The Great Sunny and Warm North

That's Montreal today and prognosticated to be so all week. I'll be here through Wednesday for the International Conference on Communication in Healthcare. I'll let y'all know whatever great stuff happens here (I'm speaking twice so it can't be all bad), but meanwhile I just have my superficial impressions of the city to share.

As you may have heard, they are all kinds of uppity about their effete effeminate language. It's illegal to have signs in English. You're allowed to put English under the French, in smaller print, but for the most part they don't even bother to do that. You'll mostly hear French on the street, but everybody is able to speak English. Of course I'm in the hotel and the staff is so perfectly bilingual its painful.

Rue Ste. Catherine is a major commercial boulevard. You can get any kind of cuisine you want here -- pizza is very popular, the usual burgers, there's an arepa place, Middle Eastern, Greek, pan-Asian, sushi, you name it. Well, one kind of food that I have not seen on offer is French. You can't get that here. The sidewalks are wide and the vehicle traffic on the light side, but the restaurants are 100% indoors. Sidewalk cafes is not a happening thing.

Rather like Basel, the high end and low end businesses are all mixed up here. Fancy watches, high priced clothing, right next to lap dances. There are also a lot of slackers, idle young adults, in some cases openly panhandling for beer and drugs. Lots of tobacco smoking. An ethnic potpourri. Quite stimulating. Now I'm off to the opening session.

Obsolescence

Tom Lehrer claimed that he gave up his public career and went back to laboring in anonymity as a math teacher because satire became obsolete when Henry Kissinger won the Nobel Peace Prize. I don't know if he meant it, but blogging about public health and health care seems kind of obsolete these days when the field is completely dominated by insane liars. I don't know what I can possibly contribute to this "discussion."

Kurt Eichenwald takes on the psychopathic Republican party in Vanity Fair, but I mean really, what's the use? A few tens of thousands of people will read it, most of whom are already pretty much tethered to reality, while 100 million will either get The Crazy mainlined by Faux News or, at best, be told by Chuck Todd that there is a dispute between people who are trying to stop Obamacare from destroying the economy and putting a government bureaucrat in every doctor's examining room; and people who are determined to have it take effect anyway just because.

The Republicans in congress are apparently determined to smash the U.S. economy and political system to rubble, half the people are cheering them on, and the corporate media are just transmitting the pictures. What is really weird is that the Camber of Commerce and most of the business establishment, which face disaster at the hands of the very monster they created, aren't trying to stop it. The vast majority of capitalists have everything to lose and nothing to gain from these nutjobs, but they still seem to think of them as their own tools and they can't stand to lose them. They will live to regret this very, very deeply.

For myself, I'm not sure what the future holds. I won't have a career, or even a job, if there isn't any federal funding for health services research. That's kind of sad since I've worked so long and hard to get to this point and I like to think that I'm starting to make a contribution in the public interest. But if the people don't want to pay for it, because government and knowledge are both equally evil, I guess I'll just have to figure out something else. It's on you, Chuck.

Jeopardy!

I keep sending these in to Alex Trebek, but for some reason they never use them. Remember, your answer must be in the form of a question.


Category: National Monuments
       Clue:  Nobody, it's an above-ground mausoleum

Answer: Who's buried in Grant's tomb?

Category: National origins
       Clue: Obviously!

Answer: Is the Pope Argentinian?

Category: Prominent Journalists
       Clue: Chuck Todd

Answer: Who?

Category: Metaphysics
       Clue: Metabolizing and reproducing entity

Answer: What is the meaning of life?

Category: Clerical Vestments
       Clue: Skirt for an Archbishop

Answer: What is Tutu?

Category: Existentialism
       Clue: Shit

Answer: What happens?

Category: Grammar
       Clue: Objective Case

Answer: Are you talking to me?

As you can tell, I didn't sleep much last night. I'm gradually getting back to normal, but it's taking a while.

Still sick . . .

though getting better. I'll outsource to Jonathan Chait. It's long -- and I know the Intertubes has made it impossible for anyone to concentrate on a single essay for more than 35 seconds -- but it's a good explanation of what's going on with the Republican Doomsday Machine over the Affordable Care Act.

