The Alternate Reality Care Act

As Paul Krugman does from time to time, he once again points out that the Affordable Care Act is working at least as well as hoped for, giving a helpful link to the latest Commonwealth Fund report that proves it. He also points out, as he does at the same time to times, that Republican politicians and they're allied scribblers and gibberers willfully refuse to embrace this reality and continue to predict the policy's imminent collapse, or even to claim that it is already happening.

Well he's right, but how can they get away with this? Part of the reason is that most people have been pretty much unaffected by it -- they still have the same employment based insurance or Medicare that they always did, so it doesn't really have anything to do with them directly, but if their congresscritter or favorite yacker is claiming it's a disaster for other people they aren't staring directly at the counterevidence. In fact, since premiums continue to go up, albeit more slowly than before, they can be persuaded to blame Obamacare for a situation that it has actually helped to ameliorate.

It is also true that people with relatively high incomes, who don't quality for big subsidies and chose not to buy insurance before, don't get the greatest deal. They might resent the mandate. There aren't many such people, and what is demanded of them is that they be socially responsible, but lots of people don't want to be. And yes, people who have benefited still have substantial out of pocket costs and their insurance will only turn out to be a good deal for them if they have major medical expenses. But that's true of the homeowners and car insurance too -- that's what insurance is for.

Still, the biggest problem is the corporate media, who won't sort out the truth for people -- not necessarily because of their philosophy of not refereeing fact and falsehood, but because they don't actually understand health care policy -- and the chickenshit Democrats who should have mounted a full-throated defense of the ACA from the beginning, and instead hid under their desks, where most of the remain.

Better Democrats, please.

The Golden Age of American Politics

Actually, there wasn't one. The present may seem particularly horrifying but it really isn't. Before 1860, obviously, we had slavery and we were busy exterminating the natives and stealing their land. Then right after the Civil War the freed slaves wound up back in bondage as sharecroppers and terrorists roamed free in the land to assure they didn't assert any political or cultural rights. There was scarcely any objection.

We had the Gilded Age in the 1920s and then yes, we got some progressive measures through in the 1930s but that was only because the circumstances were desperate and that was the only way to save capitalism. The post-war years felt a little better but then we got Vietnam, Nixon, and Ronald Reagan, followed by the triangulating Bill Clinton and He Who Shall Not be Named. Barack Obama had 2 years before racist, reactionary lunatics took over the congress, not to mention most of the states, and now we have the Age of F.F. von Clownstick.

So really, the struggle is never ending. It isn't about fixing our foul stew of plutocracy and racism, it's about keeping up the fight. I intend to do so.

The River in Egypt

Reading this piece by Elizabeth Kolbert on the coming innundation of much of Florida, specifically focusing on the imminent uninhabitabity of Miami Beach, I found myself profoundly baffled.

The governor of the state and one of its senators, along with the entirety of their political party, maintain that this is not happening, and that the claim it is happening is not just a mistake, but a deliberate hoax by thousands of scientists and allied politicians who are conspiring to rob us of our freedom because of some reason they don't quite get to specifying.

Presumably the politicians who say this know it is completely insane. I don't know about James Inhofe, he is an idiot who might actually believe it, but the delusion cannot possibly be widespread. Rick Scott and Marco Rubio are liars. And what are they planning to say when all of that very expensive real estate disappears? I mean, this isn't happening fifty years from now, after they are dead. It is happening today.

I really do not get it.

Missing the point when it's the size of the moral universe

Here is a very strange essay by physician Vyjeyanthi S. Periyakoil about his interaction with a dying patient, a Vietnam veteran who had never spoken to people about his combat experience. The man finally confesses to the doctor the reason for his long-concealed distress. The essay is all about the terrible burdens carried by veterans.

However, what the good doctor fails to observe is that the soldier's burden is that he murdered a pregnant teenage girl in cold blood, a peasant who just happened to be in the wrong place at the wrong time, because she had seen him and might have given away the presence of U.S. troops in the area. This is the doctor's take on it:

What would I have done if I had been in his shoes, I wondered. I could have let the girl go, but maybe the mission would have been compromised and my entire platoon would have been killed or taken prisoner of war.

Er, no. Evidently this was the policy of the United States army the time, but this was in fact a war crime. I remember during the war reading an outraged essay by a conservative writer about how Viet Cong propaganda was claiming that U.S. troops murdered young women with knives. What do you know, it was true. And how weird that the New England Journal of Medicine would publish this essay in this form. These sorts of personal musings are actually peer reviewed (I have done it myself), so this was read by at least three people in addition to the editors.

And the Terrorists Have Won

Now all you have to do is send an e-mail, and the second largest school system in the country will close, keeping 650,000 children home. If you think that's ridiculous, you have forgotten about the world's second most ridiculous human, Chris Christie, who said this in the "debate."

