Sunday Sermonette

Scientific American just came out with a special issue celebrating the 100th anniversary of Einstein's publication of the theory of general relativity. Special relativity, the description of the space-time continuum, the speed of light as a cosmic speed limit, and the equivalence of mass and energy, came 10 years earlier, in 1905. General relativity is the theory of gravity, which Einstein struggled with in the intervening decade.

I'm not a physicist so I would say that I barely have an intuitive understanding of this stuff. But I know enough about how physicists and cosmologists, with the information provided by observational astronomers, have put together the pieces of the puzzle that produce our modern understanding of the universe to believe it.

But a lot of people don't. I can understand why. First, the physicist's universe is sharply contrary to our intuitions and our experience. If you tell people that mass warps space and gravity slows time, that light is bent by gravity and that mass increases with acceleration, for example, it just sounds nuts.

More important, when we discovered the cosmos, the revelation destroyed the entire history of philosophy and culture. Many scientists are reluctant to say it, and some haven't accepted it, but religion -- at least anything resembling religion as we know it -- cannot survive cosmology. You can make up some new meaning for the word religion, I suppose, but Islam, Christianity, Buddhism, Hinduism, Zoroastrianism, you name it, are all destroyed. To believe any of them, you must believe that the actually existing universe does not exist.

Disposed with the bathwater of mythology is the baby of meaning. No, God doesn't care about us - or exist, for that matter - and we don't matter at all to any entity but ourselves.  Many people just can't live with that. The challenge for the cause of reason is to help them find a way.

Your tax dollars at work

Apparently having nothing better to do, the Department of Justice is prosecuting executives of Rentboy for promoting prostitution. Let us stipulate that yes, in spite of disclaimers on the web site, that is essentially what they do. But really, who cares? Let's see what the harm reduction coalition has to say:

The criminalization of sex work fosters violence, stigma, and marginalization. Harm Reduction Coalition affirms a harm reduction approach to sex work which prioritizes creating conditions that provide sex workers with information, support and resources that allow them control and autonomy over their labor to reduce their risks for violence, trauma, HIV, and other harms.

Now, I realize that it isn't all that simple. Many sex workers, actually most of them in some settings, are exploited, even enslaved. Others say they are making a free choice, which is obviously a matter of degree depending on their alternatives for making a living, but that's true for just about everybody who does what they may find to be unpleasant work.

And, if you want to stop exploitation and sex trafficking, and you want to improve working conditions, the first thing you have to do is legalize it. That way, you can regulate it, with licensing, safe sex regulations and regular testing requirements, workplace safety and wage law enforcement, regulations to protect quality of life and property values for neighbors, even the possibility of workers organizing. That's what they do in much of Europe, with variations on the theme, and it seems to work pretty well.

Yes, I find it icky and I have no interest in participating. I don't even understand it. But it's never going away, so let's try to make it better. This DoJ action is just stupid. Now, if you're looking for a male sex worker in Providence, you have to go down by the wind turbines and find somebody on the street. Lots of bad things happen that way. 

Abolition

I'm not sure why I didn't get around to commenting on this earlier. As most will know, the Connecticut Supreme Court recently commuted the sentences of the 11 men on the state's death row.

This was an unusual situation in that Connecticut no longer imposes the death penalty, by statute. However, the legislature made the change only prospectively, meaning that crimes committed before the legislation were still subject to the penalty, and that existing sentences of death were still in effect. (At the time, there were 10 death row inmates. A later conviction for a crime committed before abolition added an 11th.)

The reason for this temporal distinction is telling. It is because the legislators felt it would be politically inexpedient to commute the sentences of two death row inmates, Steven Hayes and Joshua Komisarjevsky. For those who don't recognize the names, they are the perpetrators of the July, 2007 Cheshire home invasion, a crime sufficiently notorious that the phrase is essentially a proper noun. There's no particular reason for me to link to information about it, you can easily find it if you are interested. I wrote about it here quite extensively at the time.

That these two men, specifically, were the reason the legislation was not retroactive is indubitable. That was very much in the center of the political discourse at the time, as this contemporaneous account describes:

House Republicans, the minority party in the chamber,  focused heavily on how the bill is supposed to affect only future crimes and not the 11 men currently on death row, including the two men recently sentenced to death for killing a mother and two daughters in a gruesome home invasion in Cheshire. Joshua Komisarjevsky and Steven Hayes have been sentenced in the last two years to death row for killing Jennifer Hawke-Petit and her daughters, Hayley and Michaela.

