Don't confuse me with the facts, my mind's made up

That seems to be the basic attitude of Americans toward the affordable care act according to Harvard pollster Robert Blendon. The linked Bloomberg article piles another brick onto the now solid wall of Obamacare success -- specifically, that hospitals are seeing fewer uninsured patients and getting paid for their services. That's great for the profits and stock price of for-profit hospitals and for their presumably mostly Republican executives. The percentage of Americans who are uninsured is now 13.4%, probably the lowest ever. And health care cost increases have slowed nearly to the rate of inflation.

The law is actually more successful than even it's most optimistic supporters expected. And yet:

Americans' opinions on the measure may be too hardened for Democrats to see much political benefit this year, or to fight off changes to the act in the future, said Robert Blendon, a professor of health policy at the Harvard School of Public Health. Recent polls indicate that more Americans remain opposed to the health-care law than support it, although that includes people who think it isn't liberal enough.

I'll tell you why this is. It's because Democratic politicians, as a class, are whimpering cowards who go hide in a corner at the slightest rustle of faux populist disapproval. If they would just stand up and make a full-throated defense of the law, based on the fact that it is a big success, the corporate media would have to stop pretending that it's a disaster and more people might start to figure out the truth. They have nothing to lose -- they did vote for it after all and their opponents are going to try to use it to attack them. Hiding in the corner isn't going to help. But they're just chickenshit. 

Deep Thought

Barack Obama will leave office in January, 2017 without having confiscated all the guns, interned the Bible-believing Christians in FEMA concentration camps, imposing Sharia law, or surrendering the United States to the UN One World Government.

What will the wingnuts say then?

I suppose I should say something about the Ebola outbreak

There's been considerable alarm in the blogosphere about the outbreak of Ebola virus in west Africa. Naturally, the occasion for people in the U.S. to take notice is that two U.S. citizens have become infected. It was no big deal that about 660 Africans have died from the disease. Yes, that's a bummer and horrific for the people affected. However . . .

We need to get a grip. The chances that this will become a global pandemic, or even a major cause of death in Africa, are infinitesimal. Why do I say that? Although I have heard the elocutionists on National Pubic Radio call Ebola "highly contagious," actually it isn't. Transmission requires direct contact with bodily fluids.

Yes, that's true of HIV which is a global pandemic but there's a big difference. You can't walk around with Ebola virus appearing to be healthy and unwittingly infecting people through unprotected sex or sharing needles. There is a brief period during which people are potentially infectious but not visibly ill, but during that time you won't catch Ebola by sitting next to the person on an airplane. You'd need to join the Mile High Club.

If someone were to come down with Ebola in a developed country, they would be taken to the hospital in an ambulance by EMTs who already use what are called "universal precautions" to prevent contact with bodily fluids. They would be placed in isolation and cared for by people who are rigorously protected. Any recent contacts they had would be isolated until it was clear whether they were infected, and if they survived (which many will with supportive care) they would remain in isolation until they were not longer infectious.

The outbreak is sustained in Africa because many cases are in remote locations, or if they are in the city people don't get immediate attention from adequately equipped, trained and resourced services. In the remote areas, funerary practices in which relatives wash and otherwise touch the body also result in transmission. With adequate public education and infusion of resources, the outbreak in west Africa can be contained, and I expect it will be. If it continues, it will continue to infect and kill people at a rate of maybe tens per week. That's a drag but it's close to being the least of Africa's infectious disease problems. Really. Hundreds of thousands of Africans die from Malaria, TB and diarrheal diseases every year. We should care about that more than we do, but this is actually much less.

And no, it can't happen here. At least not on any large scale. Now, if the virus should mutate and become transmissible by causal contact, we'd have a problem. But there is no sign of that. So I hope folks will keep this in perspective.

Good News to be Sure

Not sure if you wretched refuse are allowed to read this,  But the American College of Physicians now recommends against routine pelvic examinations. They do recommend that cervical cancer screening continue, but for you guys, that's much less invasive than the pelvic exam. For us, I suppose, the nearest equivalent is the digital rectal examination, which is no longer recommended as part of a routine physical. (In fact, the entire routine physical is no longer recommended, but that will be much harder to get rid of.) So, if your doctor wants to stick his finger up your ass, and you don't want him to do it, just say no.

The ACP says there is no evidence of benefit from an annual pelvic exam, "so the harms of fear, anxiety, embarrassment, pain, discomfort and false positives" mean don't do it. Obviously, if you're pregnant or have symptoms for which the exam is a useful diagnostic, that's a different story. We're talking about the concept of just doing it every year as a screening measure.

Naturally, the American College of Obstetricians and Gynecologists is still all for it because they make money off of it. And, the ACP isn't sure its recommendation will change practice. It's very difficult to get doctors to give up their bad but profitable habits. Anyway, you can take matters into your own hands and just not do it.