Said lengthiness is also the problem that has been a burr under my saddle for as long as I've been in this racket. It is just impossible to explain to people -- by which I mean not only your local parking lot attendant, steamfitter or divorce lawyer but also those people who style themselves journalists -- how the market for health care and health insurance works and what exactly we need to do to fix it. I just can't make it short and simple and also true. Especially with the entire population irretrievably lost in delusional faith in a non-existent entity called the "Free Market."

Anyway, we're at a hinge of history now folks. Chait may be a bit less optimistic than I, but I'm not in the prediction game.

Something you really, really don't want . . .

. . . is norovirus. At least I think that's what happened to me yesterday. Anyway, whatever it was, same basic idea. The diarrhea started at 3:00 am, and obviously, as I got out of bed and hit the light switch, there was a power outage. It was raining and darker than a black hole, so I spent the night groping my way back and forth from bed to toilet. By morning I managed to get downstairs to continue the performance from the sofa, but I was so weak and tired I could barely get off it to meet the recurrent necessity.

The good news about this is that it doesn't last long. The diarrhea subsided by evening and I even made it in to work today, because I had to, even though I still feel like crap. I'll have to eat something but the very idea of food is still repulsive. The other good news -- and as far as I'm concerned it is good news -- is that there is absolutely no medical treatment that can do the slightest good.* You just have to live through it, then it's over.

The reason that's good news is a) there's no way on earth I could have gotten to a doctor even if somebody would have seen me on a Sunday, and I wouldn't want to be thinking "Damn, if only." Second, it didn't cost anybody anything. If it's over in a day anyway, then okay sure if I had a $10 pill in the cabinet I could have popped that would have stopped it, that would have been worth it. Beyond that, not really.

Lesson: Wash you hands! Wash your vegetables! Keep you kitchen clean! I probably got it from restaurant food or just touching something that was contaminated -- norovirus is very contagious and there are plenty of ways to catch it without eating tainted food. But anything you can do to improve your chances I will strongly endorse.

*Frail elderly, very young and immunocompromised people can be seriously injured or killed, by dehydration Parents of young children should keep Pedialite or similar rehydration fluid in the house, just in case. Sugary drinks, however, are not a good idea.

It's going to happen, might as well hunker down

The Shrill One, here embracing the appellation, figures the Republicans have gone so far around the bend that yes, they will shut down the government and might just refuse to raise the debt limit. I'm holding off on investing my 2013 IRA contribution, because they might just knock us back into 1932.

There's more than enough blame to go around for the collapse of our hallowed republic, but let me single out the the worst offender and no, it's not the Koch brothers or the Club for Growth or Rush Limbaugh or even Fox News. It's CBS, ABC, NBC, CNN, NPR and the rest of the corporate media gang of idiots. Fox News and the Vulgar Pigboy know what they're doing, they do it on purpose, and they're just evil. They know they're lying all the time and they know how they're pushing the buttons and pulling the strings of their deluded followers. The others, however, pretend to be journalists and pretend to be providing some sort of a public service.

No and no. The coverage I see and hear consists of one or another Republican member of Congress declaring that "Obamacare" is the worst legislation of the past 50 years, that it will destroy the economy and our liberty and cost billions of jobs and raise the cost of health care." Then they have Harry Reid saying "no, we aren't going to defund it." That's the debate the people hear, in its entirety. And as Chuck Todd said yesterday, it's not his job to tell people the truth.

Polls show that the majority of people oppose the Affordable Care Act, and an even larger majority don't know what it does. I know damn well that isn't my fault, but I can't get 100 million people to read this blog.

I'll tell you what though. Roger Ailes and Rupert Murdoch and even the Koch brothers don't actually want economic collapse. I'm counting on them to make Rand Paul an offer he can't refuse.

Ripoff!

