How is this even possible?

Here's Josh Marshall on the incredible outrage of the de facto Republican nominee for president, who is being sued for fraud in the midst of the campaign, going on repeated racist tirades against the presiding judge, before large crowds and TV cameras. Yet the only headline news I can find about the nominee today in the corporate media is his press conference at which he announces making contributions to veterans organizations.

There is a serious problem here which I will call Trump outrage overload. (I may not be the first to use the term.) Before the corporate media can get around to fully reporting one outrage, he commits another, forcing them to pivot. The New York Times ran a fairly brief Reuters article on an inside page, containing this intersting nugget of information:

Legal scholars said that Mr. Trump could face consequences for his criticisms. “Mr. Trump’s conduct could be subject to sanction for indirect criminal contempt of court,” said Charles G. Geyh, a legal ethics expert at Indiana University’s Maurer School of Law. “He has impugned the honesty of the judge in a pending case,” Mr. Geyh said, “and has done so in the context of a political rally that seems calculated to intimidate by inciting anger among his supporters.”

That's all I can find about this in the corporate media. This is a major party nominee for president of the United States, folks. And this isn't even news.

The Economics of Medical Miracles

The Academy Health* blog presents an interesting quandary in health economics. We aren't quite there yet, but the day may come soon when it is possible to essentially cure genetic diseases like cystic fibrosis and sickle cell. That sounds great!

The problem is that these are fairly rare diseases, and that the treatment would be administered only once. So, in order to recoup their research and development costs, the purveyors would have to charge enormous prices -- on the order of a million bucks a pop. That's going to make you think, "Oh, this is like those other moral dilemmas about the allocation of scarce resources. We could use that money to save 50,000 African infants or something instead."

Well, yes, but actually we already are spending it on the people with cystic fibrosis and sickle cell anemia -- actually a lot more than that in many cases. We don't begrudge with CF a lifetime of treatment that may cost $6 million, and they would be much happier getting a single treatment that actually cures them. But somebody has to finance it, which means we need to radically rethink how we organize the financing of medical services.

Then there's Norwegian physician Jarle Breivik who discusses Obama's cancer "moonshot" in the NYT. Apart from the well-known problem that cancer is innumerable diseases and there will never be a cure for "cancer" per se, it is true that we can make progress against the multiple diseases called cancer and maybe achieve something we define as a "cure" for a growing percentage of people. The problem is that the rate of cancer increases relentlessly with age; whoever we cure today is very likely to develop cancer again, either from fugitive cells from the original cancer, side effects of chemotherapy and radiation, or because it just happens. And then we're all going to die eventually anyway. Meanwhile, of course, there are still those starving African kids with diarrhea and malaria.

Medicine, in other words, faces a problem of technological imperative. If we can do it, people will demand it, but we have no fair and reasonable way of sorting out competing demands for scarce resources. 


*Academy Health is the research society in health services and policy. Yeah, yeah, it ought be the Health Academy, but it isn't.

A Couple of Observations about Wrongdoing

Those of us old enough to remember Whitewater would prefer to forget. In a pistachio shell, the Clintons, while in Arkansas, invested some money in a real estate deal. The promoter turned out to be a sleazebag, and they lost their investment. That is all.

But the New York Times, which for reasons unknown hated the Clintons, produced a long-form investigative piece (written by Jeff Gerth, whose inexplicabe, irrational hatred for Hillary Clinton is as boundless as Donald Trump's ego), which insinuated that the Clintons had somehow been guilty of wrongdoing in the affair. The piece actually made no sense and added up to nothing, but was extremely convoluted and sufficiently difficult to follow that few readers bothered to deconstruct it and figure out that it was a complete nothingburger.

Michael Tomasky tells the story of what happened next. Briefly, a hyperpartisan pathological liar named Kenneth Starr wound up being appointed as a special prosecutor by a panel controlled by ultraconservative judges, and spent 3 years persecuting and tormenting everybody associated with the Clintons and finding absolutely nothing. Then Monica Lewinsky happened, so he switched to that, and we got impeachment.

Starr is now the president of Baylor University. He has suddenly taken to praising Bill Clinton for some inexplicable reason -- to which Clinton's friend say no thanks. He has also (okay, allegedly) swept sexual assaults by Baylor football players under the rug, for which he may (we are all desperately hoping) end up losing his job.*

 Meanwhile, Ronald T. Dump is planning to dredge up the Whitewater hoax as a campaign tactic. Since the corporate media has never accepted that it was, in fact, a hoax, since that would embarrass them, it will probably work.

So, in politics the simulacrum is as good as the reality. Or as Cokie says, it doesn't matter if it's true or not, it's out there.

Turning now to the world of art, a Manhattan gallery sold $80 million worth of works by such modern luminaries as Motherwell, Pollock and Rothko which were in fact painted by a Chinese immigrant in a garage in Queens. Now that this is known, the paintings are worthless. But they are in fact the same paintings they were when they were worth $80 million -- to some of the most discerning collectors on earth.

Think about it, it must mean something.

*Update: They kicked him upstairs. Once you're a big enough asshole, there's no way to fall but up.

