Map of life expectancy at birth from Global Education Project.

Monday, July 17, 2017

Not again . . . .

There seems to be a flavor of the month the past couple of years of universities covering up for grotesque behavior by prestigious professors -- in this case the dean of the USC Keck School of Medicine. It's kind of hard to believe he had time for it, given what is presumably a demanding job, but he was spending his off hours doing meth and smack with prostitutes and drug dealers. His kept woman OD'd in a hotel room, and the police happily covered it up. The university obviously found out about what was going on and let him quietly resign with an excuse that he was taking another job, but allowed him to continue to rep the school of medicine for fundraising purposes. Oh yeah -- he had been accused of sexual harassment in an earlier job at Tufts -- disposition of the case covered up --  and assaulting a colleague at a later job, outcome also kept secret.

Now, as far as I'm concerned if he was effective at his job I don't personally care what he was doing in his free time -- that's between him and his wife, mostly. However, they obviously would have responded very differently in the case of any ordinary faculty member. The knee jerk response for these big shots is that they are allowed to get away with just about anything. The ruling class within the university sticks together, even in cases where it really matters to the mission including academic fraud and sexual harassment. It just doesn't seem to change.

But really, check out the article. It's just a blockbuster investigation, great journalistic work.

Wednesday, July 12, 2017

Ignorance is bliss?

A majority of Republicans now tell Pew Research pollsters that colleges and universities have a negative impact on the U.S. That's a big change from just two years ago, and it's most pronounced among people who identify themselves as conservative.

Now why would they think that? What is the negative impact we purportedly have? I suppose the place to start in trying to figure that out is what we actually do.

First, obviously, we educate young people. What does "educate" mean? It actually has several components, which I will get to.

Second, we do research. We work to increase human understanding of the universe, including humans and human society. We do this based on standards for observation and inference, upon which there is a substantial area of broad agreement but considerable disputation around the edges. These vary somewhat among disciplines, some of which allow for a substantial values component in their discourse, others of which at least pretend to have little or none.

Our standards for observation and inference have a lot to do with the nature of the education we provide. Students do memorize facts. They also learn methods of inference and critical thinking. They learn how to distinguish categories -- what is, what ought to be, what is beautiful -- and to talk about each of these in the manner proper to its nature. They learn skills for learning. They learn logic, critical reading, methods of discourse and argumentation. Colleges and universities produce people with the knowledge and skills to expand scientific knowledge, manage enterprises, develop technology, solve problems. Without colleges and universities, we would be living like people in the 15th Century. We wouldn't have modern medicine, or telecommunications. Colleges and universities also train actors, musicians, film makers, chefs, architects, public policy makers, and engineers.

So what is bad about them? Let's go back to those categories -- the true, the good, the beautiful.

Being a conservative Republican nowadays requires believing some things that are objectively not true. Most notably, it requires believing that human activity is not causing the climate to change. It is people working in universities who are determining that yes, that is really happening. (Also, there's that little question of evolution and the history of the universe.) People in universities, including in schools of public health such as where I work, also figure out that people can be harmed or helped by features of their physical and social environment, which provides the rationale for policies such as pollution control, early childhood education, expanded health care access, and yes, gun safety policies. Note that conservatives have literally forbidden federal funding of research in the latter field -- truth that is contrary to ideology is not to be discovered.

I could go on with this but the bottom line is, reality has a well-known liberal bias. We study reality, and that's bad.

But the good and the beautiful matter as well. It was not always the case, but universities nowadays strive to be inclusive and celebratory of diversity. We encourage open debate and dissent. Now, lately there have been some highly publicized controversies -- in fact they are very few and far between -- about invitations to particular speakers who some members of a university community find offensive. These happen to be people called "conservative," which in these instances means racist and/or misogynist. Whether allowing these people to speak or not is proper is a debate I will defer. The point here is that racism and other forms of bigotry and exclusion are not generally condoned in colleges and universities, but they are condoned among conservative Republicans. So we have a disagreement over the good.

Finally there is that question of the beautiful. I expect that many people who consider themselves conservatives also have a feeling that people with college educations look down on their culture. This isn't actually true, for the most part. Some well-to-do people are snobbish, of course. And there are no doubt differences in artistic, culinary or sartorial preference among people of differing levels of education. But I can assure you that working class and low income people are just as valued and respected as wealthier people, if not more so, here in the school of public health and elsewhere in the university. We really are working to make life better for everyone, especially those in most need. And please don't confuse us with politicians.

Friday, July 07, 2017

Coercive psychiatry?

Two writers in BMJ maintain that there is a global trend toward more coercion in psychiatry. Their evidence seems largely impressionistic - I'm not sure they prove the case - but it does reopen a discussion that we haven't heard much of lately.

In the bad old days mental hospitals were indeed what Erving Goffman called "total institutions." Many people were confined involuntarily, and often for life. Their lives were controlled by rules and regimentation, and many cruelties were practiced on them including shackling, solitary confinement, and destructive brain surgery. As you probably know a mental hospital was Ken Kesey's metaphor for the oppressive conformity of 1950s America in One Flew Over the Cuckoo's Nest. Yes, it was fiction, but it resonated.

As I have discussed here quite often, the de-institutionalization movement closed most mental hospitals. This was partly a response to the more liberal values of the post-1960s era, partly a response to the availability of treatments that suppress some of the worst symptoms of psychosis, which made de-institutionalization more feasible. What did not happen, however, was the promised second half of the program, that is the creation of adequately supportive community-based housing and services. So lots of people wound up homeless, and in prison. The BMJ editorial evokes incarceration to support its thesis, but that doesn't really work: police, prosecutors and prison guards aren't psychiatrists. What this really points to is a lack of psychiatry, not that psychiatry itself is more coercive.

However, they also argue that involuntary commitment and forced treatment are becoming more common, along with solitary confinement and restraint. The justification, in their telling, is "risk management." Mentally ill people are seen as dangerous. It seems to me that in part, what we are seeing is simply the regression toward the old regime when the promised new one failed to materialize. But there are also those who have argued that more inpatient psychiatric resources are needed, on the grounds that not everybody can make it on the outside after all, at least not all the time.

Unfortunately people who are held against their will, and who have underlying behavioral problems, are difficult for staff to deal with. And it is very hard to discourage staff from taking the relatively easy path of drugging and restraint. It happens in nursing homes as well. So I'm not sure that what we are seeing is a corruption of the culture of psychiatry so much as it is a reflection of insufficient resources being put toward a more humane response to mental illness.

But there's a lot of that sort of thing going around.

Wednesday, July 05, 2017

The Rule of Rescue

I briefly mentioned the case of Charlie Gard in my last post. Now both the Pope and some clown have weighed in. (The link is to a comment on this, which I will allow to speak for itself.) Who knows exactly what the clown meant by his tweet, but the Vatican statement included the specific assertion that the Pope prays that the parents' "wish to accompany and treat their child until the end isn’t neglected," and the statement from the Pontifical Academy of Life that

We should never act with the deliberate intention to end a human life, including the removal of nutrition and hydration. We do, sometimes, however, have to recognise the limitations of what can be done, while always acting humanely in the service of the sick person until the time of natural death occurs.
To be clear, Charlie Gard has irreversible brain damage. He cannot hear, see, swallow, cry, or breathe. It is unlikely that he has any conscious awareness, but please try to imagine what it is like if he does. He is being kept alive by a machine that breathes for him, and by another machine that pumps nutrition and hydration into his body. If the machines are turned off, natural death will occur.  Indeed, it is probably fair to say that it has already occurred, and what we are seeing is only a simulacrum of life.

Oh, by the way, it costs a great deal of money to keep the machines going. The Vatican hospital has offered to continue the exercise, presumably indefinitely. Transporting him, with his machines, would be extremely expensive. Did you know -- and does the Pope know -- that some 3 million children under five die every year from "conditions that could be prevented or treated with access to simple, affordable interventions"?

Are the Pope and Donald Trump offering to do anything at all for any single one of them?

The title of this post refers to an ethical instinct that people have to provide succor to a single, identifiable individual who is in dire circumstances. They will say that no price is too high, that human life is infinitely precious. But obviously, nobody actually believes that.

