This is incredible

I don't know if anyone remembers Fat Al Gore, but back in 1998 he proposed stationing a satellite at the Earth-Sun L1 point to continuously photograph the earth from deep space. Flaky, no?

The L1 point is one of five locations called Lagrange points, which exist in any system of two orbiting bodies, where a smaller body can remain stably. L1 is nearly 1 million miles from the earth, well outside the orbit of the moon. Somehow I missed it, but NASA actually did it! The satellite is now called the Deep Space Climate Observatory, or DSCOVR (get it?) and it was launched by SpaceX in 2015. Now it gives us this amazing image:

That is the moon transiting the earth. We're seeing the side of the moon which can never be seen from earth. Although it's called the "dark" side of the moon it isn't really dark - it is illuminated just as often as the near side. Since we're seeing the lighted side of the earth (L1 is in a direct line between earth and sun, so you always see the day side), we're also seeing the far side illuminated. You can see the transit in motion here, courtesy of your tax dollars at work.

That's everything we have, folks. There's no place else to go, and nothing else to live on.

When ideology trumps reality

(I took a few days off to rest my brain. Results are mixed, but I'm back.)

You may have heard about the HIV outbreak in Scott County, Indiana. (Not sure how much of this the grand poobahs at New England Journal of Medicine will let you read, but I'll run it down for you.)

This is a rural area, almost entirely white, with high unemployment and poverty. The governor of Indiana, Mike Pence, is now the Vice Presidential candidate of the Republican party. Prior to 2015, with Pence's backing, Indiana outlawed needle exchange programs. Needle exchange has been shown to substantially reduce the risk of transmission of HIV and Hepatitis C virus (HCV); and it does not increase the prevalence of injection drug use. On the contrary, by bringing users into contact with service providers, it increases the chance that people will enter treatment. However, conservatives have succeeded in banning the practice in many states using the argument that it "enables" illicit drug use. Of course, addicts will inject any way they have to, and if they can't get clean needles, they'll share.

One more thing -- free HIV testing had not been available in Scott County since the Planned Parenthood clinic closed in 2013.

Early in 2015, a disease intervention specialist (DIS) discovered a cluster of 11 HIV infections in Scott County. A DIS is a public health worker who interviews people diagnosed with an infectious disease such as HIV and tracks down people they have potentially infected, or who potentially infected them, in order to diagnose additional cases and gain an understanding of transmission networks. Previously, there had only been 5 HIV infections identified in Scott County since 2004. All of the infected persons had crushed, dissolved and injected extended release oxymorphone.

As a result, the CDC and Indiana state government declared a public health emergency, and began intensive contact tracing and population screening. Ultimately they found 181 people with HIV in the county, nearly all of whom reported injection drug use. As a result, Pence relented and allowed needle exchange in April, 2015, after which the cumulative diagnoses leveled off and finally stabilized. As the authors also write:

A lack of health insurance could have been a barrier to the response to this outbreak, but fortuitously, in January 2015, Indiana received a waiver to provide Medicaid insurance [which] helped to ensure health care coverage in the largely underinsured and impoverished community . . . and facilitated the immediate enrollment, coverage and access to critical health care services.

I might note that people who are effectively treated for HIV are essentially non-infectious, meaning that treatment for all can stop the epidemic in its tracks.

Is there a lesson here? Yes. We were right and Mike Pence was wrong. But who do you think the good citizens of Scott County are going to vote for?

An informed perspective on the ACA

Former law professor and current federal employee Barack H. Obama offers an assessment of the Affordable Care Act in last week's JAMA. While I don't know if we can count on him to be an entirely disinterested observer, this does have some fair and balanced elements.

He rightly notes that the law has resulted in a huge decline in the proportion of people who lack health insurance, and is plausibly linked to observable improvements in beneficiaries' health status and financial security. He also gives credit to the ACA for slowing the growth of spending on health care, which is a big more speculative at this point.

But he also observes that affordability is a problem for some people. Fixing this would require increasing the funding for subsidies and changing the structure of subsidies to fix some quirks.

The big news, however, is that he notes that the ACA has not succeeded in creating competitive insurance markets in all parts of the country. Therefore, he embraces a publicly sponsored insurance option, a Medicare for all style program, where competition is lacking. This goes part of the way toward Bernie Sanders, who of course wants that everywhere. It's a pretty kludgy fix -- it would need an on/off switch depending on the current competitiveness of the market in a given region, which doesn't seem very workable.