Reality Bites Denialists

That's the trouble with cynical denial of facts you know to be true, which is what the Koch brothers and their political allies are mostly doing with global climate change denial. We know it's cynically dishonest because they keep changing their premises: it isn't happening, maybe it's happening but people aren't causing it, maybe people are contributing to it but it isn't really bad, maybe it's a little bit bad but it isn't worth doing anything about it . . .

A recent arrow in the denialist quiver has been the claim that the planet has not been warming for 15 years. Either this means the whole claim about climate change is too a hoax, nah nah nah nah nah, or else it means the problem isn't really urgent so we'll just wait for the technology fairy to save us.

More sophisticated climate scientists have been saying all along that this is not true, the global surface temperature has been on a bit of a pause but that's because the heat is going into the oceans. This is kinda wonky, but a new analysis sets us straight. Climate models based on straightforward computation of how heat is trapped by greenhouse gases have tended to overestimate recent increases in global surface temperatures, i.e. they have failed to predict the recent slowdown. This has caused denialists to claim that climate models are worthless. Not so.

All you have to do is add the El Niño/Southern Oscillation phenomenon to the models and they fit reality just fine. In other words, for the past decade we've tended to have more La Niñas -- episodes of cool southern Pacific water -- than El Niños. Add that info to the models and they do predict recent surface temperature history. But now that's changing, with an El Niño predicted for later this summer or fall and guess what? We'll have an apparent acceleration in warming. It's already started, seemingly, with the warmest three months on record. Add to that the sparse coverage of the Arctic by weather stations, the Arctic being the region that has warmed the most, and we find the planet is even warmer than we thought. Already.

We're headed for a really obvious hot spell, folks, and the oceans will continue to rise, faster than before, the arctic sea ice to disappear, and the southwest U.S. to parch and bake until cities become uninhabitable. Yes. Then Sen. Inhofe and the Koch brothers will have to eat shit.

AIDS 2014

I'm not there this year, and of course, neither is Joep Lange. The linked remembrance by Laurie Garrett explains why the International AIDS Conferences are really unique. There is a lot of science presented there -- you get the usual PowerPoint presentations with socially awkward biologists droning on about viral lineages and the blood-brain barrier, as well as social science and program evaluations and every other possibly relevant discipline.

But only about half the people there are researchers. The rest are activists and practitioners of one kind or another. And the presentations in the big hall sometimes feature science, (usually in a fairly popularized form), but are just as often political speeches, and even rallies and demonstrations.

Outside of the lecture halls and workshops, the corridors and exhibition halls are constantly enlivened with political theater, music and dance, and mobile polemical exhibitions. The conferences are an immersion into a special universe in which science, morality, and passion all collide, shattering and recombining unpredictably.

HIV is not like other diseases in being so freighted with culture, politics and morality. And Dr. Lange's career exemplifies that complexity. He was a scientist who was also compelled to be an activist and a campaigner. Of course his loss is no more egregious than the death of any other victim of war. As I said last time, I perhaps take it a bit more personally. But as a species, we just can't afford to keep fighting over tribalism. We have urgent work to do. 

MH17 and me, and us

As you likely have already heard, something like 100 of the passengers on MH17 were on their way to the International AIDS Conference in Melbourne. Of the names so far made public, I don't know any of them personally. However, I have attended two past International AIDS conferences, in Mexico City and Washington, D.C., and live-blogged them here. It certainly would not be surprising if some of the victims are people I have spoken with, or heard speak, or who have attended presentations of mine. Certainly they would have similar kinds of education, interests, and political and social commitments.

I don't have enough insight to say how this affects my feelings about the incident. I like to think of myself as a universalist humanist and want to claim that the degree of personal affinity I have for the deceased and their colleagues, friends and loved ones is beside the point in how I evaluate this atrocity. We don't yet know all of the facts, so I'll hold off the rant I have saved up for Vladimir Putin and the thuggish morons he is sponsoring in Ukraine. But I will say this.

As a species, we have only a very short time left to grow up, before we do ourselves in. We are now recognizing the 100th anniversary of World War I. Europe blundered into catastrophe due to exactly the kinds of tribalism, instinctive reliance on military technology and prowess, and the view of global affairs as fundamentally and properly a competition among nation states for power and primacy. The catastrophe this time would be incalculably worse.

So, remember that in 1988 a U.S. naval vessel shot down an Iranian civilian jet liner, while St. Ronald Reagan was president. That was just as awful, but unlike John McCain today, nobody started calling for World War III. 

Update: It turns out that 6, not 100 of the passengers were on their way to AIDS 2014. Doesn't affect my point, but for the record. 

