Map of life expectancy at birth from Global Education Project.

Monday, June 30, 2014

The Omega Man?

I wrote recently that I was losing no more than an hour of sleep each night over the prospect of a horrific global pandemic, mostly because we supposedly know what we are doing more so than the medieval folks who were decimated by the Black Death.

Well, maybe, but three essays in the new BMJ should give us pause. The problem is that scientific understanding of infectious disease isn't enough if we don't have global mechanisms for putting that knowledge to work in an emergency. I think you'll only get the first paragraphs, but it isn't hard for me to hit the high points for you.

First, Ilona Kickbusch (yeah yeah) and Mathias Bonk (also too), went to the World Health Assembly in May and they didn't have such a great time. That's the annual meeting of the WHO, involving all 194 member states. It seems that the delegations from some of the poor states didn't have high quality presentations to offer, the communications and AV technology was poor, and there were too many people there and a lot of blather. Okay, well you have to take the thick with the thin.

Journalist Sophie Arie then asks if current arrangements are good enough to prevent The Big One. Following the SARS scare, global agreements were revised in 2007. All 194 countries signed on, pledging to report outbreaks to WHO immediately and to set up monitoring systems and designating "disease free" (i.e. vermin free) entry points where travelers can be checked. But a lot of countries haven't done this yet, mostly because they can't afford it, and just don't have the means to comply.

So, Devi Sridhar and friends explain the real problem, which is that major funders -- excuse me, mostly one major funder, that is the United State government -- has drastically cut back on its core support for the WHO. Instead, the U.S. makes what it calls "voluntary contributions" which means it gets to designate how they are spent. Right now the biggest funders are U.S. and U.K. voluntary contributions, and the Gates Foundation. These don't cover core operations and they don't help poor countries set up surveillance and reporting systems. The U.S. adopted zero nominal growth -- that is, a guaranteed annual decline in real dollars -- in its contribution to the core budgets of UN agencies in 1999. Joe Biden's name is on the bill, next to Jesse Helms. So when we all die in the zombie apocalypse, you can thank Uncle Joe.

The fact is, we all live on one small, shrinking (metaphorically) planet. If we don't get over this sovereignty fetish, we're screwed.

Wednesday, June 25, 2014

Same as it ever was

Via Brad deLong, here is Amartya Sen taking down the essential conservative economic argument in 1982. Sen is responding to P.T. Bauer, who way back then was making the same Mitt Romney 47 percenter teabagger case we're still hearing about today. Bauer was a "serious" economist so he does not, as far as I know, reference Ayn Rand, but it's the same basic idea -- economic inequalities are "largely the result of people's capacities and motivations . . . . It is by no means obvious why it should be unjust that those who produce more should enjoy higher incomes."

There you have it: the Makers vs. the Takers. But as Sen goes on to show, it is evident, transparently obvious really, that people's incomes are not proportionate to their productivity. (Even if they were, one could still make a strong moral case for limiting inequality, but that isn't even necessary.) For one thing, this assertion requires that owning productive assets constitutes personal productivity. Even if it did, it is hard to see how inheritance constitutes moral entitlement.

For another, incomes vary for all sorts of reasons that do not correspond to whatever it is that an individual personally produces, which is very easy to show.

Yet these nonsensical claims made Bauer one of the most respected economists of his time, and continue to bring prestige to professors today such as Greg Mankiw. How anyone can pay deference to such ridiculous arguments may seem hard to explain but of course it is not: wealthy people endow chairs in economics, and wealthy people dominate public discourse.

Do read Sen's essay, and arm yourself for the struggle.

Monday, June 23, 2014

"End of the World" plague

I happened across this today and it inspired me to write a post I've been thinking about for a while. The link is to a story about the so-called Cyprian plague of the Third Century, possibly an outbreak of smallpox, which is said to have given a boost to Christianity.

A couple of decades back there was a virologist or epidemiologist, whose name I forget, who firmly predicted that at some time in the coming decades, an emerging infectious disease would explode and decimate the global population. He generated immense controversy in part because it kind of sounded like he was hoping for it, part of his premise being that there are too many of us. Unfortunately this story doesn't have parameters that make it easily researchable, so if anybody can remember who I'm talking about please let me know. Anyway . . .