 The question is why the debate was about this particular crime. Of the other inmates on death row, some had killed white people. (Sadly, that usually matters to public attitudes.) Some had tortured their victims. Some had multiple victims. At least one had raped and murdered a child, as did Komisarjesky. What was different about this case?

It was more recently in memory, but I think the main reason it got so much publicity and had so much political resonance was that it represented the invasion of an affluent, sheltered suburb by forces people presumed were confined to what to them was an alternate universe. Crimes like this happen in other places, and people in Cheshire don't pay much attention to them.

The Supreme Court's rationale in overturning the remaining sentences is hard to argue with. If the legislature, with the concordance of the public, no longer believes that capital punishment is appropriate, there is no reason why it would be appropriate for people who happened to commit their offenses before an arbitrary date. If it's in applicable to some, it is inapplicable to all.

Presidential candidate Lindsey Graham was exactly specific -- the outrage pertains to Hayes and Komisarjevsky, not to the other nine:

“Makes me want to throw up. Makes me want to throw up when I hear that putting these two guys to death for what they did to that family is somehow outside of the standards of decency,” Graham stated Monday to radio host Michael Medved. . . . If this doesn’t cry out for the death penalty nothing ever would and I don’t think you’re an indecent society when you take two men who broke into a family’s home, tortured two young girls, raped them, burned them alive — I don’t think that makes us indecent that they would be administered the death penalty,” declared Graham.

Well here's the bottom line. If you are for abolition, you are for abolition. Here there is no question of guilt, no evident extenuation, no question of insanity or capacity, and a crime of unimaginable depravity. But there's nothing to be gained by sinking to their level, like Lindsey Graham. We are better than that.

PS: Hayes has since claimed to be a serial killer and described killing 17 women and girls. The authorities have dismissed this as a fabrication. Prior to the event, both killers had extensive records of burglary and theft, but no convictions, or arrests, for violent crimes. Their parole to a halfway house -- where they met -- also became a political issue and resulted in some retrograde legislation. But that is for another day.

An avoidable catastrophe?

This is an observational study only, and it doesn't completely answer the question, but this analysis in JAMA Oncology certainly poses one. Understanding this is a bit complicated, and remember, I'm not a real doctor, I'm a doctor of philosophy, but let me tell you what it means to me.

Narod et al used a registry called the Surveillance, Epidemiology and End Results (SEER) database to see what happened over 10 and 20 years to women who were diagnosed with so-called Ductal Carcinoma in Situ (DCIS). These are clusters of abnormal cells inside the milk duct. Until the widespread use of screening mammography, they were essentially never detected. There's no lump to feel and no symptoms. But since mammography grew more and more sensitive, radiologists started seeing them frequently.

When one is found, the woman is told that she has breast cancer and the alternatives are presented as lumpectomy -- just removing the lesion, but it's a misnomer since there is no lump -- or total mastectomy. Some women have both breasts removed just to be on the safe side. And often they undergo radiation "therapy" as well.

But is this really cancer? And is it really the case, as assumed, that this is how breast cancer begins and these often go on to become invasive and then metastatic? What would happen if they weren't treated and we just waited?

Well, this study can't directly answer the last question because just about every woman with the diagnosis was treated. But it can tell us a few things. The easiest thing to understand is that the choice of treatment -- lumpectomy with or without radiation, or mastectomy -- made no difference in the risk of ultimately dying of breast cancer. The second observation is that Black women were at higher risk than white women of ultimately dying of breast cancer, but there didn't appear to be any difference in how they were treated, so the explanation for this is unknown.

The third observation is that invasive cancer could appear even after mastectomy. While a later occurrence of invasive cancer was associated with higher risk of death, the overall risk for these women was the same as the risk in the general population -- no higher and no lower. The exception is women who were diagnosed with DCIS at a young age. It is also the case that overall, the incidence of invasive cancer in the population has not gone down since doctors started treating DCIS.

What this suggests -- although it doesn't prove it -- is that DCIS is not in fact associated with a higher risk of ultimately getting clinically significant breast cancer, and the best thing to do is just watch and wait. There are other indications from observational data that these lesions often spontaneously remit or just sit there. What this would mean is that tens of thousands of women every year are subjected to fear, disfiguring surgery and frequent complications, at a cost of billions of dollars, for no benefit.

