Map of life expectancy at birth from Global Education Project.

Saturday, May 30, 2015

Prediction is hard

But postdiction is easy. Suppose I'd won some sort of a contest when I graduated from college and I got to go on Press the Meat and give my predictions for my upcoming lifetime. Since we're projecting my current self into the past, I'd get everything right.

Well Tim, I would say that the Soviet economic model has failed. They're going bankrupt, and it wouldn't surprise me if the Soviet Union collapses in a little more than a decade. The Warsaw pact countries will align with the West and most of the captive nations will gain independence. Russia will end up with authoritarian crony capitalism.

Also, Maoism has failed to produce economic development. Nothing much will change as long as Mao is alive -- although they may open up to the west because they need the trade and other benefits of ending their isolation. But once Mao dies I think you'll see a much more pragmatic leadership that will encourage private entrepreneurship, and an increasingly dynamic Chinese economy that may ultimately challenge the United States for global leadership. Japan, on the other hand, in spite of what everybody thinks today, is in for a long period of relative stagnation.

Right now computers are big and expensive, but you're going to be amazed at how they get smaller and cheaper year by year. Pretty soon they'll be commodities like toasters and telephones -- they'll be commonplace at home and office. And they'll be networked so they can share data. All the information you could possibly want will be at your fingertips. The job of secretary will pretty much disappear because professionals and managers will prepare their own documents using programs that will even correct their spelling . . .
You get the idea. They'd think I was completely nuts. If I went ahead and added global climate change and resource depletion, Gilded Age inequality, and the rise of radical political Islam and corresponding fanatical Christianism in the U.S., they'd have me committed. So, I'm very cautious about making predictions today.

Thursday, May 28, 2015

Another visit from Les Izmore

No doubt, if you should be among the minority of Americans who watch TV, you have seen those ads featuring famous cutie-pie older women who are totally thrilled with their osteoporosis pills. The whole reason doctors prescribe these at all is because drug companies sponsored a World Health Organization study group in 1994 that decided that  threshold score on a bone density test constituted the "disease" of osteoporosis and that people with this disease should take pills to increase their bone density, lest they suffer hip fractures.

Cometh now an international gaggle of scholars led by presumably not dour Finn Teppo Jarvinen to say hold on a minute. While having low bone density does increase the risk of hip fractures, most fractures occur in people who don't have low bone density. The proximate cause of hip fractures is falling, not low bone density. If you just depend on giving people pills, you would have to treat 175 women for three years to prevent one hip fracture. But .. .

It doesn't seem to help to treat for a longer time -- in fact if anything it might be harmful. We're spending $11 billion a year on these pills now and there also isn't any evidence that they are beneficial in women over 80. But . . .

We can make a huge difference without drugs. A meta-analysis finds that exercise training reduces the risk of hip fracture by 60 percent! And obviously it has many other benefits. Smoking cessation also is comparably useful. And . . .

Women diagnosed with osteoporosis are more likely to limit their activities to avoid falling. See above, that's exactly what you don't want to do. There are important side effects to the drugs as well, including weird femoral fractures and osteonecrosis of the jaw. The authors conclude,

The dominant approach to hip fracture prevention is neither viable as a public health strategy nor cost effective. Pharmacotherapy can achieve at best a marginal reduction in hip fractures at the cost of unnecessary psychological harms, serious medical adverse events, and forgone opportunities to have greater impacts on the health of older people. As such, it is an intellectual fallacy we will live to regret.
Well, maybe "we" will regret it, but not the drug company executives who are raking in the bucks.

Wednesday, May 27, 2015

Once again we present the Upper Class Twit of the Century

That would be Charles Windsor, whose inbreeding continues to get the better of him. The Prince of Woo "won influence over Prime Minister Tony Blair and delayed the introduction of regulations governing the sale of herbal medicines, letters between the heir to the throne and government ministers have revealed."

The story is that a European Union Directive in 2004 required that new herbal products be approved before they could go on sale in the EU. This followed many cases of people being harmed by quack medicines. Older products were grandfathered until 2011, but the definition of older would have excluded some currently on sale. Prince Chucklehead met with PM Tony Blair and wrote to Blair and various other ministers to complain. In case you didn't know, he's a big champion of anti-scientific health care fraud, among other idiocies. He succeeded - Blair ended up allowing the sale for many years of products that would have been banned under the EU directive.

The BMJ quotes Simon Singh:

These letters are almost certainly just the tip of the iceberg. We have no idea how much HRH [his royal highness] has been influencing policy via unreleased memos, during private meetings and via his now defunct Prince’s Foundation for Integrated Health. In a democracy it is fundamentally wrong that an accident of birth should enable someone to have secret influence upon those who determine health policy. Herbal medicine can work in a few instances, but in the majority of cases it is unproven, disproven, or downright dangerous, which is why the EU Directive on Herbal Medicines is so important and why HRH’s desire to delay implementation was so foolish.
Indeed. It is long past time that the British take these parasites off the dole and abolish the monarchy. 