The argument in favor of this scenario seems pretty convincing at first. There have been plenty of instances in the past in which infectious disease outbreaks have caused crashes in human populations, albeit limited geographically because not all populations were in contact. The Black Death is thought to have reduced the European population by50% or more late in the 14th Century. While it is not possible to prove historical causation, there is a compelling story that this event ultimately brought about the end of the Middle Ages and the emergence of modernity. A sudden shortage of labor, and the availability of twice as much land and fixed capital per person, raised the status of the peasantry and hastened the end of serfdom. The introduction of hitherto unknown diseases to the Americas, notably smallpox, caused the so-called Demographic Disaster which reduced the indigenous population by some 90% and made the European conquest complete.

HIV and the hemorrhagic fevers, SARS and MERS, although none of them turns out to be the apocalypse plague for various reasons, do prove that new human pathogens will continue to appear frequently. These particular viruses have limited transmissibility, which is why our global population continues to grow, but the point is, with every city on earth connected by air travel that can get an infectious person from Nairobi to New York in less than a day, when the new smallpox does arrive -- highly transmissible, highly lethal -- we're screwed, lassoed and tattooed.

Well, maybe. The most important difference is that today, we understand infectious disease. We'll know how to take effective action, both in the short term through isolation and quarantine, and in the longer term through understanding the pathogen and coming up with effective treatments and/or prophylaxis. We hope. But the deeper point is, you can't understand the future by extrapolation. Will there ever be 8 billion humans alive at one time? I wouldn't bet on it. This is only one reason.

Friday, June 20, 2014

American Exceptionalism, once more . . .

This gets old, I know, but the Commonwealth Fund has once again released is report comparing U.S. health care to other wealthy countries and once again we are the pits. As in dead last, 11th out of 11. The competitors are western European countries and Canada.

Apparently its' good to be pinko. The United Kingdom, which is the only country on the list to have actual socialized medicine -- you know, government run health care, big gummint bureaucrats employing your doctor and telling her what to do -- is number 1. There isn't really a trend in that direction however. Switzerland, which has a version of Obamacare, is number 2.

Obviously, you can quarrel with the criteria. But the U.S. fares very badly on most of them, and that includes the bottom line -- the U.S. is dead last on "healthy lives," that is outcomes amenable to health care. The UK was not good on that one either, but they spend half as much as we do and still get slightly better results. And here is the main reason why we are for shit:

The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.
If it's really more important to your average moderate income voter that rich people not pay taxes than it is to solve this problem, then by all means vote Republican. They're on your side with that.

Tuesday, June 17, 2014

More on gun violence

Lawrence Gostin, writing for the JAMA forum, makes many of the same points I did recently about the framing of gun violence as a mental health issue. Sure, most mass shooters have diagnosable mental illness but a) most mentally ill people are not violent, b) most gun violence is not mass murder (in fact it's only a tiny fraction), and c) the only good predictor of future violence is past violence. To remind us:

Although most mass killers are mentally ill, only a small minority of persons with mental illness is violent. Overall, only about 4% to 5% of overall violent crime can be attributed to persons with mental illness. At the same time, it is exceedingly difficult to predict violence based on a psychiatric diagnosis: psychiatrists’ predictions of violence are no better than chance. It is true that mental illness can be a risk factor for violence, but often only with comorbidities, such as alcohol or drug abuse. The latter are far more powerful predictors of violence than the diagnosis of mental illness. Still more powerful is a history of violence, particularly threatening or using a lethal weapon such as a firearm.
Like I said. Nevertheless, Gostin still wants to tighten the background check system so that people who have been committed to a mental institution can't buy guns easily. I'm not even sure what he means by that -- if you've ever been committed, you should lose your rights for life? If you're currently committed, you can't buy a gun anyway. Anyway, civil commitment is a somewhat arbitrary process and there is no evidence, certainly none that Gostin provides, that it is predictive of violence. After all, if psychiatrists' predictions of violence are no better than chance, why should their decisions to have people committed as a danger to themselves or others get any respect? His proposal is transparently self-contradictory.

He goes on to propose that people with a history of violence be banned from gun ownership. That makes more sense, but I despair of it working. The country is so awash in firearms that it is easy to obtain them illegally, and people who have been convicted of violent crimes do not have a proclivity to obey the law.