Right now few women are choosing to forego treatment and few doctors are recommending it. But in my view, this does create the so-called equipoise necessary to ethically undertake a randomized controlled trial, if enough women would enroll in it. If the suggestion turns out to be true, we have inflicted major damage on millions of people. Now, surgeons will find it very hard to live with that conclusion I am sure and they will certainly resist it. But it has to be considered.

Uglier and Uglier

The Trump phenomenon might have seemed amusing at first, but it's no joke now. Here's Ezra Klein on the only detailed policy proposal the blowhard possessor of inherited wealth has produced so far. In essence, it views illegal immigration as a collective crime of the Mexican people, and proposes to collect money from legal Mexican migrants and people who cross the border for legitimate reasons; and from people who send remittances to their families, in order to build his wall along the border. He also would withhold federal benefits (I'm guessing this means the earned income tax credit and dependent deductions, though Klein doesn't specify) from the undocumented parents of children who are U.S. citizens, in order to drive them out of the country. And he would implement various measures that would make it nearly impossible for people to gain asylum or refugee status.

Most undocumented immigrants, in fact, do not cross the border illegally. Rather, they overstay visas. And of course only half of them are from Mexico, and that number is declining. So singling out Mexico and Mexicans is obviously racist -- and it's worse than that since Trump insists that the Mexican government is somehow intentionally "sending" people, and selecting criminals, which is idiotic.

Trump also wants to eliminate birthright citizenship. This was originally established by the 14th Amendment for the benefit of freed slaves, but it is essential in the present context as well to prevent the creation of a subordinate caste. Look at the Dominican Republic, where Haitians who may be second or third generation residents are now threatened with deportation, and have never gained citizenship. Stateless populations of this kind also exist in many other countries, notably in the Middle East and Africa. Do we really want this here?

But we all know that Trump is a psychopath. What is terrifying about this is that it has only increased his popularity, and that other Republican candidates are lining up to endorse these proposals. It's a very sorry reflection on our culture and values. I have led a sheltered life with limited exposure to the racism at the dark heart of the United States. But that's what we are. 

Lead and Crime

It seems too pat, too reductionist, but the evidence is very powerful that childhood lead exposure has been the single most powerful driver of crime rates since the early 20th Century. The teevee still leads every night with the most lurid crime stories they can find, so the general public isn't aware of it, but the rates of violent crime, homicide, and burglary have fallen steadily and dramatically in the United States since the 1980s. Furthermore, rates of offending by young people have fallen even more sharply.

Yes, the criminal justice system continues to be racist and highly disproportionate numbers of Black and Hispanic people are incarcerated. But the prevalence of criminal justice involvement, even among minorities, is way down from its peak. This dramatic phenomenon is partly obscured by the continued high arrest and incarceration rates of older men. As Rick Nevin tells us in the linked post, from 1991 to 2013 the juvenile arrest rates fell by 63% for violent crime, and 71% for property crime. This can be entirely explained by exposure to lead from gasoline and paint.

As a sociologist, I have of course been attracted to all of the theories about the effects of poverty and cultural milieus and discrimination and how the removal of jobs from the inner city and the legacy of slavery and the punitive responses of the state and what have you created the school to prison pipeline. And while all those are no doubt exacerbating factors, none of them has been fixed, and yet this miracle has occurred.

There is of course much more to this story. Industries that used lead fought just as hard as the tobacco and fossil fuel industries against the science, and succeeded in continuing to poison children for decades. But courageous scientists persisted and the result is a much better world. Keep that in mind as Republicans continue to inveigh against environmental regulation.  Sometimes it really is just that simple.

