Map of life expectancy at birth from Global Education Project.

Wednesday, July 31, 2013

What's in a name?

If the name is "cancer," plenty. When people are told they have cancer, they ordinarily are terrified. And they and their doctors feel compelled to do something about it. Doing something about cancer normally means surgery, chemotherapy, radiation -- all extremely expensive, unpleasant, and in fact damaging to your health.

It turns out, however, that since we've undertaken massive programs to screen the general population for what is generally called cancer, we've been detecting a lot of phenomena which, if untreated, would never hurt anyone. But the doctor tells the person "You have cancer," and  off we go.

The National Cancer Institute convened a working group to, well, work on this problem, and a summary of their group working is posted on the JAMA web site. They'll even let you read it!

They give a careful explanation of issues I have often discussed here, and I think it would be good for lots of people to read this and understand it. The mass hysterical freakout we've experienced every time the Preventive Services Task Force recommends less cancer screening is proof that people just don't get it.

The key ideas are:

Some abnormal cells that look like cells that sometimes become cancerous never in fact do so. In many cases, we really can't tell the difference.

The importance of early detection of cancer, or what might become cancer, has been exaggerated. The American Cancer Society is as guilty of this as anyone. Yes, five year survival is higher with lesions detected by screening than lesions that are detected because they are symptomatic; but that's largely because a) some of them were completely harmless to begin with and b) others would eventually become harmful, but they would not have killed you within five years even if untreated. What we really need to look at is whether, over the long term, the death rate from a form of cancer goes down in a screened compared to an unscreened population. This is difficult because you can't really do a controlled experiment, but the best evidence shows that general mammographic and prostate specific antigen screening have very small effects on population mortality. (In fact, the evidence is somewhat mixed. Some people aren't convinced it does significant good at all.)

The benefits of screening are offset by the costs, which include "overdiagnosis" -- finding those lesions that aren't going to hurt you and scaring you, treating them with all the attendant harm, and spending tens or hundreds of thousands of dollars. So yes, we need to strike an appropriate balance.

Good ideas include focusing tests on higher risk people, screening less frequently where indicated (and this has to do with parameters such as how fast a cancer tends to grow), and maybe abandoning screening entirely, as many people recommend with respect to PSA.

The working group has one more good idea: don't call it cancer when it isn't. For example, so-called ductal carcinoma in situ is not carcinoma. (Carcinoma is cancer arising from epithelial cells of ectodermic origin. That's fancy anatomy, look it up if you care.) Similarly with some prostate lesions. Instead of calling these "cancer," they want to call them Indolent Lesions of Epithelial Origin, or IDLE conditions. (Yes, the correct acronym would be ILEO, but evidently IDLE sends the right message.) If you're told you have an IDLE condition, rather than cancer, you won't freak out, and you'll be more likely to say okay, what the heck, let's not do anything and just keep an eye on it.

Seems like a good idea, but will doctors do it? We'll see.

Saturday, July 27, 2013

The Bulger Trial

The good people of Boston have had more than their share of True Crime stories of late, from the marathon bombing to the murderous tight end to, of course, the Bulger trial. Having spent 25 years in Scrodtown before moving out to the country and painting my mailbox blue, I am most interested. I'm pretty sure most of the country doesn't really know what's going on in the courtroom, so let me fill you in. People who already know the story, or think they know it, might appreciate a quick review as well.

Let me first state that the news media just love gangster nicknames. They can't say, or write, "James Bulger." They have a form of Tourette's such that they must always render it "James 'Whitey' Bulger." In fact his associates called him Jimmie. And I'm pretty much 100% certain that nobody ever addressed Stephen Flemmi as "Rifleman," but you'll never see his name in print or pronounced on air without that middle name.

Anyway . . .

In Bulger's day South Boston, which was and is indeed known as Southie, was an insular Irish enclave, virulently racist and paranoid about the maintenance of its ethnic homogeneity and dysfunctional folkways. When South Boston High was integrated by a court order, the people lined the streets to throw rocks at the school buses. Southie even had it's mini-Faubus in the person of city councillor Louise Day Hicks, who famously compared black people to a spreading stain on the fabric of the city.