The Bully

Josh Marshall discusses the Republican presidential candidate's attitude toward women, and his specific attacks on Hillary Clinton, which in Marshall's view are not based on tactical consideration but are rather a direct expression of the Trumpian id. Excerpt:

Listen to Trump's words and you hear repeated lines about hurting Clinton, warning her to back off and not forcing him to hurt her again. Cut and paste them out of the context of a campaign article and they read like dialog from a made for TV movie about a wife-beater. . . .

As I've written in similar contexts, when we look at the messaging of a national political campaign we should be listening to the score, not the libretto, which is, like in opera, often no more than a superficial gloss on the real story, mere wave action on the surface of a deep sea. You're missing the point in trying to make out the logic of Trump's attacks on Clinton. The attacks are the logic. He is trying to beat her by dominating her in the public sphere, brutalizing her, demonstrating that he can hurt her with impunity.

I think that this, as much as his racism and xenophobia, his hyper-aggressive nationalism, and his anti-intellectualism, explains his appeal. Many working and middle class white men are stinging from loss of privilege. Even as their economic status is stagnant or declining, the racial and gender privileges they once took for granted are eroding. The election of Barack Obama obviously drove home the loss of racial privilege, and we have seen the intense backlash. Now along comes the prospect of a woman president and it's the end of the inheritance to which they felt entitled.

The nation, and the world, are in grave danger. I am sufficiently distressed by this that it's been hard for me to post here. I'll get back to it.

The Visible Hand

Jonathan Alpern and colleagues in NEJM discuss the plague of pharmaceutical locusts that is depriving some of the most vulnerable people of health and life. Yes, there have been a couple of famous examples, such as the psychopath Martin Shkreli who bought the rights to a decades old drug and then jacked the price up 500 times. It turns out, however, that this sort of scam has become commonplace.

As Alpern discusses, the targets are typically treatments for relatively uncommon infectious diseases, such as tropical diseases and opportunistic infections. This is because the market for the drug is small enough that it isn't likely to attract competitive manufacturers. These are people who cannot afford high out of pocket costs and may be uninsured or underinsured. As Alpern et al explain:

It seems that a new business model has emerged: companies are acquiring drugs in niche markets where there are few or no therapeutic alternatives in order to maximize their profits. Unlike new brand-name drugs, the patents of the drugs being targeted by this model expired years ago. These companies seem to have no interest in adding value to the health care system by developing new drugs. . . .

What makes this business model particularly disturbing is that vulnerable patients — such as immigrants, refugees, and people of low socioeconomic status — are often disproportionately affected, since many of the medications are for tropical or opportunistic infections. These patients often have limited or no access to insurance, or have access only through public programs, so already stark health disparities are compounded.

This is a problem only in the United States. In Europe, drug prices are regulated. The reason they aren't regulated here is because the obscenely wealthy psychopaths who have bought the U.S. political system -- including politicians, the corporate media, and economics departments -- have brainwashed us all into thinking that letting rich bastards screw us is the definition of "liberty." So that's what congress does.

The collapse of civilization

Yes, it has happened in war zones, but it's also happening in Venezuela right now due to gross misrule and the collapse of oil prices. The Gulf monarchies prepared for this eventuality by putting money away. They won't be able to live on their savings forever, but the Saudis have acknowledged that the end of the era when money gushes from oil wells is coming, and they have vowed to diversify their economy. Norway, though not as dependent on petroleum as the Saudis, is also preparing for the gravy train to end.

Alaska and Louisiana did not plan; nor did West Virginia plan for the collapse of the coal industry. All three states are in financial trouble, although of course nothing like Venezuela. (It helps that they have the federal government to help them out, although of course their political leaders won't admit that.)

The point is that it is very difficult for people to contemplate that their long accustomed way of living will have to change. The depth of denial can be astonishing. Joe Romm walks us through the climate shock we are experiencing right now. Not thirty years from now -- right now and starting last year. Scientists who specialize in this area are by constitution conservative in what they will say publicly, but obviously the positive feedbacks in the climate system are terrifying -- disappearing sea ice, burning forests, melting permafrost all amplify the process. What we are seeing now is consistent with an accelerating trend which is on the highest end of the projected range.

This is a global emergency. But it's much more important to bully and humiliate transgendered people, because that's what Jesus wants us to do.

We already knew this, but it's disturbing

Gillis and Fountain in the NYT discuss the fate of the boreal forest. That is the vast coniferous regime that wraps the earth south of the tundra, across Siberia, Alaska and Canada. Something like 1,000 square miles of it just burned in Alberta, which made the news, but it's burning more and more everywhere. You already know why: hotter temperatures, earlier snowmelt, pine bark beetles.

You may also ask why there was a city of 80,000 people by the banks of the black-fly infested Athabasca river in the desolate arctic forest -- you know, the one the people just had to flea before the conflagration. It's because they were occupied in mining tar sands, ultimately to pump the C02 into the atmosphere which was responsible for destroying 10% of their city. There's worse news, which is that if the forest keeps burning like this it will cease to be a carbon sink and will become a net emitter of carbon.