Tuesday, May 26, 2015

An old story gets new attention

I've covered the scientific fraud beat here a few times, mostly about prominent investigators with tenure and grant funding and even fame (e.g. Marc Hauser). It's somewhat hard to understand -- they would still be successful and respected even if they stuck to honest research, maybe just not quite as famous or prolific.

The more classic and purportedly understandable case if the grad student or post-doc trying to scramble over the scrum to get to the bottom run on the academic career ladder. That's very tough to do and you can see why somebody might succumb to temptation. So this has been going on forever. NIH issues findings of scientific misconduct several times a year, mostly against people in that category or junior faculty. Nobody pays any attention. The case of Michael LaCour is an exception, with a long front-page story in the New York Times (to which I do not link due to the paywall) and plenty of other hullabaloo.

In case you just got back from a camping trip, he pretended to do a study showing that lesbian and gay canvassers could change people's minds about same sex marriage, whereas straight canvassers with the same pitch were not as successful. Makes intuitive sense, of course. Lots of people don't even know that they've ever met a gay person, so sure, maybe if they actually had that experience it would get their brains out of the box. And it might even be true -- but we don't actually know because it appears he never really did the study.

The Times questions whether there is something wrong with the peer review process -- this was published in Science, which is as prestigious as it gets. But that's off the mark. Peer reviewers have no way of knowing whether data is fraudulent, they can only evaluate what's in front of them. No, the problem here is that a) the senior author of the paper, who supposedly supervised the research, didn't actually do that and b) the raw data was a secret, so nobody but LaCour ever saw it (if any existed at all).

So these are problems we can do something about. I'll leave aside the supervision question, which is largely an issue of personal responsibility. But raw data is generally held confidentially by investigators. That's because they want to be able to publish papers from it and they don't want other people to publish instead. The problem is that nobody can tell if they're lying. Pharmaceutical companies used to misrepresent the results of clinical trials all the time. Now FDA is making efforts to make the underlying data accessible for independent evaluation. But we obviously have the same problem in other fields. Even where there isn't a direct pecuniary motive, a tenure track job at Princeton is plenty of incentive for some people to lie.

Data needs to be de-identified, which is not that hard to do in most research designs. But people need to get access to it. Ways can be done to assure that investigators get ample opportunity to publish based on their own data, without making it impossible to determine if their analyses are done correctly or even if the data is what it purports to be at all. Right now, believe it or not, that is often where we find ourselves.

Friday, May 22, 2015

I commend to your attention . .

this important and eloquent essay by my former student Katie Brooks, a Brown medical student. Unfortunately, JAMA won't let you read the whole thing, but you can read the first page, which is most of it.

If you checked out the talk I posted a couple of weeks back, you'll notice that Katie is telling us that she is being taught, in medical school, all the bad ideas and habits I discussed for our pre-med students: racial stereotyping masquerading as "cultural competence," casual and unreflective discrimination, failure to grapple with the real determinants of health and illness out in the world, oblivious callousness to the problems of the most vulnerable.

It takes some courage for a student to write that. BTW in case you missed it here's the link to my talk.

Wednesday, May 20, 2015

I understand that there are two sides . . .

to the question of physician aid in dying. The California Medical Association has become the first state medical association to adopt a neutral position on a law allowing physicians to prescribe lethal doses of drugs to terminally ill patients. All the others continue to oppose it. In the U.S., it is now legal only in Oregon. Physician assisted suicide is legal in several European countries and, following a recent Supreme Court ruling, in Canada. In the Netherlands it is tolerated. Legalization is contemplated in France and the UK.

Requirements vary. In Switzerland, people don't even need to be terminally ill, they just have to convince two doctors that their suffering is unbearable. In spite of dire predictions, experience is that few people ultimately avail themselves of the option -- though more discuss it and accept prescriptions. Generally speaking, you have to make the decision while you are cognitively reasonably intact, which means this is not an option for people who are severely demented.

I'm sure you are familiar with the many perfectly respectable concerns. People may kill themselves because they are depressed, because they think they are a burden to others, or because they receive in adequate palliative care. Many people argue that with proper palliative care, nobody would really make this choice. And people with disabilities and their advocates argue that there is a slippery slope toward devaluing the lives of people with severe chronic illnesses or disabilities.

Finally, many doctors don't like the idea because they don't want to participate personally and they fear being in the position of having a patient ask for help in dying.