During Jimmie's murderous reign over Southie, his brother William was the president of the state senate and Dictator of the Commonwealth. The Democrats had veto-proof majorities in both houses, so they would nominate weak candidates for governor and not give them any support in the general election, thereby insuring there would not be a competing powerbase in the corner office. Mitt Romney was one of the Republican figurehead governors during this era. Legislators never actually voted. Billie would stand at the podium and intone, "Comes now the question pertaining to the bill to be engrossed the clerk will read the amendment." The clerk would get out three words then Billie would say "Without objection the clerk will dispense with the reading of the amendment do I hear the ayes do I hear the nays the nays have it the amendment is not adopted." Then he would bang his gavel. There might be a few senators milling about the chamber talking with each other, but nobody ever actually said "aye" or "nay."

There was an odor of corruption around Billie but he was never caught, or at least he was never prosecuted. When he got tired of politics he got one of those figurehead Republican governors to appoint him Chancellor of the University of Massachusetts, to the violent retching of the faculty. He was forced to resign when Jimmie went on the lam, and Billie was apparently in contact with him. Billie was suspected of withholding information about Jimmie's whereabouts, which if I remember correctly he never explicitly denied. Instead he made remarks to the effect that blood is thicker than water. Anyway . . .

Jimmie knows that there is no possibility he will die anywhere but in prison. In fact, his lawyers stipulated to enough facts in opening arguments to get him life. He's an old man so the Angel of Death will probably parole him in no more than five years anyway, so what's this trial all about? Why not just plead out and get it over with? Gather 'round and I shall tell ye.

Whitey Bulger (and he was known by that name to the general public) was a folk hero in Southie. They saw him as a sort of embodiment of Irish machismo and the community's transgressive identity. For one thing, he was credited with keeping drugs out of Southie.

Hah! South Boston had the worst heroin problem in the city, much worse than the black ghetto of Roxbury. This was not a secret. You could see the junkies nodding in the doorways, everybody knew enough not to park where they could break your window and steal your radio, and the ambulances were continually hauling the ODs off to Boston City Hospital. Jimmie didn't try to stop the drug trade, he controlled it. He didn't operate it, but he decided who could sell dope in Southie, he parceled out the territory, and of course he taxed it, just like he shook down the legitimate businesses. So the first thing he told his lawyers was that they had to attack the accusation that he was the local drug kingpin. In that, they have, from what I have read of the trial, failed spectacularly.

One true fact that might have further enhanced Jimmie's reputation was that he sold weapons to the Irish Republican Army. He did it for the money, of course. But this brings us to the second reason for the trial, that he wants his lawyers to trash the claim that he was an FBI informant. That has also been an epic fail. This story has long been well known and told from every angle in many books and long-form newspaper pieces. The FBI was intent on breaking up the Italian mafia, so they recruited Bulger to rat. But he wound up turning the tables and put his FBI handler on his payroll.

Bulger oversaw an operation to run machine guns, ammo and plastic explosives out to an Irish trawler on the high seas via a Gloucester swordfishing boat. (The weapons never made it to the IRA because of an informant on the receiving end.) A crewmen on the fishing boat later got drunk and spilled the beans on the operation. Unfortunately, he ended up being interrogated by Bulger's pet FBI agent, John Connolly (now in federal prison for racketeering and murder), who of course tipped off Bulger, who (of course) tortured the man to death. Connolly later tipped of Bulger that he had been indicted, leading to Jimmie Bulger's 19 years as a fugitive and Billie's fall from grace.

The last claim Bulger wants his lawyers to refute is that he murdered women. His lieutenant Flemmi testified that Bulger personally strangled Flemmi's girlfriend and stepdaughter when they became inconvenient. Flemmi could be lying about who did the actual strangling, but there can be no doubt that Bulger knew and approved.

So the trial isn't about guilt or innocence, in general. It's about Bulger's legend. And he's already lost.

