than that, they're public servants.

More on valuing health outcomes

Okay, so now for some of the low-hanging fruit.*

Ideally -- but not necessarily really -- the way treatments such as new drugs are evaluated is through randomized controlled trials (RCTs), conducted according to certain standards. One of the most important of these (and probably most often violated, in the past at least) is that the trial must test pre-specified outcomes. The reason for this stringent requirement has to do with the rules of inference. Whoo. Here goes some headbanging.

As I presume most readers basically know, the way you do an RCT is to divide a bunch of people at random into two groups. One of them gets the magic potion, and the other doesn't. Whatever your specified outcome may be, there's a chance that even if the stuff doesn't work, more people in the intervention arm will have the outcome, just by random variation. You can calculate what that probability is, given the observed difference between the two groups. It's called the p value. Pretty much arbitrarily, we say it has to be less than 5% (p < .05) in order to call the trial successful.

Here's where the big problem comes in. There are bound to be some differences, actually a lot of differences, between the two groups. If you go looking around for them until you find one, and then calculate its p value as if you had specified the outcome in advance, that p value is bo - o - o - gus. Basically, it's meaningless.

Here's another problem. In order to get a drug approved, companies have to show that based on the above procedure, it's better than placebo. But they don't have to show that it's better than an existing, quite likely cheaper, alternative. They also don't have to show that the benefit is of any particular magnitude, and they don't even necessarily have to show that it actually benefits people at all. They can rely on so-called "surrogate end points," that is, indicators that are thought to be predictive of better health outcomes, such as lower LDL ("bad" cholesterol), but which might not actually be better after all. More than once, a drug approved on the basis of a surrogate endpoint has ultimately been found not to produce the expected better outcome.

So . .. Long story short, there are quite a few interventions out there that really aren't better than cheaper ones, or which don't really do any good at all for most of the people who get them. There is a voluntary effort now by many of the medical societies to encourage their members not to use some of these, but no general authority that says, for example, that Medicare won't pay for them.

That's because Congress forbids Medicare from taking cost into account in deciding whether it will pay for treatments. We could start by not paying for stuff that isn't any better than cheaper stuff, or that really doesn't do any good. But as soon as somebody proposes it, we get ignorant idiots screaming about death panels.

Next I'll talk about some harder issues, since this one ought to be easy.





* George Orwell advised "never use a metaphor, simile or other figure of speech which you are used to seeing in print," in the interest of avoiding cliched writing. Sorry George, just couldn't find a better alternative.

Valuing health outcomes

Recent discussion here has raised one of the most contentious issues in health economics and health policy -- one that happens to be largely ignored in the political discourse. That is how we put a value on  people's states of health (once we have even figured out how to define them). That we must do so in order to make any sense out of arguments about the cost of health care and how we pay for it, to the extent that it comes up at all, is generally treated as a morally outrageous assertion.

For the present I won't even get into the valuation of other kinds of programs and policies, which may have a much greater impact on your health than whatever it is doctors do to you, but you can extrapolate some of this discussion yourself.

Some people have said that we shouldn't be so alarmed about the rising share of GDP represented by the medical industry. Medicine has much more to offer nowadays than it once did, while the cost of other necessities as a share of the economy has come way down. Since we no longer have to spend much of our income on food, and there are more effective, albeit expensive, medical treatments out there, of course we're spending more of our budget on them.

This is a perfectly reasonable point. Before automobiles existed, we didn't spend anything on them. Now buying them, maintaining, fueling and insuring them is a big chunk of our budget. But two issues remain.

1) As of now that share has long since stopped going up, in fact it's going down. Car ownership is not getting further and further out of reach for more and more people.

2) Consumers can do a reasonably good job of matching what they spend on owning and operating motor vehicles to the values they derive therefrom. Since all I want is to get from here to there reliably, I can figure out what relatively cheap car will do that for me. (Full disclosure: I just bought a slightly used Nissan Sentra.)  If I am afraid that a certain of my body parts is too small, and I think that owning an expensive motor vehicle will compensate, then my own judgment of how much to spend on a muscle car or a monster SUV may seem foolish to you, but it's my own choice.