I think you can only read the abstract (I have a magic cookie on my 'puter that dissolves paywalls), but the new JAMA has a brief review of the evidence about anti-oxidant vitamin supplements. These are the main ingredients in your typical multi-vitamin -- beta carotene/vitamin A, Vitamin C, Vitamin E -- you know, the classics. These have long been touted as promoting health and longevity, on the theory that oxidizing free radicals in the body cause cell damage. If you enter the term "antioxidant supplement" or similar into your favorite search engine, you'll get pages of ads.

Here's the bottom line, folks. The higher the study quality, the worse these look. In fact, taking Vitamin E, beta carotene and Vitamin A supplements is associated with higher all-cause mortality. Vitamin C and selenium (a mineral not a vitamin but also touted as an antioxidant) don't do anything, except cost you money. In other words, the people who are selling these, including big corporations that advertise heavily on TV, major retail chains including CVS and Walmart, and many more, are lying, stealing, and murdering people. And it's perfectly legal.

It is true that eating foods that are high in these substances is generally good for you. That would be your fruits and veggies. So do that instead. Don't buy any of this garbage.

Not exactly fraud

Obviously the cause of science, and therefore the cause of humanity, is harmed when scientists make up results or misrepresent their findings in a scientific paper. I get outraged about it, but it probably isn't all that common.

Even so, false beliefs often persist for a long time. Steven A. Greenberg, in BMJ, tells us how this can happen. This is an excellent and important piece of work which gores some very powerful, oxen, so I recommend it even though it may be somewhat heavy going.

To translate it into English, what Greenberg did was to study all the papers addressing a claim or hypothesis that an uncommon muscle disease called inclusion body myositis is caused by or at least includes in its pathogensis abnormal accumulation of beta amyloid protein, which is famous for being associated with Alzheimer's disease. (It really is found in the brains of people with Alzheimer's, but any causal relationship is unknown.)

He found a small number of original research papers that support the hypothesis, and at least as many that do not. However, in a nutshell, the negative papers were almost never cited in subsequent published research, whereas the positive papers received many citations. Furthermore, the positive papers were discussed in review articles that got even more citations, whereas the negative papers were not, further amplifying the strength of the belief.

It gets worse. Papers that either did not contain data supporting the hypothesis -- perhaps presenting it only as a hypothesis, or offering a data-free discussion -- are frequently cited attached to text claiming the hypothesis has been supported. And worse than that, papers which are not relevant to the hypothesis at all, or which even tend to undermine it, are frequently cited as supporting it. Abstracts -- which receive very limited peer review and contain only very limited presentation of methods -- are often cited as if they are peer reviewed articles. And titles of papers that do not contain original experimental data imply that they do.

Furthermore, proposals to the National Institutes of Health reflect all of these biases and falsehoods, and many of them have been funded. Yet it is not at all clear that this line of inquiry has any prospect of explaining the disease or benefiting patients.

This probably happens partly because of actually dishonesty, and partly because of carelessness. There is also a well-known bias on the part of journal editors against publishing negative findings. But the citation network also tends to grow with a powerful bias toward confirmation for reasons inherent to the research enterprise. When a finding is negative, there is nothing more to say about the subject. The investigators will not continue down that road, and they are unlikely to cite their own paper in the future because they won't be working on the problem any longer. But positive findings generate further funding, further research, self-citation, and citation by others seeking funding for related work. They make fodder for interesting review articles that tell a coherent story, whereas nobody is going to write a review article asserting merely that X does not cause Y.

Yes, these false pathways have to come to an end sooner or later, but it can take much too long.

Most outrageous scientific fraud evahh?

Probably not but it's right up there. Introducing Bruce Murdoch, professor at the University of Queensland, founding head of the Centre for Neurogenic Communication Disorders, and for nearly a decade dean of the UQ School of Health and Rehabilitation Sciences, author of nearly 400 peer reviewed journal articles and 13 books. Murdoch caused a sensation back in 2012 when he presented findings that transcranial magnetic stimulation -- basically applying powerful magnetic fields to the brain -- caused people with advanced Parkinson's disease to regain the ability to speak.

This  historic, miraculous breakthrough was then published in the European Journal of Neurology. Here's the funny part though, you'll really find this amusing. He never did the study. He made the whole thing up.