Thursday, July 25, 2013

What they really believe

Jonathan Chait tells you what you already know, but does it eloquently. The Republicans in congress are threatening to destroy the credit of the U.S. government and crash the global economy in order to prevent people with pre-existing conditions and low income workers from getting health care; and low-wage workers from having enough to eat.

In case you think it's a mystery why they would do this, let me clue you in. It is and always has been bedrock of the conservative psyche that my possessions and my enjoyments are worth much less to me if everybody else has them too. After all, privilege depends on the deprivation of others. What good is abundance if the undeserving -- be it the dark complexioned, the foreigner, the servant class -- get to share in it.

In the U.S. today, as has been classically true throughout history, the economically privilege have allied with the religious establishment to mutually preserve their prerogatives. Here again is the famous essay by Philipe E. Agre:

From the pharaohs of ancient Egypt to the self-regarding thugs of ancient Rome to the glorified warlords of medieval and absolutist Europe, in nearly every urbanized society throughout human history, there have been people who have tried to constitute themselves as an aristocracy. These people and their allies are the conservatives.

The tactics of conservatism vary widely by place and time. But the most central feature of conservatism is deference: a psychologically internalized attitude on the part of the common people that the aristocracy are better people than they are. Modern-day liberals often theorize that conservatives use "social issues" as a way to mask economic objectives, but this is almost backward: the true goal of conservatism is to establish an aristocracy, which is a social and psychological condition of inequality. Economic inequality and regressive taxation, while certainly welcomed by the aristocracy, are best understood as a means to their actual goal, which is simply to be aristocrats. More generally, it is crucial to conservatism that the people must literally love the order that dominates them. Of course this notion sounds bizarre to modern ears, but it is perfectly overt in the writings of leading conservative theorists such as Burke. Democracy, for them, is not about the mechanisms of voting and office-holding. In fact conservatives hold a wide variety of opinions about such secondary formal matters. For conservatives, rather, democracy is a psychological condition. People who believe that the aristocracy rightfully dominates society because of its intrinsic superiority are conservatives; democrats, by contrast, believe that they are of equal social worth. Conservatism is the antithesis of democracy. This has been true for thousands of years.

Wednesday, July 24, 2013

Obviously I couldn't give a FFOARD . .

what they name the baby, but what I don't understand is why anybody cares, much less why this is the screaming headline leading every news platform on the earth.

People are weird.

Tuesday, July 23, 2013

Something that really matters

I can't tell whether Americans really are completely obsessed with the birth of an heir to a useless, anachronistic institution in a faraway land, or if the corporate media just assume we will be or would rather manufacture a meaningless frenzy over nothing than actually, you know, report the news.

So here's a thing, via Brad DeLong (he alas does not provide a link to the original source):

Median household income in the U.S. today is about what it was in 1989, and has continued to decline throughout the recent "recovery." This of course as per capita GDP has increased, meaning, via simple arithmetic, that the rich have gotten richer while the middle class has gotten poorer. In other words, the recovery isn't actually happening for most people. So why is this?

It's partly because of an ongoing substitution of capital for labor, because of the continual decline of union power, because of continuing declines in public sector payrolls, because multinational corporations continue to pursue the lowest possible wages around the earth.

And yet, in the aggregate, the country is wealthier than ever. We can provide people with a better standard of living, but capitalism isn't doing it. Ergo, we need to try something else. Let's have that conversation.

Monday, July 22, 2013

The worst (corporate) persons on earth

If corporations are people, they're all psychopaths, but drug companies seem to be more psychopathic than others. Graduate student Jeppe Schroll, in BMJ, finds numerous instances in which Novo Nordisk, in published results of clinical trials, completely omitted important adverse events including deaths. I won't get too deep into the weeds here, which would just confuse the issues. I'll make it simple.

For background, a commonly used marker for diabetes control is called glycated hemoglobin, often called hemoglobin A1c and written as HbA1c. Basically, if you have high levels of glucose in your blood, higher levels of this variation of hemoglobin form. So doctors can use it to estimate what your average blood sugar level has been recently. Keeping it low is therefore a goal of diabetes management.