"The second largest school district in America in Los Angeles closed based on a threat. Think about the effect that that is going to have on those children," Christie said during his opening statement at the fifth Republican presidential debate in Las Vegas. "When they go back to school tomorrow wondering, filled with anxiety about whether they're really going to be safe. Think about the mothers who will take those children tomorrow morning to the bus stop, wondering whether their children will arrive back on that bus safe and sound." The governor then suggested the Obama administration was to blame for failing to address the threat.

Uh, governor, it was a hoax, by somebody who doesn't even know how to make a convincing impression of a Muslim. But basic logic and obvious facts are irrelevant to Republican voters, so he'll probably get a bounce in the polls.

The Paris climate agreement

Joe Romm actually has a positive view of the Paris accord, which surprises me a bit. If you haven't had a chance to get familiar with it, the 186 participating nations each have pledged what's called an "intended nationally determined contribution" toward a goal of limiting the global mean temperature rise to 2 degrees Celsius. However, the existing intended contributions aren't enough to get there -- they will need to be reviewed and ratcheted up going forward.

That sounds great but there is no enforcement mechanism. It is meaningful that essentially all of the world's nations agree that yes, there is a problem, and yes, we need to do something about it. The symbolism is powerful and it may help politicians in some countries establish more effective policies. To my mind, however, that is speculative. The agreement is purely rhetorical. It doesn't actually do anything. The economic forces driving fossil fuel consumption are unchanged.

The only really effective measure, which happens to accord with brown shoe economic theory, is a tax on CO2 emissions equal to their social cost -- which means enough to drive them to zero within a few years. In other words, we need to make investments in essential technology and infrastructure pay off. That includes energy storage, and  a "smart" electric power grid, which are necessary to make renewable energy viable. A carbon tax can also provide subsidies to low-income people so that they are not economically harmed in the short run, and subsidize energy conservation and adoption of renewable energy sources.

And yes, it will have to be global.

If the nations of the world can't come together to do that, or something very much like it, the agreement is just so much hot air. And given that one of the two major parties in the nation with the world's largest economy denies reality, we're a long way from doing anything meaningful.

Here's Bill McKibben's less enthusiastic take on the accord.

On becoming a physician

JAMA this week is a semi-theme issue on the evils of medical education. Most of it is behind the paywall but they are letting you read this on the high rate of depressive symptoms among physicians in training.

It isn't really surprising. I've had a couple of friends go through it and, first of all, the all consuming demands on medical students and residents lead to a lot of breakups with spouses and partners. Second, there are those all consuming demands themselves. And, perhaps most important, there is the unprecedented encounter with suffering and loss. All day and night you're working with sick and dying people, and watching them die, and telling them they will die, and seeing their loved ones suffer, and sometimes you think you screwed up and it's your fault and sometimes you really did screw up.

On top of that, as the issue also recounts, there is still a tendency for preceptors to be abusive and to humiliate trainees. It's just very hard to root that out of the culture.

The huge challenge for physicians is to compartmentalize -- to really be compassionate and empathic when dealing with patients and families, to really care, and then to leave it behind, at least enough to live with yourself and have a happy life. Not everyone can do this. Physicians sometimes burn out, and in addition to depression, they are at risk for addiction (the drugs are right there) and suicide. Yeah, they make the big bucks, or at least bigger than most. (Less so primary care doctors, who also work very hard.) And its no excuse for misbehavior or mistreatment of patients.

But it's not an easy job. Never forget that.

More on the peer review process

So applicants for NIH funding send in proposals in response to one of the announcements I described previously. These are very complicated documents that take dozens of person-hours to create. I don't know exactly what they are estimated to cost, but I'm sure people have figured that out and it must be many thousands of dollars. Right now, however, due to gradual budgetary strangulation by the congress, NIH is funding something like 10% of all applications.

At NIH, an official called a Scientific Review Officer (SRO) assembles a panel of reviewers. Some are standing panels that meet regularly and rotate members only every two years or so. These review the R01s, R03s, R21s and other investigator initiated proposals, but they have specialties. Investigators can request assignment to a particular review panel, or NIH can decide where to send it. One-time announcements often have what are called "special emphasis panels" that only meet once, to review those specific applications. That was the kind of panel I was on.

The SRO then assigns each proposal to 3 reviewers. Each reviewer, in turn, has about 8 proposals to review. The reviewers get access to their assigned proposals through an Internet site before the meeting. They have to read them all, including the budgets, protection of human subjects, personnel, and other material in addition to the research plan. It's quite a chore. Each reviewer then writes a critique, scores the proposal for Significance, Innovation, Investigators, and Environment (the latter is usually fine, it's a reputable research institution), and then gives an overall "impact" score. Scores range from 1 to 9 and it's like golf, lower numbers are better.