From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.Q10VWmMv.dpufFfr

The crime decline in recent years has been slower than the earlier decline in blood lead because steep arrest rate declines for youths have been partially offset by rising arrest rates for older adults. From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime, as arrest rates for adults ages 50 and older increased. In absolute terms, the violent crime arrest rate for juveniles was twice the rate for ages 35-49 in 1991, but the juvenile rate was lower in 2013. The property crime arrest rate for children under 10 was about the same as the rate for ages 35-49 in 1991, but the 2013 rate for children under 10 was just 7% of the 2013 rate for ages 35-49. - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.EZIGO3ET.dpuf

The crime decline in recent years has been slower than the earlier decline in blood lead because steep arrest rate declines for youths have been partially offset by rising arrest rates for older adults. From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime, as arrest rates for adults ages 50 and older increased. In absolute terms, the violent crime arrest rate for juveniles was twice the rate for ages 35-49 in 1991, but the juvenile rate was lower in 2013. The property crime arrest rate for children under 10 was about the same as the rate for ages 35-49 in 1991, but the 2013 rate for children under 10 was just 7% of the 2013 rate for ages 35-49. - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.EZIGO3ET.dpuf

The crime decline in recent years has been slower than the earlier decline in blood lead because steep arrest rate declines for youths have been partially offset by rising arrest rates for older adults. From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime, as arrest rates for adults ages 50 and older increased. In absolute terms, the violent crime arrest rate for juveniles was twice the rate for ages 35-49 in 1991, but the juvenile rate was lower in 2013. The property crime arrest rate for children under 10 was about the same as the rate for ages 35-49 in 1991, but the 2013 rate for children under 10 was just 7% of the 2013 rate for ages 35-49. - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.EZIGO3ET.dpuf

11.2 billion?

The UN has released a revised projection of global population and they now project that there will be 11.2 billion humans alive in 2100. They expect the most rapid growth in the poorest regions:

Population growth remains especially high in the group of 48 countries designated by the United
Nations as the least developed countries (LDCs), of which 27 are in Africa. Although the growth rate of the LDCs is projected to slow from its current 2.4 per cent annually, the population of this group is projected to double in size from 954 million inhabitants in 2015 to 1.9 billion in 2050 and further increase to 3.2 billion in 2100. Between 2015 and 2100, the populations of 33 countries, most of them LDCs, have a high probability of at least tripling. Among them, the populations of Angola, Burundi, Democratic Republic of Congo, Malawi, Mali, Niger, Somalia, Uganda, United Republic of Tanzania and Zambia are projected to increase at least five-fold by 2100. The concentration of population growth in the poorest
countries will make it harder for those governments to eradicate poverty and inequality, combat hunger and malnutrition, expand education enrolment and health systems, improve the provision of basic services and implement other elements of a sustainable development agenda to ensure that no-one is left behind.

I've got news for you: if there's no way to feed those people, they won't be there after all. And I've got more news for you. The global population is concentrated in coastal areas and those people are going to have to move. At the same time, the hottest regions will become uninhabitable and the distribution of arable land and climate appropriate for particular crops will shift. There will be serious water shortages in many places. The result will be civil conflict, famines, and likely uncontrollable epidemics. So no, there won't be 11.2 billion people. There can't be.

The question is how we get to the lower number that is actually going to happen. The options are fewer babies, or more premature deaths. That's it. Take your pick.

Eliminate AHRQ?

I don't know how I missed this but it seems the current version of the budget for the Department of Health and Human Services currently making its way through congress totally eliminates the Agency for Healthcare Research and Quality. This is as deep as the Republicans have ever sunk into yahooism.

As Jeffrey Lerner explains:

AHRQ funds the studies and systematic reviews that objectively evaluate how well clinical procedures, quality approaches, and consumer satisfaction work. But AHRQ's approximately $400 million annual budget does more than pay for studies. It helps fund what has been the missing link of American health care: what treatments work best and how errors can be prevented.

It won't do any good for NIH to fund the development of new medical technologies and treatments if the health care system fails to deliver accurate diagnosis and the competent decision making and administration of treatment. That's what AHRQ is all about -- improving the delivery of health care. And believe me, there is a lot more potential there to improve patient outcomes, more quickly, and for less money, than there is in basic biomedical science. If we aren't doing what we already know we should be doing, we're wasting all of our research dollars.

This isn't the first time this has happened. AHRQ is the successor to the Agency for Health Care Policy and Research. In 1993, when an AHCPR panel concluded that surgery should not be a first line treatment for low back pain, back surgeons succeeded in getting congress to vastly downsize the agency and limit its mission. Really. And useless, expensive and dangerous back surgery continued to be performed for decades.

I must disclose that I personally have a proposal before AHRQ, to study diagnostic error in primary care. Don't you think its worthwhile reducing the incidence of misdiagnosis? Wouldn't you like to have more confidence that your doctor won't misdiagnose you? Or would that be a waste of taxpayer money? Think about it, then write your congressperson.