Lately there has been recognition, accompanied by considerable controversy and false balance in both the public reporting and the FDA response, that some drugs which have been found to reduce HbA1c in clinical trials are nevertheless associated with a higher rate of cardiovascular disease and adverse events. This is one more indication that it's probably not a good idea to rely on surrogate endpoints in approving new drugs. After all, the most important complication of diabetes is death from heart disease. We also want to prevent other adverse outcomes but it doesn't matter if you're dead.

So, investigations sponsored by the company found that some of their products lowered HbA1c, and on this basis the drugs were approved and widely prescribed. What they didn't bother to tell us in the published reports was that some of the people in the studies died, and that they couldn't rule out that this was linked to the drug. They failed to report other adverse outcomes as well.

Now, there are all sorts of lies, and for some reason we don't generally view omission of important facts as negatively as we do affirmative false assertions. But in this case we should, because clinical trials investigators are under a prior obligation to report on adverse events. These are lies of omission which can kill people, and the motive is greed. That's evil.

Thursday, July 18, 2013

Required Reading

Tom Streithorst, in the LA Review of Books (and isn't LARB much easier to pronounce than NYRB?) offers an economic history of the past couple of centuries and tells us where we are today. I do think it's best for you to read it, but I will hit a couple of high points.

Not so much in rural Bangladesh or Burkina Fasso, perhaps, but all around the the global north and more and more of the south, "we live like Gods," as Streithorst says. Not long ago at all, the average American or European worked from dawn till dusk, lived in what we would today consider a hovel, and spent more than 50% of income on food. People in most of the world (think Irish famine) were continually one bout of bad weather or a plant disease away from starvation. Most people could scarcely read, and had never been a few miles from the place they were born.

It's nearly unimaginable how different this world is. Middle class people spend maybe 2 or 3% of their income on food. We have closets full of clothes and most people refill them every year. Less than a room and a half per person is considered residential overcrowding. Just about every family that wants to owns a machine that can transport them 500 miles away in a day.

And yet, and yet . . .

People feel financially insecure, they are struggling to get by day to day, and hardly anyone can achieve security for their old age. The economy can't supply gainful employment to everyone who wants it and much of what is available won't support a decent standard of living. Conservatives think the answer is to cut taxes and let wages fall further, so that capitalists can make more on investments and will find it worthwhile to hire more of those cheap workers.

Wrong, and completely upside down. Capitalists will hire workers when somebody wants to buy the stuff they have to sell. They'd rather make a profit that gets taxed than none at all, but again, they won't invest if they can't sell their crap. And right now, they can't. The reason is that not enough people have enough money to buy it.

Productivity defined as output per hour of work has climbed steadily throughout the past 2 centuries, but since 1970 or so, average wages in the U.S. have been stagnant. This is because capital has displaced labor. But if people don't have money to spend, they can't buy stuff and put each other to work. So, they economy was sustained by a series of asset bubbles and rising debt. This put money in people's pockets until the bubbles burst and they couldn't borrow any more. Now we're stuck.

The answer is that we need a totally new kind of economy in which wealth is, yep, redistributed. Government needs to spend money by putting people to work doing good stuff -- Streithorst favors high culture, arts and the life of the mind, others might favor more subways and replacing all those water mains that keep breaking, but there's no reason we can't do it all.

But this has to be a permanent state of affairs. Once you have too much stuff, your problem is not supply, it's demand. And no, John Galt and the Koch brothers can't create that. 

Wednesday, July 17, 2013

What terrifies Republicans . . .

. . . is of course that the Affordable Care Act will be successful. That's why they keep trying, impotently, to tear it down like a dog gnawing on granite. While I am constitutionally loath to peer into the crystal ball, it certainly seems that the early signs are favorable. Premiums in California turn out to be generally affordable, and now New York has generated an even better headline: the price of health insurance on the individual market will fall by about half.