Friday, June 30, 2017

Common Sense

The various affluent countries around the world have somewhat different ways of organizing and financing their universal health care systems, but they all cover everybody, and they spend about half as much or less than we do. Right now the British system happens to be under strain because the conservative government is underfunding it. Vote Labor back in and they'll put in enough money to fix it.

But I want to talk about rationing. It just seems bizarre to me that people argue against universal health care schemes on the grounds that they require "rationing" or denying some services to some people on the grounds of cost. Yes, that is necessary, because resources are finite and taxpayers only want to reach into their pockets to a certain depth. Ergo, you don't spend a million dollars on the small chance that it will extend the life of a horribly sick person by a week. You have to draw the line somewhere.

But obviously, that already happens right here in the U.S.A., but in a worse way. Lots of people, even with the ACA but mostly because of states that didn't accept the Medicaid expansion, don't have insurance and can't get health care and yes, they die. That's the current reality. And, before the ACA, insurance policies typically had annual and lifetime limits. Insurers also won't pay for many treatments they consider too expensive, and they found ways to kick expensive people off of their policies. The whole pre-existing conditions thing means that if you need insurance, they won't sell it to you. That's rationing, but of a particularly arbitrary and cruel kind.

Whether a very expensive treatment that doesn't do a whole lot of good should be offered to people ought to be a decision that is democratically accountable. That's what they have in Britain. These decisions are made by a body called the National Institute for Clinical and Health Excellence (called NICE) through a transparent, open process. If people object to a given outcome -- and occasionally they do, although the process is generally accepted and supported -- they can complain to their MP. Parliament oversees the National Health Service and NICE, and they can guide policy. Which you can't do with your insurance company.

Update: There was interest in how we can get to universal health care in the U.S., given the institutional obstacles to implementing a single payer system here. Scott Lemieux discusses the possibilities. He isn't totally explicit, but he seems to endorse a Swiss type system, which is sort of ACA on steroids. 

Update #2, Baby Killers: I believe somebody suggested that the case of Charlie Gard proves that single payer systems are evil. Actually it's largely irrelevant to this discussion. This is an English baby with a mitochondrial disorder who is more or less already dead but is being kept on life support. The hospital wanted to turn off his ventilator but the parents went to court to stop it. Meanwhile they were crowdfunding a couple of million dollars to fly him to the U.S. for an "experimental" (actually quack) treatment. The British court said no, the treatment is useless, and it is in the best interest of the baby to turn off the machinery. The European high court has now agreed. So this is comparable to Terry Schiavo and it has nothing to do with the National Health Service or what kind of insurance the family has. There is, however, tangential relevance: spread that $2 million around properly, and you could save a hundred children's lives -- say African kids dying of diarrheal disease, by getting clean water supply to their villages. Think about it.

Wednesday, June 28, 2017

Ideological Blinders

Here's Eduardo Porter in the NYT giving an overview of why universal coverage is worth it from the societal perspective. It shouldn't take wonkery to establish that, but apparently it does.

If you will look up at my banner, you will see that I have already known for some time that health care in the U.S. of A. is too expensive. You don't actually need to tell me that. Funny thing though -- it's a lot less expensive in all those communist totalitarian dungeons in Europe and the Great White North that provide universal coverage to everybody. In fact, the U.S. government spends as much on health care as the British government, but the British government covers everybody and they live longer! Same with Canada! Same with Norway! And the people don't feel oppressed. In fact Norway is the happiest country on earth. Yet it has -- wait for it -- socialized medicine. That's right, you pay your taxes, and the government pays for your health care. Done.

The hospitals don't post their prices, as far as I know, because there is a single payer and the single payer negotiates a single price. Which is lower than the price here. As a consumer of health care, you can't comparison shop they way you might for, say, thermal underwear because:

a) You don't know what you actually need, you need an expert, a doctor, to tell you.

b) You have no way of comparing quality.

c) You might have an urgent need that doesn't give you the luxury of comparing prices at 3 different hospitals. In fact, if you live in a rural area, there might only be 1 hospital. And you might be unconscious!

I must also point out that whether or not you can afford the health care you need is not only a function of whether you had the entrepreneurial spirit, talent and drive to become as rich as Ayn Rand; it is also a function of the pure luck of whether you are hit by a cosmic ray that causes a gene mutation that gives you cancer, or hit by a bus, or born with a genetic predisposition for diabetes, or any of an infinite number of possible misfortunes. The Free Market does not allocate these misfortunes by an invisible hand, rather shit happens.

So we need to at least start by acknowledging some simple, indisputable truths. That does not seem to be within the philosophy of some people.

Monday, June 26, 2017

Where I'm at

I'm in New Orleans for the Academy Health Annual Research Meeting. Academy Health is the weirdly named health services research society. I had a poster presentation this morning, now I'm just going to be hanging out and listening to people, mostly.

If anything exciting comes up I'll let you know. But for now I'll just say that health services research is especially wonky and boring and weird in this country because of our irrational, fragmented, wasteful, incoherent health care system. We have such an inefficient and ineffective system because of freedom, unlike those totalitarian dungeons in Europe where they spend half as much, get better results, and cover everybody. But that's slavery, which we won't allow to happen here.

Thursday, June 22, 2017

Is a fourth grade education a requirement to be a reporter?

Apparently not. An Ecuadorian couple claimed that they live without food or water, from the "universe's energy." Numerous newspapers and highly recognized web outlets published this as unquestioned fact, including Yahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro and many others. (This story appears on CNN, so admittedly there's a bit of a pot and kettle thing going on here.)

The excuse is that it was too hard to go to Ecuador to fact check. This is a really wicked problem. Many people do not believe the news in the corporate media, which means for example that they do not believe that Russia interfered in the recent U.S. election. It is hard to explain why they should believe that and not believe this. I knew that the Bush administration's claims about "weapons of mass destruction™" in Iraq were bullshit, and I argued for that extensively on this very blog; but the New York Times was enthusiastically promoting it.

So no, you can't believe everything you read in the paper or see on TV, but you need to apply critical thinking. Not everybody is good at that, unfortunately, and once they have built up a coherent alternative reality it is very, very hard to extract them from it. In order to have a  workable consensual reality, we need a smart, knowledgeable press corps with critical thinking skills that we can depend on. We do not have that. 

The result may well be catastrophe for human civilization.
ahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro - See more at:
Yahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro - See more at:
Yahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro - See more at:
the universe's energy

Tuesday, June 20, 2017

Weather Report

Here's the current forecast for Phoenix. This is pretty much applicable to the entire southwest.

Patchy blowing dust after 5pm. Mostly sunny and hot, with a high near 120. East southeast wind around 5 mph becoming calm.
Patchy blowing dust before 8pm. Mostly clear, with a low around 93. Breezy, with a northeast wind 5 to 15 mph becoming southeast in the evening. Winds could gust as high as 20 mph.
Sunny and hot, with a high near 116. East wind 5 to 10 mph becoming west in the afternoon.
Wednesday Night
Mostly clear, with a low around 89. Breezy, with a west wind 10 to 15 mph becoming light and variable after midnight.
Sunny and hot, with a high near 114. Breezy, with a southeast wind 5 to 10 mph becoming west 10 to 15 mph in the afternoon. Winds could gust as high as 20 mph.
Thursday Night
Mostly clear, with a low around 87. Breezy, with a west wind 10 to 15 mph becoming southeast 5 to 10 mph after midnight. Winds could gust as high as 20 mph.
Sunny and hot, with a high near 113. South southeast wind 5 to 10 mph becoming west in the afternoon.
Friday Night
Mostly clear, with a low around 88. West wind 5 to 10 mph becoming east southeast after midnight.
Sunny and hot, with a high near 115. Light and variable wind becoming west 5 to 10 mph in the afternoon.
Saturday Night
Mostly clear, with a low around 89. West wind 5 to 10 mph becoming southeast after midnight.
Sunny and hot, with a high near 114. Southeast wind 5 to 10 mph becoming west southwest in the afternoon.
Sunday Night
Mostly clear, with a low around 89. West wind 5 to 10 mph becoming southeast after midnight.
Mostly sunny and hot, with a high near 112. Southeast wind 5 to 10 mph becoming west southwest in the afternoon. 
The region would be uninhabitable without air conditioning. And it's just going to get worse.  Note those overnight lows barely dipping below 90. With the jet stream getting loopier, these sorts of blocking patterns will become more frequent. It's here folks. It's for real.