You've probably heard, and it's generally true, that most cases of research fraud are all about the intense, cutthroat competition for faculty appointments and promotions. We're turning out many more PhDs then will ever have a decent academic job (yes, I count myself lucky), and the competition for research funding also grows ever more brutal, so young people sometimes get desperate. Clearly, this explanation does not apply hear, as it also did not apply to Marc Hauser.

What is going on here? I'm not entirely sure but my guess is that the egotism and ambition that help drive people to the top ranks of academia are ultimately not satisfied by the very narrow circle of fame that pertains. That all the investigators in the field of neurogenic communication disorders have heard of you only slakes your hunger for admiration. When you go to those conferences, you still have to fly economy class, carry your own luggage, and make a 15 minute presentation on the same stage with assistant professors and post-docs. Your students only pretend to worship you because they want a recommendation or a toehold appointment as a lecturer. But if you can do something really astonishing, that will get your name on the television or even an appearance on a talk show, now you'll really be a celebrity, everybody will know you're the really big deal you already know you are.

In discussing other cases, I've pointed out the immense swath of destruction cut by this behavior. His students and post-docs will have trouble finding employment. The university may not be able to find alternative placement for some of them. His collaborators are disgraced. Funding that could have gone to productive research has been squandered. The very limited space in a top journal has been stolen from a legitimate study, and scientists the world over deceived. Some may have initiated work of their own which turns out to be a total waste. Thousands of people around the world have been given false hope.

Just sick.

The Gray Tsunami

You may recall recent findings that the rate of dementia among people 65 and older has been falling in England and Wales, and this is likely true here as well. It's basically because people are generally healthier. But . . .

It's very strange how the general reaction seems to have been, "Oh well then, what have we been so worried about?" News that isn't quite as bad as you thought it was going to be is still bad news. And the fact is that the prevalence of dementia still rises with age, and we're still going to have a lot more people living with dementia in coming years. The estimate here of tripling by 2050 might be too high, but 2 1/2 times as many is still a whole lot.

Now the IOM raises the alarm about cancer, another disease that is strongly associated with increasing age and which costs a whole hell of a lot of money to treat. Here's a good example of why medical advances can drive medical costs: there aren't any effective treatments for dementia, so it's actually relatively cheap. Many people do ultimately need custodial care and that can bankrupt families and strains Medicaid budgets, but Medicare is going to have to pay for all this cancer care and new therapies can cost $100,000 and up. Even though the benefit is generally small, our laws and our cultural consensus say that we still have to pay for them.

IOM also argues that advances in the field are so rapid that many physicians and treatment centers aren't keeping up; and that we'll have a growing shortage of relevant experts. It's hard to predict how this will play out. Advances in what are called medical informatics may make it easier for providers to select the right treatment protocols and deliver the latest, proven technologies. Basically, they won't have to know everything, the computer will tell them. (They will have to ask it the right questions.) Treatments that are really curative may end up saving some money in the long run, or cheaper treatments may emerge, but I'm not going to bet on that.

We can save money by all the means I talk about here -- not overdiagnosing and overtreating, not using useless treatments and tests, not overpaying for specialty care. At least we can in principle, it's proving to be very difficult politically because all that waste is somebody's income. But even if we manage to do that, medical costs will continue to increase. We're a wealthy society, we can afford it, but it means young and healthy people will have to pay for the care of old and sick people. That's a granite hard fact of life. Are we prepared to do it?

Update: And right on cue, This lands in my in-box. (I swear, it was after I put up this post.)

PLAINSBORO, N.J. – Promising targeted therapies and immunotherapies for melanoma, used in combinations so advanced they have outpaced the nation’s regulators, offer hope of survival to patients suffering from a cancer once seen as a “hopeless” malignancy, according to experts convened by The American Journal of Managed Care. A. Mark Fendrick, MD, co-editor-in-chief of AJMC, led the discussion with the following experts:

• Jeffrey Weber, MD, PhD, senior member, H. Lee Moffitt Cancer Center and director, Donald A. Adam Comprehensive Melanoma Research Center.
• Antoni Ribas, MD, PhD, Jonsson Comprehensive Cancer Center, UCLA.  
• Jennifer Malin, MD, PhD, manager and medical director of oncology, WellPoint.