The only hope, it seems to me, is cultural change. People need to understand that guns are dangerous; having them around makes you far more likely to kill yourself or inadvertently kill someone you wish you hadn't than it makes you likely to somehow defend yourself; and the more guns there are in the environment, the more violent death there will be. Make it the cultural norm, what the cool people do, that if you have some good reason to won a gun, keep it locked in a safe and only take it out when you want to hunt or shoot at paper cutouts of Barack Obama or Trayvon Martin. Require licensing of gun owners based on taking safety training and passing a test, and registration of guns, just like motor vehicles. But saying Joe is allowed to buy a gun and Fred is not, just isn't workable.

Monday, June 16, 2014

Why is marijuana illegal . . .

in most states, while chewing tobacco is not?

Tony Gwynn wasn't just a hall of fame baseball player, he was universally regarded as a really nice guy. He repeatedly eschewed the chance to make bigger bucks in order to stay with the Padres for his entire career. As baseball coach at San Diego State, his alma mater. A hometown guy who cared less about getting rich than he did about his community. Also, he leaves a wife and two kids. He was 54 years old.

And yes, it was cancer that started in his cheek, caused by tobacco. The people who market that stuff are murderers. The wrong guy died.

Friday, June 13, 2014

Mass assault of bullshit

You knew it would happen. The headline on the CBS News web site this morning: "Is the violence in Iraq Obama's fault? The worsening fallout from the Iraq war Obama ended is casting a long shadow over his foreign policy." NPR this morning featured Vali Nasr of the Johns Hopkins School of Advanced International Studies arguing that the partition of Iraq would be a disastrous failure for U.S. foreign policy and that "we" have to take responsibility for maintaining the Shiite government's control over all of Iraq. (NPR didn't bother to mention that Nasr grew up in Iran. Relevant?) And similar dreck is all over the place, coming from Republican politicians of course but also as the unexamined assumption of the corporate media. The Iraqi government that the U.S. installed, and the Iraqi army that the U.S. armed and trained, are a fortiori U.S. allies and assets and we have to continue to back them and defend them.

Funny thing -- Iran is already sending Revolutionary Guards to Iraq. Wait a minute, I thought Iran was the bad guys? Now we're supposed to fight alongside them? What's going on here?

Here's the truth. The United States has absolutely no national interest in preserving the arbitrary map of the Middle East that was drawn by departing European colonial powers. Iraq is an artificial creation, and its territorial integrity is already fictitious. Iraqi Kurdistan was de facto independent before the U.S. invasion. The Kurds have taken advantage of the current chaos to expand their own territory. If there ends up being a Sunni Arab state in part of what is now Iraq and Syria, why would it matter to the United States in the slightest? It wouldn't. This has nothing to do with us, there is no national interest at stake, and there is no conceivable reason why it should be a goal of U.S. foreign policy to prevent it or a failure of U.S. foreign policy if it happens.

ISIS is bad guys who we don't like. True. But the population of Anbar and Nineveh provinces also feels the same way about the Iraqi government, and they won't defend it. We don't know how the political situation within the breakaway Sunni region will evolve -- it may well be that ISIS, having spearheaded the secession fight, will ultimately be unable to maintain political control. Or it may be that Iraqi and Iranian forces will be able to re-exert some degree of control over the territory. But whatever happens, it is not our problem, and there is nothing constructive we can do about it except stay the hell away.

Obama was right to get out of Iraq. The Iraqi people didn't want the U.S. military there, and the government would not allow it. So they left. What happens next is just something for us to watch.

Thursday, June 12, 2014

Understanding Iraq

The corporate media, and for that matter U.S. politicians of all stripes, are fundamentally misunderstanding what is happening in Iraq. The collapse of the Iraqi army in Mosul and cities to the south along the Tigris is not essentially about the rise of ISIS (aka ISIL) as a powerful extremist force; it is fundamentally about the sectarian misrule of Iraqi Prime Minister Nuri al-Maliki and his allies in political Shiism. Former U.S. diplomat Wayne White (oddly appearing here in an Iranian web magazine), has a sharp analysis. ISIS is successful because the largely Sunni population of Anbar and Nineveh provinces hates the government more than they fear the extremists; and because ISIS has allies of convenience in Baathist revanchists and other Sunni militias and vigilante forces. As White says:

Maliki’s refusal to capitalize on Sunni Arab assistance brokered by the US was a missed opportunity of vast importance. Back in 2007-08, most Sunni Arabs were profoundly war weary after several years of bruising combat with US forces. As a result, a community previously determined to resist US forces and a government dominated by Iraqi Shi’a and Kurds, reluctantly accepted new realities. In exchange for ending their resistance and helping to battle AQI, Sunni Arabs expected a fair share of Iraq’s political pie, more government employment, and an appropriate slice of the country’s revenues. This, however, was not to be.