Friday, June 16, 2017

Breathing is Fundamental

The new BMJ has a lot to say about air pollution, starting with this editorial. Everything they say about the UK applies to the US, if not more so. Nowadays the most important source of exposure to polluted air in the industrialized countries is motor vehicle exhaust. Two components, ultrafine particles and oxides of nitrogen, cause the most damage to human health. Ultrafine particles are less than 2.5 microns in diameter -- microscopic, invisible, and odorless. They are in highest concentration near highways, which also happens to be where the nearby residents are likely to be low income people. A favorite place to site low income housing is next to highways.

As the BMJ editorial says, air pollution is the world's fourth leading cause of death. We had mass hysteria over the Ebola outbreak that killed fewer than 12,000 people in West Africa and precisely nobody in the United States; while almost nobody seems to care about air pollution to which about 40,000 annual deaths are attributable in the UK and something like 200,000 in the U.S. Now, this is a little bit misleading in that everybody dies. Attributing these deaths to air pollution means that they are accelerated, the person dies earlier than they would have if they hadn't been exposed. So the years of life lost is not as great as, say, motor vehicle crashes that affect many young people. Still, it's a way of looking at the problem that gives us a sense of its magnitude.

There is also disability associated with air pollution and it has deleterious effects on fetuses and children's development. As the linked essays states, "Although we are familiar with the effects of summer and winter pollution episodes on asthma, pneumonia in older people, strokes, and heart attacks, the wider effects of air pollution are less known. Chronic exposure impairs lung growth of the fetus and throughout childhood, increasing the risk of developing asthma and contributing to impaired cognition, type 2 diabetes, various cancers, and skin ageing and even serving as a risk factor for obesity."

Since the same exhaust pipes and smokestacks that spew out these toxins also spew CO2, which is changing the climate and destroying the oceans, we probably ought to do something about it. Instead, we are now furiously "de-regulating," because the Koch brothers want to continue to murder you for profit and the president works for them. 

Wednesday, June 14, 2017

Democracy in Action

This is actually quite bizarre. Mitch McConnell isn't just concealing the specifics of the Senate health care bill from the public and from Democrats; he's concealing it from his own members:

While there have been thrice-weekly meetings on the legislation to repeal and replace the 2010 health care law, those have mostly focused on broad policy. And while complete legislative text has not yet been drafted, leadership has begun initial conversations with the nonpartisan Congressional Budget Office on several proposals. But GOP senators say they do not know what those are. "While I haven't seen the language, I am hoping that it stays within the confines of what we've discussed within the caucus," Sen. Joni Ernst of Iowa told Roll Call.
Evidently they're committed to voting for it anyway, because they don't actually care what it does. Well, if it's anything like the House bill, one thing it will do is cause sick old people in nursing homes to be tossed out into the snow to die. The state of public discourse in this country is so debased that most voters literally do not know that the bulk of Medicaid spending goes to disabled and elderly people, and particularly for long-term care. And they have to spend all their money first and become destitute before it kicks in. This applies to lots of formerly middle class people whose savings don't outlast the ravages of age.

By the way, I am arguing public policy here. If you happen to notice an implication that conservatives are horrible people, that occurred to you on your own, I didn't say it.

Monday, June 05, 2017

Intelligence test

Republican congress returns to DC with repeal of the Affordable Care Act still on their agenda. They may not get it done, we'll see. Below please see a representation of the key accomplishment of the ACA. Can you spot the supersecret mysterious reason why Republicans don't like it?

Sunday, June 04, 2017

The Greatest Story Ever Told

The Energy Expansions of Evolution, by Olivia P. Judson, in Nature Ecology.

Do read it -- you'll enjoy it and you'll learn something. Then read my commentary.

This is the story, in part, of how Gaia got her cloak of green; and subsequent major developments. It also helps us to think about the so-called Fermi paradox -- why don't we see any evidence of extraterrestrial technological civilizations, when there's no particular reason to think we're unique or special? Finally, it's just a story of awesome grandeur that should make us focus very, very hard on overcoming the present crisis facing humanity. We are incredibly lucky to find ourselves on such an unlikely planet, let's not kick it away.

Life is believed to have appeared on earth some time before 3.7 billion years ago. But for a long time, it didn't amount to much. Extraterrestrial visitors to our we rock likely wouldn't even have noticed the microscopic  self-replicating polymers encased in oily bubbles, that were probably found only near deep-sea geothermal vents and possibly some other isolated locations. Our old idea of life originating in shallow, sun-lit tidal pools is probably wrong, because the earliest life couldn't exploit sunlight as an energy source. The sun warmed the rock and water, which radiated the heat back into space. In between, it didn't do anything.

About 3.7 billion years ago, organisms emerged that could exploit the energy of sunlight. But they didn't split CO2 and water to make hydrocarbons and emit oxygen. The early forms of photosynthesis were less efficient and required access to existing organic carbon. So one-celled organisms became more numerous, but no major transformation resulted. (They probably emitted methane, which helped warm the planet.)

Then, about 2.4 billion years ago, oxygen began to build up in the earth's atmosphere. This was because a group of organisms called cyanobacteria had evolved oxygenic photosynthesis. Actually they had  evolved a few hundred million years earlier; it took a while for the oxygen build up to get going. But cyanobacteria could now inhabit a far wider array of niches and create far greater biomass. A consequence was that it was now possible for other organisms to make a living just by eating others, but another unlikely event had to occur before that became a major industry.

Then an unlikely event occurred. An organism called an archaeon acquired a bacterium as an endosymbiont. The bacterium was very efficient at converting oxygen and nutrients into ATP, the cellular fuel. The resulting organism, called a eukaryotic cell, could grow big and complex, and they started making a living by engulfing and digesting smaller cells. Then, one of them acquired as a second endosymbiont a cyanobacterium, and the plant cell was born.

Because of the way they reproduce, eukaryotes could form complex multicellular organisms. We started to see big things that could move around and seek food. They even started eating each other. This happened around 575 million years ago. As Judson tells us:

[W]ith animals would soon come a powerful new force of nature: the acquisition of energy through the active hunting and eating of other life forms, especially, other animals. This would produce a radical shift that, within a mere 40 million years, transformed the Earth. Before this epoch, ecosystems were microbial. The advent of widespread flesh-eating launched the Phanerozoic, triggering an enormous increase in organism size85, a new tempo of macroevolutionary change86,87, new kinds of ecosystems86,​87,​88, and an increased impact of life on the fabric of the planet87.
The collective term for these critters is metazoa. A million years ago or so, one of the metazoans started to deliberately set fires in order to cook its food and perhaps ward off predators. Then it started to use fire to extract metals from ores, and shape them into highly effective tools. Then it discovered abundant fuel in the ground that could be used to power machinery -- you know the rest.

If you really think about it, this chain of events seems quite unlikely. Maybe it isn't really and it would happen sooner or later on any properly situated planet. Who really knows? But we shouldn't be surprised if it is very rare in the universe. We really need to start appreciating it.

Thursday, June 01, 2017

Bad Science

This is not really news -- there have been less rigorous critiques before -- but this research letter in NEJM has gotten people's attention. In 1980, Jane Porter and Hershel Jick of Boston University published a one paragraph letter in the Journal. They said they had reviewed the medical records of 11,882 hospitalized patients who received opioids, and found evidence of addiction in the files of only four of them.

Note that these are hospitalized people who presumably receive only a short-term course of opioids; and that there is no reason to think that subsequent addiction or opioid use disorder would wind up in the records of that particular hospital, where most of the people will very likely not be seen again once they make their way into the world.

Nevertheless, this single letter to the editor -- not peer reviewed, not even really research -- was cited 608 times. Most of the citations were used to support the proposition that prescribing opioids for chronic, long-term pain, was not dangerous. More than 80% of the citations did not even say that the patients were hospitalized. The authors of the new letter give some examples, e.g. "The medical evidence overwhelmingly indicates that properly administered opioid therapy rarely if ever results in 'accidental addiction' or 'opioid abuse.'" This assertion is based on the single citation of the 1980 letter.