 

Strife and woe

I'm working on a project now which has to do with measures a certain state's Medicaid program wants to use to reward primary care providers for quality. For various reasons, which I may get into more deeply in the future, these measures are never really great. They basically reward care processes, in this case giving certain lab tests to people with diabetes, and that can get providers falling all over themselves to do things that shouldn't necessarily be the highest priority for a patient, plus getting dinged for circumstances beyond their control.

But my mission isn't to worry about that so much, it's to worry about the accuracy of the data. So I've been reviewing electronic medical records at various clinical sites to try to understand the difference between data and reality. And no, they are never the same, we just hope for a knowable degree of correspondence. Usually we don't even have that.

So, if you select for a pre-expansion Medicaid population, old enough to have a high prevalence of diabetes, you are filtering for people who are legally disabled. What you get is incredible co-morbidity. A typical person in my sampling frame not only has a diagnosis of diabetes (although, due to the vicissitudes of data, some of them do not, oddly enough), but also serious and persistent mental illness, COPD, heart disease, kidney disease, substance use disorder, liver failure, maybe HIV and/or HepC, arthritis -- sometimes basically all of the above. Many of them are frequently hospitalized, they are constantly on the brink of homelessness or starvation -- did you know that there is a diagnostic code for insufficient material resources? It's just appalling the afflictions with which so many people live.

So no, they can't take personal responsibility. They are unable to work because they are too sick. But the same hypocritical morons who were screaming about the non-existent death panels in the affordable are act want to leave these people to die in the street. Because they're takers.

A severe economic distortion . . .

is occurring as the store shelves are stripped of popcorn in anticipation of the Great Debate tonight. Actually, 9 guys with indistinguishable policy positions flanking a blowhard bubbleheaded egomaniac and each getting in about 5 minutes of yacking over an hour and a half is not a debate. But if I had the chance to be a disruptive force in political discourse (hopefully without the egomania) here are a couple of offensive gaffes I would kindly offer.

Bibi and the bomb: Benjamin Netanyahu, the Zionist Organization of America, and Mike Huckabee do not give the tiniest shit if Iran gets a nuclear weapon. Israel possesses 100 to 200 nuclear weapons, and the means to deliver them. That's supposed to be a secret that nobody ever mentions. If Iran were to exercise it's purportedly "existential threat" by somehow smuggling its one low yield, untested nuclear weapon into Tel Aviv, the nation of Iran would cease to exist along with every city, shrine, ayatollah, military facility, industrial plant, bridge, highway, railroad, cultural institution and most of the population. Persian culture would essentially become extinct. Everybody knows that.

No, Bibi just doesn't want Iran to have the opportunity to rejoin the international community. He wants no agreement with Iran of any kind, and he wants the sanctions to remain forever. We can argue about why he wants that and why that is or is not a great idea, but that's what this is really all about. If Bibi gets his way, Iran will develop a nuclear weapon. That doesn't bother him.

Investment in health research: Yes, I have from time to time complained about the slow but steady shrinkage of the National Institutes of Health, which is hard on me personally. But you know what? That's not the most important place for us to be investing if we want to have a healthier population. As Ronald Bayer and Sandro Galea lay it out in NEJM, the comparatively poor health of the U.S. population has nothing to do with high tech medicine and everything to do with our severe underinvestment in the social goods that actually determine people's health. As they write:

[T]here is now broad consensus that health differences between groups and within groups are not driven by clinical care but by social-structural factors that shape our lives. Yet seemingly willfully blind to this evidence, the United States continues to spend its health dollars overwhelmingly on clinical care.

Everybody who works in any capacity in public health knows this. It's the central, obvious, undisputed fact of health policy, which is really all policy. Everything we do as a polity directly and powerfully affects people's health, from our tax code to our transportation infrastructure to our law enforcement practices. But we almost never talk about policy that way.

I could throw out a few more. The basic idea is, our political discourse consistently and pervasively misses the point. It's always a feint, a misdirection, from the real issues. Sometimes that's pretty transparent, as with the personality-driven and horse race focused coverage of electoral campaigns. But it's also true when politicians and pundits purport to be talking about substance. It's a shadow play to distract you from everything that really matters. Never forget that.

Note: Sorry for the absence over the past few days. I've been busy. But it should give me a few interesting things to write about.