Map of life expectancy at birth from Global Education Project.

Monday, July 24, 2017

Sorry for my absence . . .

The crisis we face is simultaneously so terrifying and so bizarre that I haven't been able to respond properly. Writing about the quotidian issues that interest me seems inadequate, while others who have a much larger audience are saying what I might say about our larger problems. But I've decided I'll keep on blogging, for my own sake if not for yours.

So, the Senate Majority Leader is insisting that his members vote tomorrow on a bill that will radically re-make 15% of the U.S. economy, without telling them anything about what's in it. Does that seem strange? Here's former Republican Senator David Durenberger, who thinks, yes that is rather odd:

This week, the Senate once again is set to vote on a health care bill that will radically change how people get coverage and who can afford their care. But unlike normal times, Senators, you are being asked to approve a Motion to Proceed to a vote:
  • Without knowing what the non-partisan Congressional Budget Office will say about the impact of major amendments and the final bill on coverage and premiums.
  • With full knowledge that the Senate parliamentarian, who rules on what can and can't be allowed in a budget bill, has said that the Senate must remove provisions intended to prevent an insurance market death spiral of sicker patients driving up costs.
  • Without knowing the details of the secret state Medicaid waivers the Trump administration insists will make the bill work.
  • Without knowing how your own state budget will be impacted.
  • Without knowing how you will defend the provisions you will only learn about later, including the payoffs and other things that will be sneaked into the bill at the last minute.
  • Without even knowing which bill you are being asked to vote on, what the defining amendments will be and how much time you will have when being pressed for a final vote you’ll be stuck with. Forever.
So why is McConnell doing this? For the past seven years, the Republican party has been obsessively demanding the repeal of the Affordable Care Act. They told their voters they were supposed to hate it, without explaining why they were supposed to hate it. (No, there aren't any death panels and the government didn't take over health care.) As it turns out, the only reason to hate it was that it was signed by a president with an African father. There actually isn't any way to repeal it without hurting tens of millions of people, but the Republican leadership is determined to do it anyway because if they don't, they'll face challenges in the next primary. So they have to keep what they are doing a secret for as long as they can.  Call your Senators' offices. Demand that they vote NO.

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.