Securing a freer hand to deal with Iraq’s Sunni Arabs more harshly appears to have been one reason Maliki and his Iraqi allies backed away from the immunity agreement needed to allow a limited US military presence to remain behind after the American withdrawal. Both the Bush and Obama administrations tried and failed to secure this. Then, within 48 hours of the departure of the last US troops in mid-December 2011, Maliki had an arrest warrant issued against Iraq’s most senior Sunni Arab official, Deputy Prime Minister Tariq al-Hashemi, charging him with alleged involvement in “terrorism.” .. . .
The Kurdish army (peshmerga) has taken advantage of the chaos to seize control of the city of Kirkuk, disputed between Arabs and Kurds. The ISIS advance toward Baghdad is unlikely to get far -- despite the mass desertion in Mosul, the Iraqi army outnumbers the insurgency by an order of magnitude, has vast superiority in heavy weaponry, and has helicopters. Worryingly, however, Maliki is raising Shiite militias to join the battle, which will only intensify the sectarian character of the conflict. The peshmerga, a formidable and disciplined force, also do not like ISIS and will probably help succor the Maliki government if it comes to that, although for now they are taking care of Kurdistan. There is also concern, however, that Iran will enter the fray and their are reports that Revolutionary Guards have already gone to Iraq.

All of this creates a likelihood that the relatively few Sunni Arabs in the Iraqi army and other security services may defect, and that full-scale civil war will erupt, perhaps drawing in the Sunni Gulf monarchies to confront Iran. Should the U.S., at this stage, intervene to rescue Maliki and the Shiite government of Iraq? Doesn't seem like it to me, but whatever the U.S. does, the situation is very dangerous. Oh yeah -- fill up your tank, gasoline is about to get  lot more expensive.

Update: Emirates News has a much more detailed factual report  than you'll get from U.S. media. Apparently ISIS has managed to get a couple of captured helicopters into the air, which definitely suggests defection by Iraqi army personnel. They also see it as going without saying that this is essentially a sectarian civil war. 

Wednesday, June 11, 2014

March Hauser: The Denoument

I missed it at the time, but it turns out the Boston Globe obtained Harvard's internal investigative report a couple of weeks ago and it's about as ugly as can be.

To whit:

The 85-page report details instances in which Hauser changed data so that it would show a desired effect. It shows that he more than once rebuffed or downplayed questions and concerns from people in his laboratory about how a result was obtained. The report also describes “a disturbing pattern of misrepresentation of results and shading of truth” and a “reckless disregard for basic scientific standards.”
In a pistachio shell, when his experiments didn't get the results he wanted, he changed the data.

I find this very difficult to understand. Post docs competing for the dwindling share of faculty appointments, assistant professors desperately striving for tenure, frustrated non-entities seeing no chance for glory, yeah, they have motives to cheat and you can make all sorts of arguments about how academic culture, the social organization of science, the competition for grant funding as public support for science yo-yos, all contribute to scientific misconduct.

But none of this applied to Hauser. He was already tenured at Harvard, already famous, already positioned to suck up all the funding he needed. He had no discernible motive for fraud. And his general program of research does not appear to be a tissue of fraud; it's just some particular experiments that didn't go his way. People often write that an experiment "failed." There's no such thing. If it's well done, then the result is informative, no matter what it is. Maybe it turns out that your idea for a warp drive won't allow you to travel faster than light after all, but now you know something that you didn't know before. Maybe your monkeys can't figure out how to do division, but now you know. It still counts, and it has the virtue of being true.

Evidently Hauser is out on Cape Cod somewhere working with at risk youth. I hope he isn't purporting to be a role model.

Monday, June 09, 2014

Isn't there anything we can do about this shit?

I'm guessing you're probably like me, and you're starting to get a little bit tired of wackos committing random acts of mass murder. Yeah, it's a bad thing.

So everybody's got a diagnosis and a prescription. Better mental health services. Rooting out misogyny and delusional extremism from the culture. Making it harder for nutcases to get guns. All that sounds good, if not necessarily evidently possible, but . . .