Joe Romm makes it crystal clear. We can't afford even the 2 degree warming target. We can't delay action, wait for a technological fix or afford ourselves the luxury of time. The time is now.

John Oliver Smashes

If you haven't seen this already, it is everything you need to know. Scroll down for the embedded video. It's a long form riff, so make sure you have enough time.

It's stuff I talk about here all the time, but it's better when it's funny.

Medical Nemesis

You may have heard about this analysis in the BMJ that says medical error is the third leading cause of death in the U.S., after heart disease and cancer. This isn't actually supposed to be news, what the authors are really saying is that we need to keep track of it better and deal with it better.

A bit more about that anon, but let me also say that it isn't exactly, precisely true. Although they give as an example a case in which a botched medical procedure affirmatively caused a death, some of the cases that counted are more examples of medical error failing to prevent death from disease or an unrecognized lesion. It's sort of like saying that a faulty guardrail, rather than a driver who falls asleep at the wheel, is a cause of death. In other words we have an expectation that effective medical intervention will be provided when it is possible, and we're willing to call failure to prevent death a cause of death.

On the other hand, medical intervention can cause death when there is not any error per se, or at least it's not clear that there is. There is a certain risk associated with surgery or pharmaceutical treatment, which has to be weighed against the likely benefits. At what point less than perfect judgment or execution gets defined as an error is not usually clear, either. We don't know the details of Prince's case yet, but soon we might be asking, "Should his doctor have written that prescription for opioids after his surgery?" At what point did continuing to give him percocet become an error?

So what Makary and Daniel are saying is not that we should blame health care providers and that those incompetent, careless doctors are killing us all. What they are saying is precisely the opposite: that we need to create a culture that doesn't blame, but fixes problems. Medical professionals are human. They will make mistakes. The difference is that in most professions, mistakes are seldom or never fatal.

So they propose, first of all, that death certificates include a notification that medical error was a factor in the death. I'm not sure how well that would work -- the physician responsible would likely be the one filling out the certificate, there are liability issues, and as I say, how do we really know when what happened qualified as an "error"? This seems unrealistic to me.

On the other hand, we could have a culture and a practice in which avoidable death and injury are discussed openly within the provider institution, and procedures are put in place or reinforced to prevent recurrences. In order to have continuous quality improvement, you need to limit blame and negative consequences of mistakes so that you don't just drive them underground. But on the third hand, some individuals should not be practicing, or should be required to take time out to be retrained or solve personal problems such as addiction that are interfering with their performance. You can't make quality improvement entirely blame free.

So this is really about balance. It isn't about a dichotomy, and it isn't simple.   

Political Science

I've been pretty sure that Ronald T. Dump was going to be the Republican nominee for president for a while now. Nevertheless, it does smack my gob. Sure, with a party that nominated George W. Bush and a country that actually elected him, at least the second time around, it may not seem that big of a stretch. But Chimpy was disciplined enough to repudiate white supremacists, not call his opponents "pussy," or accuse their fathers of murdering JFK, just to offer a few examples. He also managed to stick to a script and articulate reasonably consistent policy positions, even if they were untethered from reality. His racist dog whistles generally stayed above 20,000 Hz.

While I'm still pretty confident that reporters will be asking questions of Madam President at the first press conference of the next administration, the triumph of the malignant clown, even within the party of Goehmert, has many people questioning the fundamental premises behind electoral democracy. Could the smoke-filled rooms of yore possibly have produced such a result?

Scott Lemieux points to Sarah Palin to say "Well, yes." But Palin came along after the really decisive factor, which was not the primary process but the television. Reality today is what lies behind the glass in your living room. That's what made both candidates possible. Remember that democracy in the past produced plenty of atrocious outcomes -- presidents who supported slavery, and then segregation; the Native American genocide; the Vietnam war. Name your poison. We've never expected it to particularly yield good results, just candidates who are reasonably presentable in public. Trump would not necessarily be a worse president than Herbert Hoover or William McKinley -- although he would be scarier since they didn't have an atom bomb. He's just cruder and more impulsive. But the stakes today are much higher. 

Relative Risk and Tort Law

Now here's a difficult problem -- mull it over and see what you think. A woman has been awarded $55 million in damages from Johnson & Johnson based on the claim that talcum powder caused her ovarian cancer.

Here's the 4-1-1 the actual relationship between talc and ovarian cancer. (I'm not sure if you can read it -- I have a magic cookie.) Summary:

Case control studies suggest that women who use talcum powder on their genitalia have about a 20%  increased risk of ovarian cancer, or maybe as much as 30%. That sounds pretty serious, but case control studies aren't conclusive about proving causation. Prospective cohort studies haven't confirmed this, but it would be nearly impossible for them to do so, because of what is called statistical power.

Ovarian cancer isn't all that common. In a 10 year follow-up period, 2 out of 1,000 women will be diagnosed with it. If the increased risk from talcum powder really is 20%, you would have to follow more than 100,000 exposed women and 100,000 unexposed women for 10 years in order to prove it. Put it another way -- the chances that an exposed woman will develop ovarian cancer attributable to talcum powder use is (2/1,000) * .2 = .0004, or 4/10,000.

Is the verdict justified? You decide.