What they don't tell us is that this all happened in the context of heavy promotion of the long-acting opioid OxyContin by Purdue Pharmaceuticals, which was spending lots of money to promulgate these claims. They turned out to be false, and the result is the epidemic we face today.

So yes, science can be corrupted, by money as in this case, and in other ways. I spend a lot of time on this blog complaining about it. The good news is that the truth comes out in the end, but sometimes it takes too long. I should also make it clear that some scientific findings are simply not in doubt. Climate science is not corrupted by money -- on the contrary, the big money has been trying to corrupt it, and failing, for decades. So don't draw the wrong conclusions. But we need to keep our critical thinking faculties sharp.

Update:  I should have noted that the state of Ohio is suing Purdue and four other drug companies for causing the opioid epidemic.

Tuesday, May 30, 2017

The Merchants of Death

It's been a while since I've written about tobacco, but the UN has provided a good occasion with the release of a new report on the eve of No Tobacco Day, which is tomorrow.

Smoking has been in long-term decline in the U.S., although tobacco addiction continues to afflict 15% of the adult population. So the psychopaths who get rich by murdering people have concentrated their efforts abroad -- specifically, they target poor and low-income people in low income countries.

The UN reports that tobacco now kills 7 million people every year. (It killed my father and my grandfather, by the way. In my father's case, starting with a stroke that put him on a decade-long course of dementia and decline.) To quote the press release, that's just for starters:

Tobacco use causes serious disability and significantly increases the risk of a number of additional diseases not immediately linked to it such as tuberculosis.  However, it is the wider economic and development impacts of tobacco that must be better understood.  With the tobacco industry doing all it can to increase tobacco consumption in low- and middle income countries, we must all take action to bring tobacco use to an end,” says Dr. Vera Luiza da Costa e Silva, Head of the Convention Secretariat.
Global estimates show that every year tobacco use costs the global economy USD 1.4 trillion, nearly 2 percent of global gross domestic product, but take into consideration only medical expenses and lost productive capacities. In addition to the health and economic consequences for individuals, families and nations, tobacco growing causes up to 5 percent of deforestation worldwide and results in biodiversity loss and soil degradation, as well as water and soil pollution from pesticide use.
“Effective tobacco control through the implementation of the WHO FCTC is essential for development. Saving lives, while growing economies, protecting the environment and providing resources for other sustainable development efforts is exactly the type of win-win action that can help countries achieve the Sustainable Development Goals,” says Magdy Martínez-Solimán, UN Assistant Secretary-General and Assistant Administrator and Director of UNDP’s Bureau for Policy and Programme Support.
We imprison people who are addicted to other drugs, while tobacco company executives make millions. They should be in prison.

Wednesday, May 24, 2017

No, Obamacare is not collapsing (wonky)

The Republicans are justifying their effort to strip millions of people of health insurance in order to fund tax cuts for rich people by claiming that the Affordable Care Act is "unsustainable" or, in the words of Donald of Orange, "collapsing."  The Urban Institute has done a thorough analysis of the state of the ACA. Since people nowadays have short attention spans, I'll give you the pistachio shell version.

First, some background. As you can read in my banner, the U.S. spends far more on health care (which I would prefer to call medical services but that's a lost cause) than any other affluent country. Yet they all cover everybody, and they are healthier! How can this be? We're less healthy in part because we don't cover everybody, but also because we have greater inequality, gun violence, and other social determinants of health are generally worse here.

What is more, prior to the ACA, the situation was getting steadily worse. The growth in what the Urban Institute calls National Health Expenditures (again, they mean medical services) exceeded growth in GDP by about 2.5% a year, in other words health care was gobbling up more and more  of the economy. At the same time, the number of uninsured people was growing.

The ACA put a stop to that. Obviously, it extended coverage to millions of people; yet the growth in National Health Expenditures actually slowed way down. This was partly a result of the recession and slow recovery, but also because of the ACA. The Act included Medicare payment reforms that reduced overutilization; the managed competition structure of the exchanges; and yes, reductions in Medicare payments to providers.

So what about the claims that premiums on the exchanges are skyrocketing? Actually in most of the country they are fairly stable or even declining. They are going up in places where insurers may have set premiums too low initially, and where there is no competition between insurers. They are really spiking in Arizona where state law allows for the sale of policies that aren't compliant with the ACA, which draws healthy people out of the risk pool. These problems could be fixed by regulations that pull in more competition and by getting more people to enroll. It's most difficult in rural areas. But the bottom line is that Obamacare premiums in most states are similar to, or even lower, than premiums for employer-provided insurance.

Finally, what about growth in Medicaid spending? Medicaid enrollment grew not only because of the Medicaid expansion under the ACA, but also because of the aging population, which means more people who are eligible because they are over 65, and more disabled people under 65. (The rate of disability rises with age well before age 65.) But Medicaid is the most efficient insurance there is! It costs less per enrollee than private insurance or Medicare, even though it's good, comprehensive insurance. And the cost per enrollee is growing more slowly.

So the Republicans want to drastically slash Medicaid. Who are we talking about here? Welfare queens? No, mostly elderly people who need long term care. What they want to do is kill your grandmother, to pay for tax cuts for rich people. That's because they are good Christians.

Sunday, May 21, 2017

You don't need a weatherman . . .

To know which way the wind blows.

I often maintain that I am reticent to prognosticate. However, the excitement over the "when does the residency end" pool is just too great for me to resist.

So no, I don't think he can survive till the mid-term. One major reason for my conclusion is that he is too ignorant, stupid, and crazy. Actually the stupid and crazy are weirdly intertwined, so it's often hard to know which is really operative in a given brain fart.

The second variable in my equation is the nature of Trumpism. There in fact is no such thing. He managed to sell himself as the champion of disaffected white racists who knew they were mad about something but weren't sure exactly what it was. The only concrete promises he made are either impossible to keep or already totally abandoned. (Yes, we're fine with cutting Medicare, Medicaid and Social Security. No, you aren't getting a $35 and hour job in a steel mill.) There is no organization, no movement, and no ideology behind the "movement" Trump claims, but only a bombastic, vulgar and bullying pose. Which means there is no real base and nobody to save him.

Third, it is by now obvious that the campaign was a tool of a hostile foreign power. Some degree of this claim is already publicly established. Whether Cheeto Benito was really involved, or is just a dupe, is not entirely clear. I think he kind of knew what was going on, or was at least exposed to the information, wasn't really an active participant, but didn't think it was any sort of a problem. Oh, we're getting help from my friend Vlad? That's nice.

Whether the Republicans in congress would ever find the cojones to impeach him I don't know, but a totally ineffective presidency will not be helpful in advancing their incredibly unpopular legislative agenda. So yes, I think they'll find a way to push him out. But the wreckage from this catastrophe will endure for decades.

Thursday, May 18, 2017

A couple of press releases about the so-called American Health Care Act

A lot of stuff hits my in-box that I should probably share. This from Avalere is a finding that Trumpcare would cut Medicaid funding for non-disabled children by $43 billion over 10 years. Children are the largest group covered by Medicaid, although disabled people and elderly people in long-term care account for the majority of actual spending. The whole thing is long and wonky but the bottom line is:

Avalere also examined the impact of per capita caps at the state-level, and found that all 50 states and the District of Columbia would lose Medicaid funding for traditional children. The reductions ranged from $59 million in North Dakota to $5.1 billion in Texas.
 Meanwhile, the Robert Wood Johnson Foundation finds that Dumpcare would cause a sharp increase in premiums for lower income older adults, who currently receive much more generous subsidies under the ACA.

"Age-related tax credits, while easy to understand, do not target subsidies most efficiently,” said Katherine Hempstead, senior adviser at the Robert Wood Johnson Foundation. “Tax credits that don’t reflect differences in ability to pay and geographical variation in the cost of health care will lead to significant loss of coverage, as suggested by the most recent CBO score of the AHCA.”
The reason the Republicans want to do this is to provide a huge tax cut to wealthy people. That is the only reason. In every other way, it makes things far worse for the American people, and particularly the people who voted for the current Resident. Don't let you representatives in congress lie to you about this.