I think that these understandable fears are addressable by a well-thought out legal and regulatory regime. But it is really impossible to draw bright lines here and plenty of dystopias have been imagined around state sanctioned and facilitated suicide. (Including by Kurt Vonnegut Jr. who I greatly admire.)

I am quite confident in opposing the death penalty under any circumstance, supporting reproductive rights for women, and the withdrawal of active life support on the patient's or health-care proxy's choice. This doesn't feel so clear to me. It does stop somewhere, but we need to have a serious, honest public discussion about where. I won't disparage any opinions based on a true set of premises.

(And no, there aren't any death panels in Obamacare.)

Tuesday, May 19, 2015

Must read links

I don't know if this is true, but if it is, you had better start thinking about it. Zack Kanter thinks that autonomous vehicles -- that get from point A to point B with no human operator -- will pretty much take over within 10 or 15 years. That means you won't own a car, you'll summon one. There will be no traffic congestion, almost zero crashes, and you'll get around faster and with less fuel. That sounds great, right? It will also bankrupt GMC, Ford and Chrysler; destroy the automobile insurance and repair industries and the used car market; put 6 million people with driving jobs out of work; and otherwise transform the economy and society massively and unpredictably. Maybe. I was quite skeptical but I'm less so.

Here are the 15 best behavioral science graphs of 2011-2013. The graphical representation of information is essential to both the communication of quantitative data, and to persuasion -- it can illuminate or mislead. These are universally illuminating. Also some bonuses -- there are more than 15 here. You'll learn a thing or two from the content, as well as admiring the presentations.

Friday, May 15, 2015


No, not a bankster or a torturer. Jamie Dimon, Dick Cheney and Donald Rumsfeld still walk free. Still, this guy Kevin Lowe is one sick puppy. He's a physician who ran phony clinics for the purpose of writing prescriptions for oxycodone. One of his physician employees, Robert Terdiman, wrote more than 17,000 scrips in 18 months, totaling 3 million pills, which sell on the street for up to $30. And that's where they were going -- the clinics didn't directly serve addicts, rather they generated supply for a distribution operation. Lowe posted $5 million bail, but Preet Bharara has gotten his man. According to the press release, Lowe cleared $7 million out of the $165 million in total value of the bogus scrips. Twenty four other people have plead guilty, but Lowe chose to go to trial.

Lowe will be sentenced in August and faces up to 20 years. 

Now, here's the thing. He could have made a ton of money legitimately. He was a physician who owned a chain of clinics, most of which were totally on the up and up. Becoming a gangster running a massive criminal enterprise was a choice made entirely freely and with a perfectly good and lucrative alternative. So what is going on with this asshole? By the way, 20 years isn't nearly enough. He should leave prison feet first, as far as I'm concerned.

Wednesday, May 13, 2015

Incidents and Accidents

Charlie Pierce joins a huge chorus taking the opportunity of the derailment in Philadelphia to decry our national neglect of essential infrastructure. It seems likely that this will ultimately be ascribed to operator error -- excessive speed on the curve -- like the Metro North derailment in 2013. However, there will always be human error. The technology to prevent this exists, is not very expensive, and is in fact mandated by the Railroad Safety Improvement Act of 2008. It's called positive train control, and it would have slowed down those trains even if their operators had dropped dead.

However, if you read down to the bottom of the above link, you will find:

PTC systems are eligible for funding under the Railroad Rehabilitation and Improvement Financing Program; however; no railroads have approached FRA for funding of PTC projects using this program. PL110-432 has also authorized Railroad Safety Technology Grants that can be used to support PTC projects at $50 million per year from 2009 to 2013; however, the funds have not yet been appropriated.
 In Europe and Japan, trains routinely travel at speeds in excess of 150 mph, and are one of the safest modes of transportation. (The first high speed rail network, in Japan, started operating in 1964 and has never had a fatal accident.) They are far more fuel efficient than automobile or air travel, and of course emit less carbon. In principle, electrified high speed rail can be zero emission depending how the electricity is generated.

Now, in order to build a modern, super safe, low carbon high speed rail network that will result in enormous economic benefits into the future and help save the planet, we will have to invest money. Which means that people will have to pay taxes -- mostly rich people because yes, they're the ones who have the money. They are also the ones whose wealth depends on the publicly funded highways, schools, airports, law enforcement and other public goods they don't want to pay for. And they are willing to invest millions of dollars in order to buy politicians who will make sure they don't have to.

Update: Less than a day after the deadly Amtrak crash on the Northeast corridor between Washington and New York, lawmakers on the House Appropriations Committee voted down a proposal that would have increased funding for U.S. rail infrastructure. I may vomit.

Monday, May 11, 2015

The Big Lie

Jeb Bush tells Faux News that he would have invaded Iraq in 2003 had he been president, based on the intelligence available at the time.