This may seem like sorta, kinda the opposite of what you may have heard about the effect of the ACA in general -- that it will actually make health insurance more expensive for young, healthy people -- but the explanation is what's so great about this for prospects of getting through to people who are unclear on the concept (which is 90% of the population).

New York State is unusual in that it already has guaranteed issue, but, obviously, without the individual mandate. That makes it a perfect experiment that shows why the individual mandate is necessary and good. Right now, New York state has 2.8 million people with no health insurance, and only 17,000 (that's right, only 3 zeroes) who have purchased policies on the individual market. The reason is they're much too expensive for almost everybody, because of adverse selection, i.e. the only people who buy them are people who are sick enough that it's worth their while paying the exorbitant premium. Insurance companies, expecting an influx of new customers who are less expensive to insure, therefore are cutting their prices. Lots of people will be eligible for federal subsidies to buy those cheaper products, so it will be well worth their while even if they are on the young and healthy side.

That's the whole idea, folks. Yes, you may feel you'd rather not buy health insurance right now because you're invulnerable, but by making people like you buy it now, we make sure you'll be able to afford it when you need it. That's the point of insurance -- to spread risk, and make everybody more secure. Sure, there will be glitches, especially in the states whose governments aren't cooperating, and the corporate media will blow them way out of proportion. But if people's actual experience is good (and for most people, nothing will change), maybe the 2014 mid-terms will turn out differently from what people are expecting.

Monday, July 15, 2013

Physicians and dying

Before I get to the question of this post's title, let me make the obligatory George Zimmerman statement. No, I have nothing unusually insightful or unique to add, but neither does anybody else. If you can strap on a gun, see a kid simply walking through your neighborhood, stalk him, and shoot him dead, and have no legal accountability or responsibility whatsoever -- in fact you get your gun  back and you are free to do it again -- we are not living in a civilized country. (Yes yes, the sole, only and single reason Trayvon Martin was suspicious was because he was black. But everything I say here is true regardless.) It seems that according to Florida law, if you claim self defense, it is the burden of the prosecution to prove beyond a reasonable doubt that your actions were not in self defense. I don't think that losing  a fist fight is grounds for murder even if you are, in some sense, defending yourself, but even so: if you live in Florida, and you want to murder somebody, just get them alone, kill them, and claim they attacked you. That's all you have to do.

Okay, now on to business. Bill Noble, a British palliative care specialist, doesn't like a proposal in the land of the bowler and bumbershoot to legalize physician assisted suicide. It might surprise you -- and it did surprise some folks the last time I wrote about this question -- but I'm quite leery of this idea myself. Nothing terrible seems to have happened so far in Oregon, which did legalize it a few years back, but it still raises some distressing problems.

All of these proposals, like the Oregon law, have safeguards. The people must be terminally ill, you can't help a patient die just because the person is suffering. Also, they can't be diagnosed with depression or other major mental illness. But, if you've been reading this blog, you already know that neither of those criteria has the status of a "fact." Doctors are notoriously inept at predicting how long people have to live, and the diagnosis of depression is largely arbitrary. Obviously, if you're very ill, suffering, and don't have long to live, you're probably unhappy. Calling you "depressed" or not is pretty ridiculous either way.

In another vein, it seems to me quite disingenuous to claim that this choice can reliably be assessed as non-coerced. People's opportunity to die a natural death with dignity depends very much on their material and social resources. People are inevitably going to consider, at some level, the burden that their care puts on others -- both personally and financially, no matter what they say or how you talk with them. Palliative care specialists claim that often, not enough is done to relieve suffering and that people will often change their minds about wanting to die if they are given better care.

Noble thinks that even if you do conclude that there are meaningful criteria to distinguish those deserving of help in killing themselves and those who are not deserving, it should not be the job of physicians to make these decisions. He suggests a team of social workers, but I think his real point is that these proposals radically redefine medical ethics and the role of the profession, and a lot of doctors are just very uncomfortable with it.