Oh yeah, and this just in: the "high risk pools" which are supposed to cover people with expensive pre-existing conditions are underfunded by 3-5 times. In other words, the Republican solution is indeed "let people die."

"Traditional high-risk pools are symptoms of poorly regulated and inadequately subsidized insurance markets," said Katherine Hempstead, senior adviser at the Robert Wood Johnson Foundation. "To properly finance them is extremely expensive, which is why they tend to be underfunded, resulting in inadequate access to coverage for those who need health care the most."

Wednesday, May 17, 2017

Idiot wind

Blowin' every time you move your teeth.

Two stories from Daily Kos, one about the upcoming world tour, the other on Republican attempts to defend Cheeto Benito in the Comey affair.

It turns out that our Resident has too short an attention span, and is too ignorant, to participate in a standard NATO meeting, so heads of state are being encouraged to limit their speeches to 2 to 4 minutes. Also, it seems he doesn't understand the Israel-Palestine conflict, even though he's about to visit both countries.

Meanwhile, the new talking point about the White House scandals is that he is too stupid to know what he's doing, so you can't blame him.

This has long been obvious. He evidently really thought that he could replace the Affordable Care Act with some policy that would cover everybody, be cheaper than the status quo for consumers, and come with a big tax cut. Then he discovered, much to his surprise, that health care is complicated. (Actually, it isn't all that complicated. It costs money so if you want everybody to have it, wealthier and healthier people have to subsidize poorer and sicker people. That's called arithmetic.)

Here's Tony Schwartz, official biographer, who has spent many a long hour with the man:

Trump was equally clear with me that he didn’t value — nor even necessarily recognize — the qualities that tend to emerge as people grow more secure, such as empathy, generosity, reflectiveness, the capacity to delay gratification or, above all, a conscience, an inner sense of right and wrong. Trump simply didn’t traffic in emotions or interest in others. The life he lived was all transactional, all the time. Having never expanded his emotional, intellectual or moral universe, he has his story down, and he’s sticking to it.
A key part of that story is that facts are whatever Trump deems them to be on any given day. When he is challenged, he instinctively doubles down — even when what he has just said is demonstrably false. I saw that countless times, whether it was as trivial as exaggerating the number of floors at Trump Tower or as consequential as telling me that his casinos were performing well when they were actually going bankrupt. In the same way, Trump sees no contradiction at all in changing his story about why he fired Comey and then undermining the explanatory statements of his aides, or in any other lie he tells. His aim is never accuracy; it’s domination.
That doesn't work when you are president of the United States. I think there is a limit to how long the congressional Republicans can play this game; one way or another he'll be gone before the midterm election. We just have to hope that World War III doesn't come first.

Monday, May 15, 2017

Do not consume the flesh of tetrapods

Well, maybe birds are okay, it isn't entirely clear. The horrific harm to the planet from human meat consumption doesn't seem to be motivating very many people to stop it, but maybe the risk of death will.

With a total of more than 7.5 million person years of observation, further analyses by Etemadi and colleagues (doi:10.1136/bmj.j1957) now show an association between high intakes of red and processed meat and elevated total mortality and mortality from most major causes: cardiovascular disease, diabetes, cancer, and hepatic, renal, and respiratory diseases.
As the BMJ editorialist goes on to remind you of what you already know or should know -- even though you have been carefully avoiding thinking about it -- 30% of the earth's land surface is now pasture, or devoted to growing animal feed, which means:

Damage to planetary health includes depletion of aquifers15 (producing 1 kg of meat protein requires more than 110 000 L of water22); production of 37% of anthropogenic methane (with 23 times the global warming potential of CO2) and 65% of anthropogenic nitrous oxide (almost 300 times the potential of CO2); groundwater pollution; and 64% of anthropogenic ammonia emissions, which contribute significantly to acid rain and acidification of ecosystems.15 The combination of rainforest destruction for livestock and the production of greenhouse gases by livestock contributes more to climate change than do fossil fuels used for transport.15
There is also antibiotic resistance, recombinant influenza (from pig farms), and human hunger -- 95% of soybean is fed to animals. Contrary to common belief, our hunter-gatherer ancestors prior to the last ice age consumed much less meat than we do. So did people in Europe right up until the 20th Century. Our meat based diet is unprecedented in human history. So just stop it.

Wednesday, May 10, 2017

What we already know . . .

is more than enough. Here's another tl;dr for you, from the editor of Foreign Policy, David Rothkopf. I'll just give you a few pull quotes:

On a daily basis, Republicans watch their leader violate not only the traditions and standards of the high office he occupies, but through inaction they enable him to personally profit from the presidency, promote policies that benefit his cronies and his class to the detriment of the majority of the American people, and serially attack the principles on which the country was founded — from freedom of religion to the separation of powers. . .

America looks like a country it has never been. Trump is a laughingstock in the best of circumstances, a disgrace based on his known behavior to date, and a threat to global order and security with each action he takes. He discredits the office he holds and the government he leads. . . . 

Only if an independent prosecutor is appointed will America be seen as being the nation of laws it has long represented itself to be. Only if a thorough investigation takes place that includes an examination of Trump family ties in Russia (and elsewhere) and how these may have compromised the United States will the message be sent that America is the nation that has for so long been seen as an example to the world.
Well sure. But the problem is really worse than that. The institutional failures that brought us to this point are so massive, so pervasive, that there may not be any way out. The Republicans in congress still show no convincing signs of the slightest interest in the truth. They know that their policy agenda will be catastrophic for the people who voted for them, and they need to ram it through now. The continual degradation of political discourse and democratic institutions is in their long-term interest, because it was necessary for them to come to power and will have to grow more profound in order for them to keep it. I do not foresee a single patriot emerging from the Republicans in the senate. 

Monday, May 08, 2017


Andrew Bacevich has 24 questions about U.S. military and foreign policy that seem pretty obvious once he mentions them. Yet for some reason they never seem to occur to people -- if by people one means politicians and reporters. Do read the whole thing, but here are a couple of free samples to get you to click on the link.

2. American military supremacy: The United States military is undoubtedly the world’s finest.  It’s also far and away the most generously funded, with policymakers offering U.S. troops no shortage of opportunities to practice their craft.  So why doesn’t this great military ever win anything?  Or put another way, why in recent decades have those forces been unable to accomplish Washington’s stated wartime objectives?  Why has the now 15-year-old war on terror failed to result in even a single real success anywhere in the Greater Middle East?  Could it be that we’ve taken the wrong approach?  What should we be doing differently?
I'll give you 10 and 11 as a package deal:

10. Hyping terrorism: Each year terrorist attacks kill far fewer Americans than do auto accidents, drug overdoses, or even lightning strikes.  Yet in the allocation of government resources, preventing terrorist attacks takes precedence over preventing all three of the others combined. Why is that?
11. Deaths that matter and deaths that don’t: Why do terrorist attacks that kill a handful of Europeans command infinitely more American attention than do terrorist attacks that kill far larger numbers of Arabs? A terrorist attack that kills citizens of France or Belgium elicits from the United States heartfelt expressions of sympathy and solidarity.  A terrorist attack that kills Egyptians or Iraqis elicits shrugs.  Why the difference?  To what extent does race provide the answer to that question?
You get the idea. These are questions designed to pry open minds. Maybe they''ll work for you.

Friday, May 05, 2017

Should Senator Menendez resign?

Just to make sure you know I'm not a blind partisan -- which I hope has been obvious -- Sen. Menendez of New Jersey is unworthy of his office. First let me back up a second to point out that conservative complaints about people defrauding public benefits programs are always about welfare queens in Cadillacs. In fact the main offenders are physicians.

This particular schtickdreck, ophthalmologist Salomon Melden, has been convicted of defrauding Medicare of $190 million. You read that correctly. Along the way, he became BFF with Sen. Menendez, to whose campaigns he contributed $1 million (pocket change to him) and to whom he gave rides on his private jet. Mendendez's spokesman says this all very sad, but it has nothing to do with the Senator. Right.

In fact Menendez interceded in the dispute between Melgen and Medicare. Melgen billed $57m for single use vials of Lucentis, a treatment for wet macular degeneration. Each vial had more than a single dose, and Melgen would use one vial to treat as many as four patients, billing Medicare each time. Medicare later clawed back $8.9m in a case that reached the Supreme Court.