That's what they all say. Except the "intelligence" was fake, as we all actually know. Paul Pillar, who was National Intelligence Officer for the Near East and South Asia from 2000 to 2005 is probably the right person to ask

The most serious problem with U.S. intelligence today is that its relationship with the policymaking process is broken and badly needs repair. In the wake of the Iraq war, it has become clear that official intelligence analysis was not relied on in making even the most significant national security decisions, that intelligence was misused publicly to justify decisions already made, that damaging ill will developed between policymakers and intelligence officers, and that the intelligence community's own work was politicized. As the national intelligence officer responsible for the Middle East from 2000 to 2005, I witnessed all of these disturbing developments. . . .

The administration used intelligence not to inform decision-making, but to justify a decision already made. It went to war without requesting -- and evidently without being influenced by -- any strategic-level intelligence assessments on any aspect of Iraq. . . .

Official intelligence on Iraqi weapons programs was flawed, but even with its flaws, it was not what led to the war. On the issue that mattered most, the intelligence community judged that Iraq probably was several years away from developing a nuclear weapon. The October 2002 NIE also judged that Saddam was unlikely to use WMD against the United States unless his regime was placed in mortal danger.
Will the corporate media call out Bush on this Big Lie? No, because they were complicit.

Friday, May 08, 2015

It definitely can't happen here

Unfortunately. I don't know how much of this you common riffraff are allowed to read, but a British doc writes a commentary in BMJ asserting that private medical practice is unethical.

It can't happen here for a few reasons, not least of which is that unless you want to work for the military or the VA, there isn't much of an option. British M.D.s, as I assume you know, are mostly salaried employees of the National Health Service. However, some people with money think they get better service if they pay a physician out of their own pockets so doctor set up private practices to get themselves richer. But, says Dr. Dean:

[L]et’s face it: the whole business is largely a con. Patients think that paying must mean higher quality medicine, but—like paying more for shampoo with added vitamins—the promise is far greater than the reality. Rich and famous people may use private facilities to shelter from the public gaze; for most “ordinary” private patients, though, the main advantage is simply to jump the NHS queue. Private hospitals are like five star hotels, but for the most part they are no place to be if you are really sick.
And why aren't the rich people getting higher quality medicine? Easy:

The business of medicine and the practice of medicine are at odds. Private medicine encourages doctors to make decisions on the basis of profit rather than need. When confronted with a choice between two treatment pathways in equipoise—one that earns the doctor no money and the other with a fat fee attached—that conflict is stark. I cannot say, with hand on heart, that I have never chosen the second option.
In short, as I have explained here many times, the idea that the mythical "free market" is an appropriate way to organize health care is utterly nonsensical. I can go on at much greater length why that is so, but this should be enough.

The entire U.S. health care system is unethical, and everybody who works in it is part of an unethical structure. It's about vacuuming up money first, and taking care of people somewhere down the list. How to fix it? Socialism, baby. Just like the Brits.

Wednesday, May 06, 2015

Too much news

Two British welfare recipients, about whose existence I do not give a rat's ass, had a baby. In even bigger news, they named her.

It seems the military is planning to take over Texas, in collaboration with Walmart and the Chinese army. That sounds like an excellent plan to me. In fact it's long overdue, I hope they'll get on with it.

NASA has been experimenting with an engine that purportedly can accelerate a vessel in space without throwing off reaction mass. According to the known laws of physics, that is impossible -- but that's actually good news, it means they can use cold fusion as the energy source.

Monday, May 04, 2015

I used to be a skeptic

I admit that I wasn't thrilled about the Affordable Care Act when it first became law. I had the same objections that most of us with a portside list had. It didn't do enough to contain costs, it left the insurance companies leeching on the system, it was just a gravy train for hospitals and medical suppliers and long-term affordability was highly doubtful.

So far, however, so good. The latest Commonwealth Fund survey finds that it's been a major success in reducing the number of people who are uninsured, reducing the number of people who delay care because of cost, and reducing the number of people who have trouble paying bills or who have medical debt. It's working to make life better for millions of people.

But how about cost? In fact the growth in health care spending has been well below recent experience. There's debate about the reasons for this, but clearly the ACA did not cause an increase in cost. I am now cautiously optimistic that there is simply no politically plausible path for Republicans to destroy the ACA, and given that it is becoming more and more entrenched, the only way forward for Congress is to improve it. As Medicare demonstrates effective reforms in the structure of reimbursement, those changes can be made widespread in the private insurance market as well. If we move from fee-for-service to Accountable Care Organizations, we'll get better health care for less money. And the ACA has created a platform for doing that. Doctors and drug companies and hospital execs may howl, but it will be impossible to take this away from people and that means it has to be affordable. That's the political dynamic ahead of us, I (confidently?) predict.