Medical services -- or health care if you will, though I think the phrase is a misnomer -- don't work that way. As a consumer, I am inevitably very uncertain about the value I will derive from a given medical intervention. Let's leave aside for now the substantial additional complication that I may not have to pay for it, or at least not for most of what gets charged for it. Rather we'll take a social level view, as a taxpayer or insurance ratepayer. Is it worth it to get an imaging procedure, take a pill, have surgery? And let's also leave aside the fact, noted a few days ago, that the price may vary hugely depending on the vendor. Let's assume some identifiable average cost.

At this point, especially if life expectancy is at issue, a lot of people will just try to toss out the whole problem and say that you can't put a price on life or health. That is a feckless response because we in fact do. Your health insurance premium costs a finite amount, which some people can afford and others cannot. Medicaid doesn't cover most people who can't afford private insurance. Medicare covers almost everybody over age 65, but now a lot of people are saying we can't continue to pay as much for it as we are now, or at least not as much as we are likely to in the future under current policies. When you have needs your insurance won't pay for, either you pay for them yourself, or nobody does, in which case you suffer or die.

So, we have finite resources that we probably ought to allocate on some rational basis. But this is very difficult. Here are some of the challenges:

1) Benefits of medical interventions are usually quite uncertain. My car gets me to work and back reliably, but I'm not sure what lisinopril is doing for me. I have some vaguely quantifiable risk of heart or kidney disease without taking it, while it is far from clear how much that risk is reduced when I do take it. Exactly when I might develop symptoms, how severe they might be, and how gravely that would burden me, none can say.

2) There are almost always alternatives. I might be able to lower my blood pressure by taking great care with my diet, exercising more strenuously and regularly, and having a less stressful life. All that sounds lovely, but it may also come with costs or be simply unattainable. I could take different pills, with different side effects.

3) There might be other issues which are more urgent for me, for example if I were a tobacco addict, or severely overweight. Handing me a pill to lower my blood pressure might actually give me an excuse not to do something about all that -- but that's an imponderable.

4) It is very likely impossible for me to make any of these calculations on my own. That's why we pay physicians for advice about these matters. But do they know what is really important to us? Can they weigh, on our behalf, some highly uncertain relative probabilities of outcomes that even we ourselves can't be sure how to value?

5) The knowledge base on which any such calculations could be made is constantly changing, as is my personal situation -- my age, my comorbidities, my physical and social environment, my income.


Next, I'll try to define some of the easy problems -- the low hanging conceptual fruit that we can harvest easily and should; and the hard problems.

Situational Ethics

A town in Georgia is contemplating an ordinance requiring every household to own a firearm. I'm going to go out on a limb here and guess that the same people who agree with the local police chief that "I think y'all are showing the people that you're in full support of the Constitution, and as far as the Second Amendment goes, that you stand behind it, you stand behind people's rights," also think that it's tyranny to require them to buy health insurance.

I doubt they've even thought about that.

Another Open Door Crashed Through

But, sometimes you need a prestigious panel to lead the way. The report of the National Commission on Physician Payment Reform is here. The highfalutin' name is maybe a little pretentious -- it was convened by the Society of General Internal Medicine, not the gummint. And yes, internists -- primary care docs -- have a lot of skin in this game. But they say all the stuff that needs to be said.

I've been raving about these issues here for years, so I'll take this opportunity to hit a couple of high points that might fit on a bumper sticker, maybe a really big one.

First of all, did you know that the U.S. already spends about as much public money -- taxpayers' money -- per capita on health care as the other rich countries that have universal coverage and better results? It's true -- we spend more than Canada, Switzerland, France, the UK, Australia and many others. Then we spend an approximately equal amount of private money on top of that. As a result our total spending on health care per person is more than twice the average of the other wealthy countries, and by far the highest on earth. And yet we don't provide any health insurance at all to 48 million people. And our population's health status is worse than that of Paraguay.

In other words, if we were as smart as the cheese eating surrender monkeys, we could take the public money we are spending today on health care, and provide excellent health care to everyone, without making anybody pay a single dollar out of pocket. 

Why is that? Basically: we pay more for the same goods and services; we pay for a lot of stuff we'd be better off without; we don't pay enough for stuff we need more of. The fee-for-service payment model creates an incentive to do more, but not to get the best results. We pay much more to certain specialists who do expensive, high technology procedures than we do to primary care doctors who can figure out what we really need, do the cheap stuff early that really matters, and save us from unnecessary or even harmful and very expensive interventions. To whit: a radiologist earns, on average, $315,000 a year, while a primary care physician earns $158,000. No wonder there is a crushing shortage of primary care physicians, and no wonder we get far too many imaging procedures.