Menendez tried to justify Melgen’s billing, leading to an audience with the then health secretary Kathleen Sebelius. But she told the senator: “The government is not going to pay for the same vial of medicine twice.” Melgen would later agree to pay back another $32m that he billed for Lucentis.
Menendez faces a bribery trial in August. No, I don't want Chris Christie appointing his replacement, and it wouldn't be just since Christie is extremely unpopular and a special election would almost certainly be won by a Democrat. New Jersey law is confusing, but it appears that Christie would not have to call a special election and could appoint someone to serve until the 2018 regular senatorial election. Obviously Menendez intends to hang in there until and unless he is convicted. With the usual legal maneuvering that could get us pretty close to November 2018. But it feels wrong.

Thursday, May 04, 2017

A political death wish?

I can't outdo Jonathan Chait in eloquence or informativeness regarding the grotesque House bill purporting to repeal and "replace" the affordable care act. The only purpose of the legislation is to cut taxes for rich people.

Republican efforts to repeal Obamacare without a replacement failed. But they are attempting the next closest thing: a bill the party leadership will try to rush into law without the barest elements of due diligence. There have been no hearings, no studies, no Congressional Budget Office analysis; not even the text of a bill circulated the day before Thursday’s vote.
Other than that, the bill will leave 24 million people without insurance, raise premiums for people in their 50s and 60s, cause people who become seriously ill to lose insurance just when they need it most, and, as Chait puts it succinctly, "Millions of Americans will lose access to medical care, and tens of thousands of them will die, and Congress is eager to hasten these results without knowing them more precisely. Their haste and secrecy are a way of distancing the House Republicans from the immorality of their actions."

The fact is that people will notice this when it happens to them. Whither the Republicans in congress then?

Update: It seems Jamelle Bouie agrees with me. The political strategy behind this is incomprehensible.

Wednesday, April 26, 2017

Al Gore keeps getting fatter

Back in 2013 (remember the good old days?) Joe Romm wrote about the consequences to South Florida of sea level rise of 2 meters or a bit less. That was the consensus expectation at that time for the end of this century. Okay, you and I don't expect to be around that long, but with just a three foot rise, half of southern Florida will be under water. By the time we hit the six foot mark, Miami Beach will be completely gone, as will most of Miami. Past the turn of the century, sea level will continue to rise, ultimately by 70 feet if the Antarctic ice sheet largely vanishes -- which, at the rate we're going, it will.

Well, it looks like it's happening even faster. New projections say that 3 meters in sea level rise is possible by the turn of the century. That's about 10 feet. So Miami Beach will be gone long before then. By the way, so will Mar-a-Lago, which sits about 3 feet above present sea level. Whaddya know.

Saturday, April 22, 2017

This is amusing . . .

Someone (an anonymous coward) wrote this in a comment:

Imagine trying to explain to a bunch of liberal professors that in the history of the world, no other economic system has created more wealth for more people than capitalism. It just goes against their deeply held socialist and political beliefs.
It's fascinating what people think goes on in universities. In all of my travels through Tufts, Brandeis,  Boston University and Brown University as a graduate student and faculty member, I have never met a single liberal (or other) professor who does not know that economies that fall broadly into the classification of capitalist have become the wealthiest. As a matter of fact (funny thing here!) Karl Marx believed that capitalism was the most dynamic economic system for creating wealth. Nowadays, there are very few professors anywhere in the U.S. who think that Marx mostly had things right, but even if there are a few, they do not need to be convinced that "no other economic system has created more wealth than capitalism." All those liberal professors, with their briar pipes and leather patches on the elbows of their tweed jackets, believe it or not, actually know this.

However, economists -- and other people who think about the economy, such as sociologists, political scientists, and historians -- have various viewpoints about how best to organize and manage complex, modern economies. Capitalism, as I have suggested, is quite a broad concept and there are many capitalist economies in the world today, and in history, that have had differing characteristics. I should also add that the term "socialist" has come to be conflated with Soviet communism, which leads to much misunderstanding.

In Europe, the term "democratic socialism" as most people use it refers to advocacy for a program in which government assures certain standards of welfare within an entrepreneurial, market economy. As in the U.S., there is also some amount of government enterprise and economic activity -- perhaps our correspondent has noticed that someone maintains the roads, puts out fires, educates children and so on. People who call themselves socialists may want to see government do more to invest in human, physical, and intellectual capital than it does now. But socialism as it is commonly used today really refers to a form of capitalism.

Economists today -- even respectable conservative economists -- understand that markets are not forces of nature. They are social constructs. They require various forms of regulation and public infrastructure to function. The question is how best to structure and regulate them, not whether they ought to exist.

If you are interested in what liberal professors really think and argue about the economy, you might check out the blog of Bradford DeLong, a Berkeley (I know) professor, which is very active and has all sorts of interesting material pretty much daily. He's an economic historian, so there's a lot of emphasis on that, but there's plenty of other stuff as well.

Educate yourself, is always my advice.

Friday, April 21, 2017

Science and Politics

I would imagine I don't have to tell you that I think objections to the March for Science on the grounds that science shouldn't be "politicized" are absurd. Science is already politicized, which is exactly the point. Here's one take that's worth reading from Tim Requarth.

We eggheads get all scrambled trying to understand why people just won't listen when we 'splain the scientific truth to them. As Requarth explains, the problem isn't that they have a knowledge deficit that we can plug with our smart words. It's that they are motivated to believe by particular interests or loyalties. Scientists spend years getting their brains trained to apply certain standards of evidence and to change their conclusions when the evidence calls for it. But that makes us weird.

Here's Dave Levitan on the ways politicians deny and distort science. One pull quote I like:

Q. The “I’m not a scientist” line has become all-too-common, and it’s the basis of your book title. Why is this refrain bullshit in your view?

Dave Levitan: The basic reason is it's absurd for politicians to have to tell us what they're not an expert in. They don't say I'm not an economist. They don't say I don't have a degree in Middle Eastern studies or civil engineering, yet they're still perfectly willing to opine on these issues. So it's sort of a bizarre subset that they think it's a reasonable thing to say.

Here's why this is hard to talk about. We do claim to be experts in our fields, and we do make a privileged claim to truth. Cosmologists do not consider the age of the universe to be subject to debate (within a margin of error); biologists do not consider the fact of evolution and the antiquity of life (again, within a range) to be matters of opinion; climate scientists state that anthropogenic global warming is a fact, no longer a hypothesis. An if you disagree, you are just wrong. We know more than you do.

People don't like to hear that. However, as Levitan suggests, they commonly make exceptions. They respect the expertise of their physicians, plumbers and auto mechanics. On the other hand, I have to agree, all three categories of professional are capable of corruption, and of fudging or even lying in the service of a bigger paycheck. People might think that scientists are doing the same, to get grants or whatever.

Here's what's wrong with that. We aren't one auto mechanic trying to sell you a transmission rebuild that you don't really need. Science is a community of millions of investigators, graduate students, research assistants, and administrators. There is nothing that a scientist wants more than to prove that everybody else was wrong and get credit for a breakthrough. And there is no way that all those people are somehow going to successfully conspire to fool the entire world, and nobody is going to blow the whistle on them.

But it's also hard to explain to people that errors do happen -- in fact, we think that in some sense, everything we think we know is wrong because we can ultimately find a more precise answer. But the errors get fixed, the precision increases. Newton's theory of gravitation has been supplanted by Einstein's. In a sense Newton was "wrong," but he was a lot closer to the truth than Ptolemy. There is some question now about whether general relativity is exactly correct. Maybe physicists will improve on Einstein some day. They're trying really hard! But relativity works well enough for the Global Positioning System and robot probes to Jupiter, so you'd be a fool to deny it.

So I'm not sure what to do. Trying to explain stuff to people that they are motivated not to understand isn't going to get us very far, especially if they feel they are being talked down to or what they think is their own expertise isn't respected. Well sorry, but if you aren't an expert in physics and biology then no, you don't know as much as somebody who is. You should try to learn more if you are interested, but you need to approach that learning with a truly open mind. And if you can't be bothered, that's fine too, but then you need to stop thinking you know better.