Here's the problem, looking at this from a public health perspective. We really don't know how to predict that somebody is going to be violent. Well, that's not quite true -- past violent behavior is a useful predictor of future violent behavior. There is an elevated risk of violence among people who are simultaneously seriously and persistently mentally ill, and also have substance abuse disorder, but even there it's only a minority. But being mentally ill, as a general category, is not predictive of violence. Most people who commit bizarre acts of violence against strangers could be said after the fact to have a diagnosable mental disorder, but that's really tautological. Whether you want to say that people who behave in extremely deviant ways have a disease or not is really just a semantic argument, it doesn't mean anything. The point is, we can't predict.

And that's really nut. We aren't about to start restricting political speech in this country, and we shouldn't. Direct threats of violence can be against the law, but Glenn Beck's conspiracy theories and George Will's endorsement of rape and Bill O'Reilly's provocations against abortion providers -- you just can't draw the line. If the culture is full of angry, hate filled people with ideas that they use to justify violence, there isn't any law you can pass against it.

And, we can't start taking rights away from people who get a diagnosis of mental illness, that we extend to everybody else. In case you didn't know it, the vast majority of people qualify for a psychiatric diagnosis at some point in their lives, if not all the time. Getting a psychiatric diagnostic label is pretty much a random event that doesn't mean anything.

Finally, by now, the U.S. is saturated with firearms. We're never going to recall them. I'm all for reasonable regulation, just like we regulate cars and drivers, but that's not going to stop a nutjob.

So, if we could improve our ability to predict who's going to go postal, we might be able to do something. But until that happens, I despair.

Campaigning against motherhood and apple pie

Republicans are still insisting that the Affordable Care Act is a disastrous failure, and they still plan to build this year's congressional campaign around repealing it. But a funny thing happened on the way to the trainwreck. As Krugzilla shows, it's working just fine, thanks, in fact at the high end of expectations. The number of uninsured people in the U.S. fell sharply after the main provisions of the law went into effect, and gains in employment jumped at the same time.

But, most voters still don't know what's in the act, how it works, and why it works the way it does. They just know they're supposed to hate it, but they don't know why. I actually don't think it will be a winning issue for Republicans, but that it isn't yet a winning issue for Democrats is largely because of our dysfunctional corporate media, that dutifully transcribes politicians' fact free commentary without bothering to explain the reality. Until that changes, the long decline of the United States will continue.

Friday, June 06, 2014


You'll often see people who I agree with about a whole lot of important subjects defending the importance of animal research to the advancement of medicine and the relief of human suffering and disability.

The picture most people, including scientists have of the typical course of biomedical research is that you first create an animal "model" of human disease; you study the animals to try to understand the disease better; then you test treatments in the animals. Ones that seem promising then get clinical trials in humans. According to this putative reality, If PETA gets its way, and we can't do this any more, we will never find cures for multiple sclerosis and Alzheimer's disease and pancreatic cancer and all those other horrors. It's too bad for the animals, but human welfare and survival are more important.

According to Pandora Pound and Michael Bracken, writing in BMJ, not so. In order to make the best judgments about what treatments work in humans, we do systematic reviews and meta-analyses to pull together information from all the available studies, assess its quality, and combine the highest quality information to generate conclusions and assess  how confident in them we can be. Lately, investigators have worked hard to overcome the problems of publication bias, cherry picking of results and other flaws in the scientific enterprise that often lead to overuse of treatments without good evidence. We have a long way to go, but we're getting better at it.

In animal studies, however, there is far less accountability for quality and synthesis of results. Pound and Bracken cite one survey that found only 12% of animal studies used random allocation and only 14% had blind assessment. Selective analysis and publication bias result in distortion of "entire bodies of research," according to another reviews. Meta-analyses are rare.

When treatments enter clinical trials in humans based on animal research, they are overwhelmingly likely to fail. P&B also note that decades of research have failed to yield a single treatment for stroke, ALS, and other conditions.

Not only are there problems with research quality, reporting and synthesis, but it is questionable how useful animal models are for understanding human health or predicting human responses to treatment in the first place. There are just too many differences between humans and rodents, or even other primates, for treatments to translate in most cases.

There is an enormous vested interest in animal research, and you know these claims will generate massive yelling and screaming. Note, of course, that this is unrelated to the conduct of basic research intended to understand the animals themselves. We're talking about biomedical research purported to ultimately benefit humans. That relationship is far more tenuous than most people believe, and the effort generates enormous waste and massive failure much more often than it generates anything useful. That's what Pound and Bracken are arguing. This is a debate that people need to approach with an open mind.