All this talk about the unsustainability of Medicare and Medicaid, and how we just have to cut benefits and raise the eligibility age, is either ignorant blather or deliberate lies. We can easily afford high quality care for everyone. But we aren't even having the right discussion.

More on the Nanny state

Our good old Swiss friend Ana brings up the subject of the U.S. not taking care of its people. Apropos of this question is Sarah Conly's book  Against Autonomy: Justifying Coercive Paternalism,
reviewed here by Cass Sunstein. 

Sunstein is reasonably convinced by Conley's basic argument against the libertarian presumption that we ought to leave people alone to make their own mistakes, e.g. not mandate motorcycle helmets or seat belts, ban gigantic cups of sugar water as Mayor Bloomberg wants to do, ban smoking in restaurants, that sort of thing. Her argument is essentially that people don't know what's good for them, and that they will often end up wishing that somebody had gotten a little bit paternalistic with them.

That's true enough, but both Sunstein and Conly seem to entirely miss another, perhaps more compelling point, which John Stuart Mill, the Godfather of the libertarian argument, also missed.  It is very rarely true that a person's bad choices harm that person, and that person only. It just is not the case that if you don't wear a motorcycle helmet and you end up with brain damage, the rest of us care only out of misplaced altruism.

It's astonishing to me that somebody as smart as Sunstein doesn't see this instantly. Let's make it as easy as possible. Suppose the mangled cyclist has dependent children. We can be as Randian as we want about this and presume that nobody should give a rat's ass just because they love him. But now somebody has to take care of his kids. Or let them starve I suppose, but who really wants to go there?

Oh yeah. The guy previously worked, paid taxes, maybe improved his property thereby enhancing the neighborhood, gave to charity, and spent his income thereby enriching his hard working neighbors. Now he's lying in a long-term care facility sucking money out of other people's pockets.

I mean, how could people not see this? And yes, it's just as bad if you decide to spend your days drinking 48 ounce cups of soda and wind up weighing 300 pounds, then get diabetes, osteoarthritis and heart disease. It isn't only your problem, it's all of our problem.

Duhhh.

I'm not really getting this scandal

That would be the horse meat thing. If you're perfectly happy to eat cattle, pigs, and sheep, why is it shocking and horrifying to eat horses? Especially since the whole premise of the story is that consumers couldn't tell the difference -- it takes DNA testing to discover it. The corporate media are covering the discovery of horse meat in some European prepared foods as if it's some sort of public health catastrophe. It also turns out that it is currently illegal in the U.S. to slaughter horses for human consumption. So we ship them to Canada or Mexico so they can meet that fate elsewhere.

I'm sorry but this is just bizarre. For the record, I personally don't eat any of the above. But I am not seeing the issue here, sorry.

On to more substantive issues. We're experiencing a major freakout here at the public health research shop. Whole research programs, Ph.D.s, post-doctoral fellowships,  and oh yeah, my job, are premised on the assumption that the federal investment in health research will be reasonably stable. It doesn't make a whole lot of sense to grant degrees, do post-doctoral training, and launch people on careers if there isn't going to be any way to sustain them next year. But that's the position in which we now find ourselves.

You may not think that an 8% cut in federal support for scientific research sounds all that catastrophic. So let me enlighten you. The National Institutes of Health commits the vast majority of its extramural funding to multi-year projects, typically 3 to 5 years. Some major longitudinal studies are considerably longer. Ergo, an 8% budget cut means essentially no new grants this year, at all. Or very close to none. Therefore, all of us who are completing funded projects and are ready to go on to the next funding cycle are going to be left high and dry. Our work will lurch to a halt. We'll be laying off staff and maybe ourselves.

This may sound like self-pleading. Sure, I want to keep my job and do the work that is important to me. But this is about you too. What we're trying to do is make health care more effective, and yep, cheaper -- more affordable to the taxpayers. We're trying to find better treatments and cures for the ills that plague us. We're trying to make the health care system meet your needs better, be more equitable, more humane, and more directed toward the outcomes that patients want. And, overwhelmingly, the public supports that. The people want us to keep doing what we do.

So what I'm not getting is, what is the constituency for this? How do Republicans think they can win elections by screwing the people? Explain it to me.