Black Hole in the East River

The New York Times, for all it's flaws, is still indispensable as one of the last redoubts of journalism. This should make your blood boil. According to an internal study, which the New York City Department of Health and Mental Hygiene tried to keep secret, prison guards at Rikers Island assaulted and seriously injured 129 inmates over an 11 month period. That's "serious injuries" only, which means they were too severe to be treated in the prison clinics. More than 3/4 of the victims have mental illness diagnoses.

There have been a couple of recent incidents of mentally ill Rikers Island inmates dying from neglect. One guy cooked to death in an overheated jail cell, another died after ingesting detergent and then being ignored as he begged for medical help. But this is different -- this is guards beating the crap out of people, sometimes in revenge for having urine thrown at them or the like, sometimes to control people who are acting out, sometimes apparently just for fun.

So yeah, impunity for corrections officers, as well as terrible conditions in the jail and terrible working conditions for the officers, is intolerable. But here's the worse problem -- about 4,000 out of 11,000 Rikers inmates are diagnosed with mental illnesses, which exceeds the entire census of psychiatric inpatients in the state. Jail is where we send mentally ill people today.

And this has been building for a long time. Back in grad school I took a course called something like Social Control of Deviance Through the Courts, which was taught by a judge. We took a field trip to the Massachusetts high security prison, and we met with a group of lifers. Most of them were career criminals who had been in and out of jail for much of their lives until they finally got the big ticket. And they told us they had seen the change. You would know the guys, back in the day, one of them said,  but now half of these guys belong in the Pine Street Inn. That's Boston's big homeless shelter.

The judge explained what was happening: mandatory sentencing laws. It used to be he had discretion. Mentally ill people sometimes do things like trespassing, random destruction of property, aggressive panhandling, subsistence theft, inappropriate sexual expression, which gets them arrested. The judge could commit these people to treatment. Now he can't, he has to send them to jail. And that is obviously the worst possible place for a mentally ill person to be. Yeah yeah, criminals get a tautological diagnosis of sociopathy but that's not what we're talking about here. We're talking about psychosis, bipolar disorder, and the like, combined with social marginalization and deprivation.

It's a crime against humanity.

A couple of modest observations

My colleagues and I analyzed a whole lot of medical visits by people with HIV and we did find some differences depending on patients' race and ethnicity. (Click on the link and you also get to see an unflattering picture of me, engaged in the bizarre practice of neck binding.)

Black patients tend to talk less than do other patients in physician visits -- this has been observed before. And doctors talk to Black and Hispanic patients about medication adherence more than they do with other patients, regardless of whether there are any indications that the patient is non-adherent (which is the fancy term for not taking the pills on schedule). These docs are all white or Asian, BTW, except for two African American women at one site. So we can't sort out any effect of physician ethnicity or provider-patient concordance from this data. But on the other hand, that's the real world. There just aren't a lot of Black or Latino physicians.

Not sure what this means or whether these disparate communication patterns are a big problem -- just  worth noting that ethnicity still matters. The call for a "race blind" society is fallacious. We aren't race blind and we won't be any time soon, so pretending we are just evades the issue.

Ho Lee Crap

While cleaning out an old storage room, NIH found at least six vials of smallpox virus. Unsecured. Just sitting there. With no accompanying documentation.

Okay, so they've been found, and secured, and will be destroyed. By international agreement, the variola virus can be maintained at only two ultra-high security laboratories, one in Atlanta at the CDC, the other in southwestern Siberia. There has been considerable controversy about this and many people -- including  YT -- have argued that these samples should be destroyed. The problem is that since smallpox was eradicated in 1979, no-one has been exposed or vaccinated. And, there isn't a lot of vaccine available. If smallpox were to get loose in the world -- don't even think about it.

It is not necessary to retain samples for any conceivable reason. Vaccine is made from a related virus, cowpox (hence "vaccine," from the Latin for cow). The genome is obviously fully described. Nobody is doing any research with variola nor is there any research that one can imagine doing. The only possible use of variola is as a weapon.

This discovery is disturbing because it suggests that there could be other overlooked samples somewhere -- or possibly not overlooked at all, but just kept in secret by some government laboratory somewhere. eww.

Les Izmore, continued

Friday's BMJ features a discussion of the Choosing Wisely campaign, which I have referenced here a couple of times. The essential question is whether we can substantially reduce wasteful medical interventions simply by moral persuasion and cultural activism, even without changing economic incentives. Author Richard Hurley says that a survey finds a majority of doctors will order unnecessary tests if a patient insists, and goes on to write "Doctors order unnecessary interventions for a multitude of other reasons, including fear of malpractice suits, to appear to be doing something rather than nothing, to try to demonstrate thoroughness, and because of how they were taught."

Oddly, he doesn't mention what would seem to be another important reason, which is they get paid to do it.