* Mine is policy and practice related, so it's factual basis does inevitably get mixed up with values. But I find a lot of critics here don't succeed in separating out my factual assertions -- they end up arguing against facts because they are unwilling to state their value disagreements.

Tuesday, April 18, 2017

Too Long, you don't have to read . . .

. . . because I'll tell you, as a follow-up to my previous post. David Gorski has good things to say, as he does here, but if brevity is the soul of wit Dr. Gorski is not at all witty. (I think he already knows that but he can't help himself.)

Anyway, so-called "Right to Try" legislation has passed in 33 states, and an effort is underway to pass a federal version. This is one of those policy ideas that looks great on a bumper sticker and is impossible to refute in 30 words or less. Since the voting public gets turned off by wonkery, politicians who know better duck and cover when these proposals come along, so they pass.

The idea is that terminally ill people should have the right to try experimental treatments. Maybe they haven't been proven safe and effective yet, but they got through the first round of trials so it appears they might work, and what have you got to lose? You're dying! Why would the nanny state deprive people of a chance to extend their own lives if that's what they want to do?

Okay. First of all you need to know that the formal process for drug approval consists of three "phases" of trials. Phase one just consists of giving small and gradually escalating doses to a small number of patients, maybe 30, just to establish a level that doesn't produce acute toxicity. Passing this stage is all that is needed for the "right to try" to kick in.

But these drugs may not even have passed phase II trials. These are somewhat larger and last longer. They are underpowered to prove that a drug is safe and effective. They are intended to establish that the trends are in the right direction and that no obvious safety issues emerge in longer term use, so that the much larger investment in a Phase III trial can be justified. Only after successfully completing at least one Phase III trial can a drug be considered for approval.

It turns out that only 30% of drugs that enter Phase II trials even go on to Phase III, let alone win ultimate approval. So the first thing you need to know is that the likelihood that people could benefit from "right to try" is lower than you probably thought. Since the ostensible beneficiaries are already terminally ill, it's actually extremely low. Even safe and effective drugs are almost never miracle cures -- they might extend life for cancer patients if used early enough, but they almost never reverse advanced cancer. And yes, they can indeed harm people.

Terminal illness is actually a pretty loose concept. Doctors are very bad at predicting how long people have to live; it's very common to outlive a prognosis of 6 months to live, by a lot. So it's possible to significantly shorten the life of a person with a supposedly terminal illness. It's also possible to make them sicker. So gambling with an unproven treatment is not a no-cost bet.

And "right-to-try" legislation forbids insurance companies paying for these treatments, at their own insistence. That means the legislation affects only people with the means to pay out of pocket; and the drug companies can charge whatever they want, which is probably a lot. So you're handing over your kids' inheritance for something that is more likely to harm you than to help you.

Finally, the existence of "right-to-try" may deter people from participating in clinical trials in which they might get the placebo. Which means it will be harder for us ever to know for sure whether the stuff works. The proposed federal legislation is even worse because it actively forbids the FDA from taking adverse events in "right-to-try" patients into account in evaluating the treatment. The only point of that is to relieve the drug companies of all risk.

This is nothing but a cynical move to take money from desperate people and give it to drug companies, under cover of fake compassion and the usual nonsensical libertarian arguments. The FDA already has the authority to approve "compassionate use" of experimental medications on a case-by-case basis. That's how it should stay.

Thursday, April 13, 2017

Libertarian pharmacy policy

It's a famous story. Thalidomide is a sedative which was prescribed for morning sickness in pregnant women, starting in about 1960, in countries around the world. Not, however, in the U.S., because an official of the Food and Drug Administration named Frances Kelsey felt the application had insufficient data on safety, including whether the drug crosses the placenta. Turns out it does, and it can cause severe birth defects in which babies are born with flipper-like limbs.

At that time the FDA did not oversee clinical trials, and it pretty much took the drug companies' word for it about safety. As the linked article says:

The tragedy surrounding thalidomide and Kelsey’s wise refusal to approve the drug helped motivate profound changes in the FDA. By passing the Kefauver-Harris Drug Amendments Act in 1962, legislators tightened restrictions surrounding the surveillance and approval process for drugs to be sold in the U.S., requiring that manufacturers prove they are both safe and effective before they are marketed. Now, drug approval can take between eight and twelve years, involving animal testing and tightly regulated human clinical trials.

Drug companies don't necessarily like this. Some do, because they feel they depend on their reputation for safety, although as we have discussed here many times they frequently game the system by keeping unfavorable trial results hidden, and other unsavory practices. Recent efforts at reform have aimed at improving the system, by requiring registration of clinical trials and public availability of all results, among other reforms.

Comes now a reality TV star who wants to appoint as FDA commissioner a man with no research experience or academic background who is an investment adviser and member of pharmaceutical company boards. As Daniel Carpenter informs us in NEJM, "The Trump administration’s approach to the Food and Drug Administration (FDA) is guided by a libertarian belief in markets over science, and Gottlieb apparently shares this view." The idea is that bad drugs will be driven out of the market by consumer experience.

Of course, if your baby is born without arms it will be a bit too late for you, but that isn't the only problem with this philosophy. Lots of diseases and symptoms get better on their own. You can't necessarily tell whether the medication helped or not. Nor do you necessarily know that an adverse effect is attributable to the drug. You should read Carpenter's essay, but here's how he finishes:

The medical community and the Senate should greet this nomination with scrutiny. To this end, I propose some questions for Gottlieb. Perhaps the most important is one that can be answered only by his behavior: Will Gottlieb, if confirmed, listen more to FDA scientists or to his Trump administration superiors, corporate-board colleagues, and think-tank associates? At stake is not just the FDA, but the scientific regime of clinical pharmacology and the credibility of American therapeutics.

Questions for Scott Gottlieb.

  • • You will have to recuse yourself from decisions about certain companies’ products because of conflicts of interest. How many companies, and which ones?
  • • You have argued that there are “interim endpoints that can be used to more quickly gauge a medicine’s benefit.” Under your leadership, how would the agency commit to restricting the use of a drug or removing it from the market if later-stage evidence turns out to present a much weaker benefit profile?
  • • You have argued that the FDA has an “unreasonable hunger for statistical certainty.” How, then, do you explain the fact that the FDA approves new drugs and devices more quickly than any other regulatory agency? Do you see accelerated approval, compassionate use, and breakthrough designations as inadequate, and if so, why?

Wednesday, April 12, 2017

Saint Ronald

Iraq and Iran fought a horrific war from 1980 to 1988. Saddam Hussein was unquestionably the perpetrator. He repeatedly used chemical weapons against Iranian troops, then in 1988 he attacked the Kurdish village of Halabja, in northern Iraq, with mustard gas, killing thousands of civilians.

The president of the United States was conservative demi-God Ronald Reagan:

In 1983, President Reagan sent a special envoy to Baghdad. He was Donald Rumsfeld, and that visit resulted in the now famous picture of Rumsfeld shaking hands with Saddam Hussein. This was in December of 1983. This was at a time when the US was secretly aware that Iraq was using chemical weapons against the Iranians almost daily. There's evidence that the battlefield intelligence provided to Iraq helped the Iraqis better calibrate their gas attacks against the Iranians. Around this time, the administration concluded that Iraq's defeat in the war would be contrary to US interests in the Persian Gulf. The economic aid to Iraq started in 1983, and by the end of the war amounted to more than a billion dollars. . . .

Near the end of the war when Saddam Hussein used chemical weapons against his own citizens, the Kurds. We know a great deal about this now. At the time, the United States prevented a move in the UN to impose economic sanctions against Iraq, saying that the sanctions would be useless or counterproductive. So in effect, the United States defended Saddam Hussein's use of chemical weapons even as late as 1988, and this kind of a relationship continued through the Reagan administration and into the first President Bush administration until the very day that Iraq invaded Kuwait in early August 1990.
Just so you know.

Thursday, April 06, 2017

Gas Schmas

It's interesting that the Assad regime's nerve gas attack on a village in Idlib has generated sudden outrage, including from people who thought Assad was just peachy until yesterday such as the White House resident. We're having an emergency meeting of the UN Security Council and the U.S. is threatening to take unilateral action -- presumably meaning bombing some things and people -- if the UN doesn't act.