I'm the first to concede that one of our greatest cultural pathologies is the denial of mortality. Death is not necessarily a tragedy, or I should say that any given individual death does not necessarily add to the overall tragedy of the human condition. Our time will come, and our refusal to accept that is at the root of a good deal of disordered thinking and bad public policy. (Weirdly, it's religious people who believe in an afterlife who seem to suffer from this delusion the most.) But it has traditionally been the job of doctors to delay that time, if possible and worthwhile, not to hasten it. This idea has many implications which people seem to stop short of thinking through. So no, I'm not yet convinced this is a good idea, although I'm willing to listen.

Sunday, July 14, 2013

Cross posted from Today in Afghanistan . . .

UK newspaper the Mail reports that Prince Harry witnessed a war crime by U.S. soldiers in Afghanistan. Really. Excerpt:

Prince Harry was no more  than 220 yards away when a US trooper standing aboard an armoured vehicle cocked a .50 calibre machine gun and fired successive bursts at Afghan shepherds tending their goats, The Mail on Sunday can reveal. The shocking incident, which  was confirmed last night by the Ministry of Defence, triggered a war crimes investigation by US military police. It took place on Harry’s first frontline tour of Afghanistan, which, until today, has been shrouded  in secrecy. . . .

According to a British eye- witness the three shepherds were peacefully minding their own business when they were engaged. Given the force of the heavy machine gun rounds it is likely  they suffered serious or fatal  injuries, though their bodies were never recovered.
This would have happened in 2007. Note that although the story says the M.P.s investigated,  I am unaware that anyone has been prosecuted for this murder, nor that any investigation has been publicly acknowledged. I wonder if the U.S. corporate media will bother to report this? So far I haven't seen any mention of it.

We'll never know how many atrocities U.S. forces committed in Afghanistan, with total impunity. But the Afghans have a pretty good idea.

Wednesday, July 10, 2013

If you're interested in public health, this is kind of cool

If also a bit depressing. The Institute for Health Metrics and Evaluation at the University of Washington has released a report on the state of health in the U.S., based on the Global Burden of Disease data from the World Health Organization. The depressing part is that, as we already know, the U.S. population is in worse health than all the other wealthy countries. We don't live as long, we're sicker, and we're more depressed. That isn't news so I won't dwell on it.

However, the cool part is all of their data visualization tools. You can quickly see trends in all the causes of death, by age category and sex; compare countries; see how leading causes of death have changed places over time -- all sorts of enlightening interactive graphics are at your command!

One of the most interesting is an interactive map of the U.S. in which you can see various health status indicators by county. Funny thing -- they've made longer life expectancy bluish and shorter life expectancy reddish. I don't know what they were thinking, but with the exception of Utah (Mormons don't smoke or drink, doncha know) the map ends up looking a whole lot like another map you may have seen. (Push the slider all the way to the right to get the most recent year, and click on female rather than male to get the strongest picture.) Yep: the redder the state, the sicker the people. Why do you think that might be?

Why is the corporate media obsessed . . . .

with this plane crash in San Francisco? I was watching the ball game on Saturday and idly switched to CNN during a commercial when I first saw the completely static video of the tailless plane sitting on the runway -- a shot that seemed to stay up about 80% of the time while CNN went totally wall to wall with this for two whole days. MSNBC also dusted off Ed Schulz to go wall to wall with this in place of their usual weekend lineup of tabloid psycho-porn. The local and network newscasts on both weekends were devoted almost entirely to this story -- in which nothing was happening and there were no significant developments -- as were all of the major news websites pretty much right through Monday, and it's still just barely tapering off.

As plane crashes go, this was as minimal as it gets -- two people dead. The basics of what had happened were immediately obvious -- the plane landed short and its tail hit the seawall at the edge of the airport and broke off. We knew that five minutes after it happened. That's still what we know.

Meanwhile, they had another perfectly good, far more consequential and even more photogenic industrial disaster available to obsess over, the train derailment in Quebec that destroyed an entire downtown, was still very attractively on fire, killed dozens of people, and has important public policy significance. But it didn't interest them in the slightest. The turmoil in Egypt, abortion controversy in Texas, imminent implementation of the Affordable Care Act and associated difficulties, you name it, they ignored it. For three whole days. Instead, they sat there and talked about the absolutely nothing that was happening in connection with a minor event that was long over.