Anyway, what's more interesting about this essay is the discussion of the political background. Physicians don't generally think they have responsibility to reduce health care costs, and in the U.S., at least, the general public thinks that these efforts constitute "rationing," which is evil from the pit of hell, and that any effort not to give some form of medical test or treatment to somebody is all about death panels and murdering people to save money.

What we have so far not gotten across to enough folks is that medical tests and treatments can do harm as well as good, or just be useless. Money wasted on a useless test, drugs or surgery is money that can't be spent on something beneficial, and meanwhile people are directly harmed. But the cultural authority of medicine in the U.S., and the God-like status of physicians, prevents people from understanding or believing this. So the Choosing Wisely campaign has to go beyond targeting health care providers and effectively target the general public. Is anyone prepared to do that?

Brain Dump

For reasons I won't go into I watched a regular network news broadcast last night and one third of the entire broadcast was about (now) hurricane Arthur. This storm is expected to brush the Outer Banks as a minimal hurricane then decay in the cold waters of the North Atlantic while turning out to sea, possibly giving part of New England a rainy day. It would be news, of course, if Cape Hatteras and environs got through a summer without a hurricane. Why is the teevee news so obsessed with ordinary, mildly unpleasant weather? Well, for one thing I suppose they don't have to think or do any work.

As I have occasionally confessed here, I am a long time Red Sox fan. Last year's epic season, culminating in the Championship that Healed The City, has been followed by . . . Feh. The team is so incompetent, so lifeless, you'd think they've been zombified. And that's actually the only explanation I can think of. Other than the defection of center fielder Jacoby Ellsbury to the forces of darkness in New York, it's the same team. They replaced Ellsbury with what was supposed to be the second coming of Willy Mays, Jackie Bradley Jr., who indeed has great speed, a great outfield arm and can, as they say, steal every base but first. He's been struggling with the Mendoza Line* all season, but even so, one less bat shouldn't turn the team from champs to dreck. The fact is nobody is hitting. El Papi tremendo, El Papi enorme, El Papi largo y anchoso, El Papi que ocupe mucho espacio, El Papi de gran vólumen, El Papi de maximo tamaño, i.e. Big Papi David Ortiz can still hit home runs, but otherwise his production is nil. He used to hit timely base hits and doubles to drive in runs, but now he's dinger or bust. The rest of them can't hit anything. So why do the Sox Sux? The moral is that for all we obsess, sports don't mean anything, it's just shit that happens.

And yes, Tim Howard put on an astonishing performance in the World Cup, especially against Belgium, but that just covers up the main truth which is that otherwise, the team sucked a moose. The score should have been Belgium 10, U.S.A. 0.

I bought a tractor with an excavator so I can dig out stumps and otherwise landscape and make beautiful gardens. I expect to find it delivered when I get home today. I'll have fun! Other guys get BMWs and hair transplants to soothe their mortal angst, I got a backhoe.

I'll have a few things to say about health and health care in coming days. I mean it. Stay tuned. 

Mission Creep, Shmeep

Okay, so first Obama sent 300 special forces to advise the Iraqi military. Their mission was to make helpful suggestions such as "Don't abandon your weapons and flee." (I've always felt that's a good principle of military doctrine.) Apparently that advice was insufficient so Obama announced he was sending another 300 Marines to guard the Baghdad airport and the U.S. embassy, and the road between. Hmm, what contingency might make that a priority?

Reuters gives a good overview of the current situation. Notably, the Kurdish and Sunni Arab members of parliament walked out before a government could be formed; parliament will not meet again for a week. Meanwhile, government forces have been unable to regain any territory, violence is rising in Baghdad and to the south of city, which is now essentially surrounded by insurgents on three sides; Kurdistan has announced that it will hold a referendum on independence in three months; and mortar shells have fallen on the Golden Mosque in Samarra, the Shiite shrine which was destroyed in 2005 sparking the horrific civil war.

Iraq is irretrievable. It is no longer a viable nation. That is not, however, a defeat for the United States or a failure of the Obama administration. It is history. Once the hubris and incompetence of Dick Cheney and Donald Rumsfeld blew the country up, there was no turning back. The international borders of the Middle East, drawn in secret by France and Britain following World War I, are dissolving. The issue is not the Islamic State, which certainly cannot survive for the long term. It is only the immediate instrument of chaos.

The issue is that Iraq and Syria were never viable nation states to begin with. Our responsibility is to do what we can to limit the humanitarian catastrophe, and ultimately to contribute what we can to a settlement among the bewildering array of parties and guaranteeing the security of new boundaries. But the United States does not, and cannot, control events and there is no reason why the U.S. should try. The news is very bad for the people who live there but for now, it is what it is. Pushing in more weapons and more combatants means more people get shot and blown up. So let's not do it.