Biggest problem, of course, is that there is no way in the Delta quadrant of the galaxy that a Republican House would ever pass this. But, it does give Hillary something to campaign on.

Side Note: That the major scandal to come out of last night's hate fest on the lake is that Melania Trumps speech contained some purloined words tells us everything we need to know about the corporate media. Blatant ugly lies; bigotry; depraved fear mongering: all okay worthy only of stenography. Non-politician given ghost written speech that contains a bit of borrowing -- that's your screaming headline. Bring on the giant meteorite.

It doesn't take a genius . . .

. . . to figure out that the entire basis of the Republican presidential candidates appeal is racism. Kevin Drum gives us a more opionated discussion of this obvious fact.

As a friend just ranted at me, however, the corporate media for the most part (Confessore piece above obviously excepted) and even, it seems, many Democratic politicians have at best tip-toed around this. Hillary Clinton obviously doesn't have nice things to say about him, but just calling him a con artist and a fraud is not mentioning the elephant in the room.

For the teevee news, of course, the candidate is good for ratings and that's all they care about. That's what made him the Republican nominee, his ubiquity on cable news. They obviously don't want to alienate his fans.

But the same goes for many Democratic politicians. The Bill Clinton presidency was largely about trying to win back the Reagan Democrats by pandering to their racism. Hillary knows that accusing racists of being racist is the best way to make them feel offended. Telling the country that racism is foundational to white working class culture would be the truth, but it would also be an excellent way to make sure you could not be elected to office outside of Berkeley or Jamaica Plain.

How worried am I? Not very worried about hearing the Marine Band playing Hail to the Cheetoh Dusted Thief, but disturbed by the weakness and corruption of our institutions. Donald Trump may be too vain and undisciplined to carry his schtick over the finish line, but somebody smarter and emotionally stable might come along and carry off a more successful version of the act. In the meantime, we could see a lot of unpleasantness.  

Anybody who isn't paranoid is nuts

One of my research projects was to develop a questionnaire assessing the knowledge and beliefs of people living with HIV about the disease and treatment. I did qualitative interviews first to harvest the kinds of ideas people have and then translated those into structured questions. One of them is:

 "Some doctors are paid by drug companies to prescribe certain HIV medications."

People can call that correct, partly correct, or not at all  correct, but I didn't score this question when I calculated their overall accuracy because it's not exactly true and it's not exactly false.

Susan Chimonas, in the journal Democracy (which I very much commend to you as a most excellent freebie)  uses this recent study in JAMA Internal Medicine as the occasion to write about the problem of pharmaceutical industry influence on prescribers. I say she uses it as the occasion because we already know all this. Even very small gifts can have a substantial influence. They talk about $20 meals but even pens and sticky note pads have been shown to have an effect. My old office at Tufts Medical Center had boxes of office supplies stamped with the pharmaceutical brand names. The drug companies obviously wouldn't waste their money on this if it didn't work.

Now, there isn't any stated quid pro quo. You don't actually have to prescribe Toxovan to get the free lunch or the triangular pen. This is actually a weird trick about human psychology. It's surprising how well it works. Transparency is often touted as the solution -- drug companies should have to disclose their gifts to prescribers, prescribers should have to disclose the gifts they accept. But that doesn't work. The only solution is to ban the practice. Drug companies should not be permitted to give anything to prescribers. The information they need is in the so-called "label" (actually a substantial pamphlet) approved by the FDA. The docs should read it. That is the only interaction between prescribers and drug companies that should be permitted.

What rough beast . . . slouches toward Bethlehem to be born?

I'm kind of an old guy now, and I lived through the '60s -- the Civil Rights Movement and massive police and KKK violence in response, the Vietnam War protests and the Chicago convention, the assassinations, the urban riots, the Weather Underground, the Black Panthers . . .

It seemed as though everything was spinning out of control. People got scared enough to nominate Barry Goldwater,  and then elect Richard Nixon, but eventually everything calmed down and the country held together. The truth is though, the underlying fractures in our society didn't heal, they just got painted over for a while. Is this historical moment more dangerous, or do we have more cultural resources now to overcome the turmoil and fear?

I'm not sure yet. Has progress been an illusion, or are we just seeing the one step back after two steps forward? We'll just have to stay tuned.