Tuesday, June 03, 2014

About those carbon emission regulations . . .

How important are the proposed EPA regulations on power plant emissions? Actually not too shabby, I would say. Ben Adler at Grist runs down the content of the proposal, which is more than your average newspaper or talking head has bothered to do. The regulations bind the states to reductions based on their (2005) baseline, defined as emissions per megawatt hour of generation, however they want to do it. The 2005 baseline is cheating because emissions are already down from that year, due to abundant natural gas and the recession, mostly. So there's a head start, and the target -- a 30% reduction by 2030 --is considered unambitious by environmentalists.

But -- this will establish a national policy and give the U.S. more credibility in international negotiations. That is if and only if a Democrat is elected president in 2016, of course, because the regulations probably won't even be implemented until then. As Ezra Klein explains, Republicans were actually for controlling carbon emissions until recently. In fact, John McCain and Sarah Palin ran on a platform of a cap and trade system that would reduce emissions by much more than Obama's proposal. Really. In 2008, John McCain said this: "Whether we call it 'climate change' or 'global warming, among environmental dangers it is surely the most serious of all." But then the Koch brothers purchased his withered soul.

The proposed EPA regulations are far too little by themselves to save us from catastrophe. But they will force a substantive public debate, for a change, and at least we're starting to do something. Dangerous and costly warming is inevitable, but we can still keep it to the low range of awful.

Highly Misplaced Fear and Trembling

It's been amusing (I guess that's the word) watching Republican politicians freak out over the exchange of 5 Taliban prisoners for a U.S. soldier. Yes, these guys were high ranking -- actually they were mostly civilian leadership of the Taliban government. They are described as "hardened killers" but that's because the Taliban regime was violent. The only people they ever bothered were Afghans. They can't be prosecuted because they haven't violated any U.S. laws. They were prisoners of war, which means they have to be released some day.

The U.S. has been trying for some time to arrange a peace deal in Afghanistan, as has the Afghan government. Qatar has been acting as intermediary all along. This is just part of that process, a necessary clearing of one obstacle which may help get to a result that will end the violence in that long-suffering country. Meanwhile, there are thousands of Taliban fighters. Adding five old guys to their numbers isn't going to suddenly make the Taliban more dangerous. It's inconsequential.

But we seem to view "terrorists" (which they actually aren't) as having supernatural powers. It's ridiculous. And oh yeah, whether Bowe Bergdahl deserted or was derelict in his duty is completely irrelevant. Get a grip, folks.

Sunday, June 01, 2014

Progress report

For anyone out there contemplating arthroplasty of the thumb,  I can tell you that after nearly 8 weeks I am slowly regaining good use of my left hand. Wednesday and today I used the weed wacker, which actually doesn't require a contribution from the left thumb -- you pretty much grab the handle with the fingers -- but even so, that would have put unbearable pressure on the sore spot not long ago. I also used a chainsaw, briefly, yesterday and today, but decided not to resume major combat operations just yet.

So yeah, I'm hopeful that this will work in the long run. Still, it's a really violent intervention. They remove the trapezium -- the bone at the base of the thumb -- and stuff the cavity with tissue harvested from a wrist tendon. There has got to be a better way, but I'm guessing they figured out how to do this by experimenting with trauma reconstruction. You would never inflict it on someone with a useable hand, no matter how painful, purely on spec. That means they started out with people whose trapeziums were destroyed, so that's what they know how to do. There is, obviously, no animal model for the human hand so PETA will be glad to know that's out.

There are some slightly different approaches to this surgery but they've never had head-to-head trials. My surgeon does it his way and that's that. Unfortunately, this is true of many medical interventions. That's why there's a lot of emphasis these days on comparative effectiveness research but we have a decades long agenda ahead of us. I expect few people are really aware of how much we are still struggling with an insufficient evidence base for medicine. Obviously, we've learned a lot and medicine is getting more effective, but we still don't know, in many cases, how to make the best use of the technology we already have, nor do we necessarily understand what we're doing.

In the case of osteoarthritis, why is bone-on-bone contact painful in the first place? There are no nerve endings in bone. Yet we can only fix it by removing and replacing entire joints. I think we're missing something here.