I suppose it's the weird media magnetism of plane crashes that has made Al Qaeda so obsessed with causing them. And yeah, TV talking heads make a lot of money and fly a lot so that probably makes them care about it. But I don't really get it. To most of the audience, this must be just as boring and pointless as it is to me.


Monday, July 08, 2013

More of Less is More

Some folks at BU review evidence about a diagnostic test, called CT pulmonary angiograms. (I think you can only read the abstract, but I shall summarize well.)

A pulmonary embolism is a blockage in an artery in the lung. Sounds bad, right? And indeed it can be: symptoms can include respiratory distress, chest pain, and rapid heart beat and it can be fatal. The treatment is to take anticoagulant drugs, normally warfarin. This present a risk of bleeding but it beats dying. So we want to diagnose them all and make sure we don't miss any, right?

That's what doctors thought to and they were accordingly delighted when CT scanning came along. It is now possible to inject iodine into the blood stream and create very high quality images of the arterial network in the lungs, which means they can find even tiny embolisms. This has largely replaced an older method called ventilation-perfusion scanning, in which the patient inhales a radioactive gas and has a radioactive material injected, and a gamma ray camera can then image where air and blood are getting to within the lungs. Although that sounds scary, it actually subjects the person to a lower radiation dose than does CT scanning. However, it is less sensitive.

Doctors love the CT pulmonary angiography scan because they don't want to miss any of those "silent killers." But, what the BU researchers find is that since CTPA was introduced, the diagnosis of pulmonary embolism has increased by 80%, but deaths from pulmonary embolism have barely changed. It turns out that the procedure can detect tiny (isolated sub-segmental, referring to a small branch artery) embolisms, but apparently, these are harmless. In fact the body can reabsorb them, and it may well be that evolution has actually favored the lungs performing the function of filtering out tiny blood clots originating elsewhere. In one study, of 65 patients found to have these tiny embolisms who did not receive anticoagulants, none had any adverse effects.

As the authors summarize, anticoagulation is actually a leading cause of medication-related death. In one case series of patients given anticoagulants for isolated sub-segmental embolisms, 5.3% had major bleeding. Being told you have a condition that could kill you, and having to take a dangerous medication, is obviously unpleasant for people. And the cost? In 2006, hospital admission for a pulmonary embolism cost $44,000.

But the drug companies and medical device companies push these procedures hard. Hospitals need to have the latest scanners so they can appear cutting edge and high tech, but in order to justify paying for them, they have to use them. We're getting far too many of these scans, which increase the risk for cancer as well as costing money and finding all sorts of incidental abnormalities which aren't actually dangerous but have to be investigated, at great expense and angst. We should knock it off.

Friday, July 05, 2013

Too much news

You hardly know where to begin. Anyway --

Obama has decided to delay the insurance mandate in the ACA by one year. This is actually wise. In this respect, the law was horribly crafted. The first thing you learn in Public Policy 101 is not to create a "cliff," meaning in this case that there was no employer mandate at all with 49 full time employees, then it kicked in for all a company's employees when they hire the 50th. You don't need to take the course to see why that doesn't work.

The right way to do this is to impose a penalty on the 50th employee and subsequent employees only; therefore no cliff and if you need a 50th employee, the added cost is small so you'll probably go ahead and do it anyway. Once you get up to 60 or 70 or so, you'll say what the heck, might as well start offering insurance for everybody -- as most companies that size already do. Meanwhile you've paid a bit to help the subsidies for people buying individual insurance. Congress could fix that, of course, but they won't -- unless the Democrats take both chambers in 2014. The fate of humanity depends on that happening, so start working now.

Oh yeah, the fate of humanity. I'm sweltering as I write this, taking the day off from work and no AC at home. I wonder what will happen when all those folks who've fled the northern winters for the sunny paradise of the Southwest find the place uninhabitable?