NIH than computes the average score of the 3 reviewers and tosses out, without further ado, all proposals in the lower half. (The applicants will get to see the reviewers' comments, but they are now dead.) At the meeting, everybody sits around a big table with their computers plugged in and off we go. The first reviewer of each  proposal makes a verbal presentation and critique, followed by the other two reviewers, then the whole gang is free to ask questions and make comments. Often the scores of the three reviewers are quite different. They may converge after discussion, but occasionally people dig in their heels, and they don't.

Then the entire panel gets to score the proposal. Since only the three assigned reviewers have been able to read it carefully (the rest just skim it while it's being discussed), most go along with the average of the assigned reviewers, or they maybe lean toward the high or low depending on whose arguments they find convincing. And that's pretty mu6ch it.

You need to be in the top 10% or maybe a little lower to have a chance at funding. NIH staff can put their thumbs on the scale where there is a close call, and the National Council ultimately has to approve all awards, but the peer review process goes 95% of the way toward the final result.

There are a lot of reasons why decisions aren't close to perfect. Reviewers often don't have quite the right expertise, they may have their own axes to grind about scientific controversies, and they may even try to spike the competition although I'm sure most are doing their best to be honest and fair. If the competition wasn't so horrifically intense, a little bit of slop would be more tolerable, but right now it's just torturous. People complain about the peer review process all the time but nobody seems to have a better idea.

Science marches on

This is not funny and I am not playing it for humor. It is however quite thought provoking. The VA has approved experimental penis transplant surgery for veterans whose genitals have been destroyed in the war. This will use deceased donor organs.

You may have read the Earnest Hemingway novel The Sun Also Rises, about a veteran with this injury. There are serious downsides, including the need to take immunosupressive drugs which may result in opportunistic infections, and of course organ rejection. Whether the donor penis will ever be capable of intromission or produce the desired neurological effects seems highly uncertain. It is also just plain  weird concept to contemplate.

I won't say more about it because I'm not sure what to say.

Where I've been

I spent most of the past week in Bethesda as a member of a proposal review panel for the National Institute of Minority Health and Health Disparities. I'm not allowed to say anything about the proposals, but the fact that the meeting happened, and my participation, are a public record, as is the announcement for the proposals we reviewed.

I thought people might be interested in how the various components of the National Institutes of Health (NIH) go about spending your money. It's too complicated to go into all of the details, but I'll hit the highlights. NIH consists of several different so-called Institutes and Centers (I/C), of which NIMHD is one. Other examples are the National Cancer Institute; National Heart, Lung and Blood Institute; and the Fogarty International Center. Congress allocates money to the various components, and may establish some priority issues for them, but beyond that they have considerable discretion.

Each I/C has a national advisory council which sets general priorities and has final approval power over funding awards (a general term which includes grants, cooperative agreements, and contracts, each of which work a bit differently). Awards to external researchers -- mostly in universities -- are called "extramural" funding. In addition, most of them have some intramural funding in which they run their own labs and employ their own scientists,  but most NIH-funded research is extramural.

Based on congressional mandates, national council guidance, and staff decisions (with occasional requests for additional public input), the I/Cs issue so-called "Parent Announcements" which invite ideas for research projects from investigators and are completely open; and so-called "Program Announcements" and "Requests for Applications," which have increasing degrees of specificity. (They also make awards for training and career development, which I'll only mention here.)

The main kinds of research awards with "parent announcements" are called R03s, which are small awards for preliminary work, usual using already available data, to figure out what it would take to do a study and to generate hypotheses. It isn't necessarily expected to result in scientific findings, other than perhaps a paper on methodology or suggestive observations. The R21 is an "exploratory and developmental" award. It is enough money to do some real science, but isn't necessarily expected to have enough statistical power to draw definitive conclusions. Rather, it is preparatory to an R01 which is a full-scale research project. The R21 might yield methods and measurement instruments, or demonstrate the feasibility and safety of an intervention. In terms of clinical drug trials, it is equivalent to a Phase 2 study.

Investigators who win these awards are given the money and they just run with it. NIH doesn't get involved except to require annual progress reports. However, if you don't end up with publications they aren't likely to fund you again.

The proposals we reviewed this week were for so-called U01 awards, which are cooperative agreements, That means NIH staff will work with the investigators to implement the projects. That makes our job as reviewers slightly different because it means we don't have to assume that the project will be implemented exactly as proposed. If there are "addressable" weaknesses, which could be fixed in cooperation with NIH staff, but we like the project otherwise, we can still give it a good score.

Next, I'll explain the review process and exactly what the heck I did.