 “Melanoma has gone from being regarded by many oncologists in the community as an impossible-to-treat and hopeless malignancy to a disease that one might argue is the poster child for new targeted and immunologic therapies,” Dr. Weber said.
However, these drug combinations are not cheap, and the panelists warned that there is only so much that cancer patients, their employers and those who fund government health plans will be willing to pay. Already, Dr. Ribas warned, some melanoma patients lack access to cutting edge drugs like ipilimumab, depending on where they seek treatment and whether they have appropriate insurance coverage.

Is Our Journalists Learning?

Maybe so. David D. Kirkpatrick, in the NYT, has abandoned the practice of stenography to point out that three congressional Republicans, visiting Egypt, don't know their sphincters from the Sphinx. Michelle Bachmann, Louis Gohmert and Steve King all think that the Muslim Brotherhood committed the 9/11 attack -- really! Kirkpatrick, in gross violation of journalistic norms and traditions, points out that isn't true, and in fact the Muslim Brotherhood renounced violence decades ago and strongly condemns al Qaeda and all terrorist tactics.

Then there is this:

Representative Louie Gohmert of Texas, appearing with her and Representative Steve King of Iowa, compared the leader of the military takeover, Gen. Abdul-Fattah el-Sisi, to George Washington. Mr. Gohmert overlooked the new government’s mass shootings of hundreds of mostly unarmed protesters, its sweeping roundup of thousands of political opponents and its suspension of all legal protection against arbitrary arrest or other police abuse; instead, he commended General Sisi and the appointed civilian leaders for creating a government where the rule of law was “king.”

This appears on the same day that Paul Krugman's column decries conservatives' general lack of acquaintance with reality, e.g. Rand Paul insisting that government employment has exploded under Obama, global warming denialism, and so forth.

Alas, the New York Times is largely irrelevant. The TV news will never point out when a politician  is lying, in fact they tend to absorb conservative falsehoods as verities. We are in very grave danger with these deluded lunatics running congress, and a corporate media that treat them respectfully while decrying "partisanship" on both sides. You bet I'm partisan when the other side is crazy, but if Alan Grayson says something to that effect, he isn't to be taken seriously.

So it's tough to go on blogging into the wind. Oh well, might as well keep on as not.

 

I'm just befuddled

I think Barack Obama must have a brain tumor. What in the Alpha Quadrant would make him utterly determined, against overwhelming public opinion, the international consensus, and the most basic common sense, to blow up stuff and people in Syria?

Since I stated my own, entirely correct opinion about this proposal a few days ago, I've pretty much found that just about everybody with one neuron to rub against another agrees with me. Mr. Obama's bit supporters are the same people who brought us Iraq and waterboarding, being against which is the reason B. Hussein Obama is now president. And yet here's John Kerry -- Winter Soldier John Fucking Kerry -- going on about Munich and appeasement.

I'm happy to be able to break it to you John -- Assad is not going to conquer Europe, or even the part of Syria he's already lost. And nobody is proposing to give him Czechoslovakia, or even a parking spot. What we are proposing is not to blow up some Syrians on top of the ones who are already being blown up for the purpose of "sending a message" that he should stick to blowing people up rather than gassing them. This is idiotic. And by the way if you're worried about chemical weapons falling into the hands of people who might use them against U.S. interests, or otherwise beyond the current conflict in Syria, the best way to make that happen is to make the Assad regime collapse. Somebody should probably explain that to president John McCain.

What is most bizarre about this is how counterproductive it is when Obama should be using all his bandwidth to promote the Affordable Care Act and explain it to people as it rolls out just three weeks from now. He's stepping all over his own lines with this insanity and meanwhile destroying the credibility with the world community that he has won back after the disasters of the predecessor regime. And oh yeah, he's just compounding the political damage from the Snowden revelations.