Wednesday, July 03, 2013

Cure Schmure

No doubt you have encountered the hype about a purported cure for HIV infection. That would indeed be great news, but sadly, no. Here's an example of the selective and misleading coverage this is getting.

Two men who happened to develop some form of cancer (not specified in the public story) while also being HIV+ received the treatment called "bone marrow" transplant, continued to take antiretroviral medications throughout the procedure and recovery, and now appear to be free of HIV. They seem to have turned great misfortune into good fortune, but in reality, this is a big, fat, so what?

Here's the real deal. The procedure they underwent is more properly called an allogeneic hematopoeitic stem cell transplant (HSCT). Nowadays they don't actually transplant bone marrow, but rather the cells that reside in bone marrow which are the progenitors of blood cells. Doctors do this for a few different reasons. The most common is that the person has some form of leukemia -- abnormal proliferation of white blood cells, which is a kind of cancer. In this case, if chemotherapy doesn't work, the alternative is to destroy the person's HSCs with radiation or chemicals, and replace them with cells from a donor. Other reasons are lethal abnormalities of red blood cells -- aplastic anemia, and the procedure is increasingly being done for severe sickle cell disease.

The reason this appears to cure HIV is that the virus lives in white blood cells. Replace them all, and you eliminate it. It may also lurk in other reservoirs, but if so the new immune system gets to work on a very low presence of HIV infection, and is able to wipe it out.

That's all well and good but it does not mean that everybody living with HIV should now go and get one of these procedures. Alas, the cure risks being worse than the disease, because HIV can be controlled with drugs, but allogeneic HSCT creates a risk of what is called graft vs. host disease (GVHD). The new immune system was originally somebody else's, and it is likely to recognize the recipient as foreign, whereupon it starts destroying the person's tissues and organs. This is basically incurable and causes severe symptoms and a short life. In order to prevent it, you have to take immunosuppresive drugs which means that you have -- wait for it -- immunodeficiency. Which was your problem in the first place. In spite of this, some people get GVHD anyway. (And, I should have added originally, you might die while you're waiting for your new immune system to reconstitute. In fact you have about a 25% chance of that happening. It's a desperation move, not an ordinary treatment for anything.)

So whether a feasible cure for HIV/AIDS might somehow follow from this observation is unclear, but personally I don't see it. If there is a path from here to there, it's a long one. The bad news is that lots of people will see this overhyped story and get false hope, or believe that a cure exists which is being withheld, or offered only to the wealthy. I wish the hope were real, but not yet. Keep taking your pills.

Monday, July 01, 2013

Category Error

It seems there is a new conservative society trying to get established in graduate schools of "business, medicine and public policy," inspired by opposition to the affordable care act. They think the reason you don't read a lot about the wondrous powers of the Free Market™ to heal our health care system is because we're all socialist atheist commies.

No, actually the reason you don't read in Health Affairs all about the stuff they fervently believe in is not because academia is ruled by ideologues, it's because what they believe is not true, and the purpose of academic inquiry is to find the truth. Excerpt:

The Duke group’s guest speakers included Dr. Keith Smith, an Oklahoma City anesthesiologist whose surgical center lists the costs of its medical procedures online in a move toward price transparency. The practice only accepts private health insurance, not Medicaid or Medicare. . . .

The Benjamin Rush Society traces its roots to 2008, when Canadian activist Sally Pipes organized a Washington meeting with support from the Kansas City-based Ewing Marion Kauffman Foundation. Its credo: “the profession of medicine calls its practitioners to serve their patients rather than the government.” Conversely, they also support so-called “concierge medicine” in which those with more money pay for individualized care otherwise unavailable.

Now, personally, I have no problem with that. They can refuse to take insurance and only work for rich people if they want to. However, it does not follow that the Free Market™ therefor is the solution to our dysfunctional health care system because think about it Randroids: what happens to people who cannot afford to pay Dr. Keith Smith for an appendectomy when there isn't any Medicaid or Medicare?