I agree that it is bad to attack civilians with poison gas. It is also bad to blow up 3,800 people using rockets and artillery shells, summarily execute tens of thousands in mass hangings, blow up hospitals and mosques, and starve people to death. The Assad regime did all of that, and more, before the nerve gas attack, which was apparently okay.

Look, I'm against all kinds of war. But to freak out over chemical weapons in this way is to imply that bombing, torturing and starving people is okay. This is an idiotic, meaningless distinction. We need to get over it.

Thursday, March 30, 2017

More simple proof that libertarianism is a crock

The right to ride a motorcycle on public highways without a helmet is a classic liberty claim. So what if it's risky, or the nanny state thinks it is? It's my right to make the choice -- it's my life.

As the linked essay by Busko, et al demonstrates, it is in fact risky, although opponents of helmet laws will often proffer alternative facts. In 1967, under the oppressive rule of Communist president Ronald Reagan, the Department of Transportation issued a program standard making helmets mandatory for motorcyclists, and congress voted to withhold federal highway funds from states that didn't enforce the guidelines. Soon, all but three states had helmet laws. There ensued a sharp decrease in motorcycle fatalities and head injuries.

All glory to Her Holiness Ayn Rand, freedom again prevailed in 1976, when people's choice president Gerald Ford signed legislation repealing the mandate. The following year, motorcycle-related fatalities increased by 23%. Free at last, thank God almighty we're free at last! By the way, just so you know, motorcycle fatalities are 14% of traffic deaths, even though motorcycles account for less than 1% of miles traveled; and motorcyclists are 27 times as likely to die in a crash as automobile occupants. Have fun!

Now maybe you think it's just fine if fools want to kill themselves and it's no business of the government to tell them not to. (I won't speculate about what freedoms you don't want people to have, I'll stipulate for the sake of argument that you aren't an outrageously blatant hypocrite. But do think about that.)

Here's the problem.  Two thirds of the cost of treatment for motorcycle-related injuries are borne by the public, mostly Medicaid. Bikers who are disabled cannot work, and usually become public charges. They, along with the dead ones, no longer pay taxes and their families are deprived of support, may also become public charges, and in any event their children and other loved ones will suffer. While your liberty to be a moron is at stake, so is my liberty not to have to pay for your foolishness.

This is the fundamental problem with libertarianism. All decisions involve tradeoffs between one person's liberty and another's. Your liberties don't stop with you.

Tuesday, March 28, 2017

Ratcheting up

Here's a long form piece in the Gray Lady about the history, present and likely future of Medicaid. I think you should read the whole thing but I'll give you a couple of pull outs.

Medicaid started small, as a minor add-on to Medicare. Originally, it was coupled to what was generally called "welfare," Aid to Families with Dependent Children, and hardly anybody noticed. But over the years, bit by bit, Democrats managed to expand its scope to include people with disabilities, elderly people in nursing homes, and low income families that were not on welfare. By now, the assumption that able-bodied adults should be able to afford health insurance is decisively false.

In fact, far from creating a culture of dependency and discouraging people from working, Medicaid makes work possible for people with children with disabilities and/or severe health care needs; or elderly relatives who need care. And it keeps people in the labor force who need health care to be able to work. So part of the cost is recouped in taxes. Anyway, people generally don't seem to understand that government spending isn't like household spending. Every dime spent on Medicaid is income for health care providers, pharmaceutical and medical device manufacturers, and related services; and profit for shareholders.

Medicaid pays for half of all childbirths in the U.S. A large majority of Americans either benefit from it themselves, or have friends and relatives who do. The Republicans' disastrous American Health Care Act would have taken Medicaid away from the population that benefited from the ACA expansion, and then gradually reduced funding over the years forcing the states to spend more of their own money, or drop beneficiaries and services. That turned out to be politically impossible.

The Republicans aren't going to take away Medicare or Social Security either. Once people got these benefits, and realized how much better they made life for everybody, eliminating them became politically impossible. He was obviously lying, as he always does, but when Ronald T. Dump was campaigning for president, he promised to protect Medicare, Medicaid and Social Security, and even to provide health care for all. He knew he needed to speak those lies in order to have a chance. Of course, in reality, he supported Paul Ryan's bill that would have destroyed Medicaid. But they failed. Now we can go about the business of continuing to expand Medicare and Medicaid, providing a public option on the ACA exchanges, and one day --

Universal, comprehensive, single payer national health care. That is our right.

Monday, March 27, 2017

Reclaiming Truth

When the Internet, and particularly the World Wide Web were young, many people had a utopian vision of a global free market of knowledge and ideas. Everyone could contribute to the total mass of truth, logic and debate, and we would ultimately enter an age of enlightenment.

Something like the opposite seems to have happened. Lots of people have gone through the looking glass into their own alternate realities. We have a "president" who lies so habitually that it's a surprise if he says anything that's true. Yet his true believers enthusiastically follow him into opposite world. We have the outlandish pizzagate, global climate change denial, birtherism  . . .

A partial explanation is this concept of blue lies. (Apparently that's supposed to be somewhere between white and black but I think it's horribly kludgy term.) The idea is that lies that don't hurt your own tribe or in-group, but are directed outward, strengthen group solidarity. It overlaps somewhat with confirmation bias, because deciding we were wrong about something doesn't only threaten our own ego, it may threaten our group identification.

I don't claim to be completely immune from these afflictions, but I think I'm less susceptible than most, because I am trained as a scientist and I make a conscious effort to practice critical thinking. I work hard all the time to evaluate evidence and not to come to firm conclusions that don't have strong support. And I do change my mind when confronted with good evidence that contradicts my previous beliefs. That is why, for example, I am now an atheist after once preparing for confirmation.

We are in desperate trouble if we can't get more people to think critically and start basing their beliefs on good evidence. The first thing people need to do is put more trust in the scientific enterprise. Yes there is scientific fraud and there are unreproducible findings. Scientific claims lie along a continuum of credibility. Don't believe the hype about a single clinical trial or a finding in laboratory rats -- it's a long way from initial observations and hypotheses to strong scientific consensus.

However, there is a great deal that we know. The universe is more than 13 billion years old. Life on earth is more than 3 billion years old and we got here by way of evolution. People are burning so much fossil fuel that we are putting carbon dioxide into the atmosphere at a rate which is causing the climate to warm, storms to become more violent, and the seas to rise. Cutting taxes on wealthy people does not make working people better off. And so on. We need to accept a common reality, or we are doomed.

Friday, March 24, 2017

The Art of the Fail

Orange Julius spent the campaign, the transition, and the first month of his occupancy of the office of president proclaiming that his great new health care plan would cover everybody, with better health care, at lower cost. Only a few fringe lunatics like Paul Krugman and Cervantes had the audacity to claim this was not possible.

After 8 years of screaming about death panels and socialism, and passing -- what was it, 36? -- bills to repeal the ACA, secure in the knowledge that president Obama would veto them, Republicans suddenly found themselves in the untenable position of actually being able to do what they had campaigned on for the past 8 years. What we learned from the exercise is that they do not in fact know anything about health care policy.

There is no such thing as a free market for health care, there are no free market solutions, and the only way to secure liberty for people is through a market that is structured and regulated by government. The best way is universal, comprehensive single payer national health care; but some countries manage to do it with kludgier solutions. Switzerland, for example, has Obamacare +. It has private insurance companies competing for customers, selling tightly regulated policies. They cut out the middleman with the individual mandate and subsidies, and instead give everybody a voucher to buy insurance, funded by taxes. Britain has real socialized medicine, with physicians as government employees. Canada's physicians are mostly private entrepreneurs, but their customers have insurance provided by the government.

There are a few ways to do it but the reality is:

  • Every affluent, capitalist democracy on earth spends less -- a lot less -- on health care than the U.S.
  • Every one of them covers 100% of their citizens and legal residents, with good, comprehensive insurance.
  • Their populations are healthier than ours and live longer.
  • Their people are more content with their health care systems than we are.
  • They all enjoy freedom or liberty or whatever you want to call it more than we do, because they don't live in perpetual fear of being wiped out by serious illness or dying on the street. 
This is reality. It is the truth.  There are no alternative facts.