And why? What exactly is the affirmative goal? He claims it's to defend the "international norm" against use of chemical weapons but a) the U.S. hasn't been bothering to defend said international norm for the past 50 years or so -- in fact the U.S. used chemical weapons in Vietnam, assisted Saddam Hussein in using chemical weapons, used white phosphorus in Fallujah (yep) and held massive stockpiles of nerve gas until recently.

Syria is not a party to the international convention against chemical weapons use, and the Geneva convention is silent on use within sovereign borders. In other words, the Assad regime did not in fact violate any treaties or international law by this action. You might like it less than you like shooting people and blowing them up, for some reason, but personally, I don't think it matters.

If Obama hadn't been threatening military action, he probably could have gotten a Security Council resolution of condemnation, or at least statements from the European Community and the Arab League. He would have had leverage to get the Russians to temper their support for Assad, but now he's just pissed them off and destroyed any hope of organizing a negotiated solution to the Syrian tragedy. He's made the Iraqi government more hostile and he's greeted the new Iranian government's very obvious and likely sincere diplomatic overtures with a punch in the mouth.

If he goes ahead and does this without congressional authorization, there will be a resolution of impeachment in the House and it might even pass. Then we'll be screwing around with that for the next six months while we hit the debt limit and the continuing resolution for government spending authority expires. It's time to lay in the canned goods, folks.

If it's not a brain tumor, what is it? Somebody please explain. 

Update: Juan Cole has a hypothesis, although it's not very convincing to me. Basically, the U.S. strategy in Syria has been to try to build up a secular fighting force that can beat out the Islamists on the battlefield. That will take a loooonnnnnggg time. The attack in Ghouta, according to Cole, was a response to this incipient force (which is being trained in Jordan) making advances in the Damascus suburbs. The idea is that Obama wants to make Assad fight "fair," (whatever that means) so the strategy has time to develop. Maybe so but is there any reason not to explain that publicly? Then we could have a meaningful discussion.

Just thought folks might like to see these

A pair of fawns came into my front yard a couple of weeks back. They've been hanging around the area together, but I haven't seen their mother, which is a bit odd. Anyway they seem to be doing okay. Some of these behaviors were a bit surprising to me - a lot of self-grooming. Most people live in cities now, so this sort of thing probably seems special if you do. It's nothing out here.

Incentives

A multitude of cogitators, writing in JAMA Internal Medicine, have computed the annual cost of hospital-acquired infections in the U.S. They use the term "healthcare associated infections" but they actually limit the analysis to certain of the most important infections caused by hospital care. They come up with an annual cost of $9.8 billion per year, not counting the pain, suffering and death of the victims.

Okay, that's a bummer. But here's what is, to me, the interesting part. As the authors point out, we've been making some progress on reducing this problem, but it's been slow. Here's the rather dry money quote:

However, despite the availability of solutions, the strong ethical case for improvement, and the intuitive argument that saving lives ought to save money, large-scale progress against HAIs has been slow. Only recently have health care organizations begun to achieve successes and overcome doubts about the scalability of pilot studies and vanguard institutions. Along with leadership of patient safety professionals, an important driver of progress is the move by payers to deny reimbursement for health care related to preventable harm.^10- 11 By placing the costs of HAIs with hospitals, this shift has accentuated the fiscal case for prevention.

Let me translate this into lay language. Until very recently, hospitals made money  by making people sick. That average $45,814 cost of a central line bloodstream infection? That's what the hospitals were paid when one of them happened. The more central line infections, the more revenue. This is a particularly meaningful issue for me because a major teaching hospital of Harvard University (as my surgeon's card bragged) botched what should have been minor surgery on yours truly, and then tried sending me a bill for $25,000 back in 1991. That's on top of what my insurance had paid them. I refused to pay it, they sicked a collection agency on me, I told the collection agency what happened, and the collection agency guy actually called me up to apologize and said they would drop the matter. Most people, however, pay up, plus they probably had already made a profit off of the insurance.

If you think this is insane, you're sane. However, the new reimbursement policies are by no means universal. And they don't go far enough. If your auto mechanic screws up, he is responsible. So should your doctor.