Opioid Prescribing Policy

A major political deal in my former home state of Massachusetts has been reform of opioid prescribing regulations, and you can read all about it here. This law had strong bipartisan support from the Democratic legislature and Republican governor as well as the Massachusetts Medical Society. The opioid abuse epidemic has gotten the attention of lots of state governments and many of them had passed laws like this a few years ago.

Speaking of the Massachusetts Medical Society, they publish the New England Journal of Medicine which today has this from Ellen Meara and colleagues. Alas, they can't find any evidence that these laws do much good at all, if any. Their data came from people under 65 who receive Medicare benefits because of disability. That's obviously not representative of the general population but on the other hand they have high rates of receiving opioid prescriptions and account for a highly disproportionate share of related adverse events. Furthermore, there is no obvious reason why these state laws would not affect opioid prescribing to them as much as it would to others.

There are several sorts of provisions they looked at, many of which are components of the Massachusetts law. These include limiting the quantity of initial prescriptions, requiring prescribers to consult a Prescription Drug Monitoring Program (which tells them if patients are also getting prescriptions somewhere else), and various other provisions. But it turns out that there is no meaningful difference in long-term prescribing, high levels of prescribing consistent with addiction and overdose risk, multiple prescribers, or actual overdose, when states adopt these laws.

Now maybe they take more effect over more years, maybe they have a small effect that the study couldn't detect, and maybe non-disabled people are different. But the takeaway seems to be that this problem is not solved by trying to impose restrictions on physicians. We need to change the culture and practice of medicine, and that means for one thing doctors' skills to communicate with patients and manage pain without overusing opioids. The legislature doesn't have any magic bullets.

About the death panels . . .

(This is a repost from a while back but I want to re-start a discussion.)

Uwe Reinhardt wrote the following:

The . . . opponents of cost-effectiveness analysis [include] individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

Yes, believe it or not, the James Madison Professor of Political Economy at Princeton University does not believe that human life is infinitely precious. Of course he's going to hell, but what about you? Let me try something out. My colleague Peter Neuman did a survey of oncologists in the U.S. and Canada. He asked them whether they agreed strongly, somewhat, neutral, somewhat disagree, disagree strongly - the usual survey question -- with the following statement:

Everyone deserves access to effective cancer treatments, regardless of the cost.

What's your response? You'll probably be happy to know that most oncologists agree. Then he asked them another question. (I've altered the parameter slightly to get this over with faster.)

Suppose a new treatment for cancer is introduced that costs $200,000. How much added life would it have to offer someone -- let's even say it's you! -- before you would pay for it out of your own pocket? How about if it were paid out of shared social resources? How much extension of life would it have to offer before paying is justified?

One day? One week? One month? Six months? A year? I don't know what your answer is but I'll bet there are very few people who think it's worth spending $200,000 to extend somebody's life by one day. And if you think we are morally compelled to do so, then consider: More than 2 million children die every year from water born diseases; a child dies from pneumonia every 15 seconds; for $250,000, we could save tens of thousands of them.

Why is tobacco legal? Why do people go down into coal mines? Why do we start wars? Every time you get in a car you are proving that the value of life, to you, is finite, because riding in cars is dangerous and lots of people die from it.

The intuition that life is infinitely precious is closely tied to an idea called the Rule of Rescue. Little Timmy fallen down the well is the classic example, but coal miners are a good one also. When miners are trapped under the ground, the coal company and government agencies spare no expense. Drilling equipment is shipped in, high tech seismic equipment, skilled crews work 24 hours, and of course it’s also all the cable news, all the time. If the miners are rescued, the people give thanks to God, although they generally spare him the blame when rescue fails. But the same company has likely been evading safety regulations all along in order to save a few dollars, and the worst that happens to them is a small fine, and there’s little or no public outcry or even any attention paid.

So how we view the preciousness of life depends very much on the obviousness and imminence of death.

The rule of rescue is important to this discussion not only because of the way it affects our allocation of resources, but because it refutes the liberty claim against compulsory insurance. Someone who can afford insurance, but exercises a choice not to buy it, and then is hit by a bus or has a serious illness, will impose a claim on others – family, purchasers of insurance, taxpayers, somebody somehow will pay for their urgent care – and thereby others will be deprived of property and their liberty impaired. No-one can be said to have a right to do that.

Further implications of these observations, which ought to be thought of as very mundane but which are in fact, completely outside the bounds of acceptable political discourse in this country, are to follow.