Stayin' Alive

Yep, you're probably nuts

2012-01-31T09:01:00.000-05:00

My friend Gary G. discusses the upcoming, brand new, shiny DSM-V in the NYT. I believe I may have noted here once or twice that the psychiatric diagnoses aren't real entities. If a diagnostician makes the judgment that you have two from column A and three from column B of whatever subjectively rated symptoms are on the list, you get a disease label. But whether any two people with that label have the same disease, or any disease at all, is completely unknowable.

If Gary had more space, I expect he also would also have mentioned that applying disease labels to psychological traits or states is necessary in order to get insurance companies to pay for drugs, prescribers' time, and counselors. I will also extend his remarks (I'm sure he won't mind) to say that applying a disease framework has other important consequences.

Despite the complete lack of evidence (in fact plenty of evidence to the contrary) that psychiatric diseases are caused by "chemical imbalances" that are "corrected" by psychiatric medications, many people, including the psychiatrists who prescribe them, continue to believe that they are. And the disease framework is essential scaffolding to the deep cultural proclivity to respond to distress by finding a defect in the sufferer and trying to fix it by pumping in a chemical or some similar technical intervention. Perhaps we could look for the cause of suffering outside of the sufferer, and try to fix that; or decide that sometimes, it makes sense to suffer and that some good can come from it.

But no, all problems are medical.

Oh yeah -- Elsevier

2012-01-30T12:25:00.001-05:00

I have spewed my malice at the greedy scientific publishing company a few days ago. My wrath has its response: A petition and boycott (to whatever extent you can manage) of Elsevier. I'm totally down with it.

Once again my passion to tread the boards is awakened

2012-01-30T10:49:00.000-05:00

Believe it or not, I majored in theater (excuse me, theahtuh) in college and did quite a bit of acting in my youth. Got sidetracked by politics and science and whatnot but I do kind of miss it -- especially since I think I've figured it out and would be much better at it.

Anyway, I've been helping a colleague who is trying to train pharmacists to use Motivational Interviewing techniques to get people to take their pills. Actually it's more complicated than that but no sense getting into it. My mission is to role play a patient who is trying to control his blood pressure by losing weight and exercising and eating right and who believes he is succeeding based on his self-monitoring of his blood pressure at home.

Again, without going into further details or objections, this experience has driven home for me how very difficult it is for health care providers, of whatever particular stripe, to resist being Daddy. They typically see their job as getting us to do what they want us to do. That's okay, it's understandable, the whole point is they are experts and they're supposed to know what's good for us, otherwise why are they paid?

But there are major problems. If they don't actually know what's going on with us, they might just be wrong about what's good for us. However, if all they do is lecture us and threaten us with death if we don't carry out their orders, we are likely not to tell them what's actually going on because a) who wants to listen to that and b) nobody likes to be pushed around. In this case, the pharmacists saw it as their job to get me to take the pills, not to control my blood pressure. And they undermined my efforts to do it the natural way by insisting that hardly anybody could succeed at that so why don't I give up and take the pills? Having me not take the pills and keep losing weight would have been a defeat.

Now, admittedly, few people do succeed long term at weight loss and other behavioral risk modifications. That's why doctors give up very quickly and prescribe diabetes, hypertension, and cholesterol-lowering medications. On the other hand, half the people don't take the pills either. But they won't have an honest discussion with the doctor about that if all they'll get is flack.

Having played this part, I totally feel that way on behalf of my character. Supposedly the subjects have been trained and they're going to call me back and try again. I'll let you know how it goes.

I've never quite wanted to go there . . .

2012-01-27T13:22:00.001-05:00

But, it looks like we're there anyway so let's talk about it. You may have heard tell of this new paper in Psychological Science, the essential point of which is that lower IQ is associated with prejudice and conservative ideology. I've sorta kinda danced around this in discussing the prevalence of liberalism in academia and the canard about "liberal elites," but it isn't really a very good debate strategy to accuse your interlocutors of not being the brightest bulbs on the tree.

So let's cut to the chase. The association of lower cognitive ability with social conservatism, endorsement of intergroup inequality, and authoritarianism is well known. It is not by any means a new discovery. This is a fact: people with higher measured IQs and better grades in school are more likely to be liberal, tolerant of difference, and open to social change. The authors of this study cite plenty of research going back a decade or more.

What this study adds is actually fairly modest. Using large, longitudinal data sets, they found that British children with lower cognitive ability were more likely to grow up to be adults to be racists; and that this can be explained in large part by their having more endorsement of right-wing authoritarian ideology. A separate analysis of U.S. children had similar findings with regard to anti-homosexual prejudice. "In psychological terms, the relation between g [a hypothesized general intelligence] and prejudice may stem from the propensity of individuals with lower cognitive ability to endorse more right-wing conservative ideologies because such ideologies offer a psychological sense of stability and order."

Put more simply, confronting the real complexity of the world is taxing for many individuals. It is easier for them to contemplate the world in simplistic terms, while they are disturbed by diversity, disorder and change.

While I have no doubt of this, it does not seem to be a finding that can usefully be imported into political discourse. Telling people that they are stupid, or that their beliefs are a marker of limited intelligence, won't win you very many arguments. So I'm not sure what we can really do with this information.

Slow Apocalypse Now

2012-01-26T13:01:00.000-05:00

Our political system is determined to ignore the immense dangers of global climate change, but if James Murray and David King are right, they will have a harder time ignoring peak oil, because it's already here.

As they point out, in spite of the sharp jump in petroleum prices since 2005, global production has not increased. We're stuck at 75 million barrels a day globally, and the rate of production just doesn't respond to prices. Supply is totally inelastic, which is why the price has been so volatile. And forget about the Canadian tar sands and Brazilian offshore oil and all that saving us -- they can't even make up for the ongoing depletion of existing oil fields. To meet the The US Energy Information Administration projection of a 30% increase in production by 2030, they write:

If realistic declines of 5% per year continue, we would need new fields yielding more than 64 million barrels per day — roughly equivalent to today's total production. In our view, this is very unlikely to happen.

Non-conventional oil won't make up the difference. Production of oil derived from Canada's tar sands — sometimes called the 'oil junkie's last fix' — is expected to reach just 4.7 million barrels per day by 2035.

In fact, they don't think oil production will increase at all. It will likely decline. And the current bubble in natural gas production is almost over. Those fracking fields? They only last a few years.

The consequences for our civilization are, frankly, appalling. You might feel you can take some comfort that carbon emissions probably won't meet worse case scenarios, but they will continue, and the planet will continue to warm, even as struggles over petroleum resources grow more desperate and, quite likely, more violent. The reason is that we just aren't doing anything serious about this. The economy runs on fossil fuel and it can't grow or even keep going without it.

Taxes on billionaires, regulatory uncertainty, and Kenyan Muslim socialist health care aren't what's stopping us. It's peak oil.

Vocabulary

2012-01-25T15:03:00.000-05:00

Reporters routinely refer to Mitt Romney as a "venture capitalist" and to Bain Capital as a "venture capital firm." Neither is correct. Venture capitalists underwrite high risk new enterprises, usually with innovative technology or business models. Most of their bets don't pay off but they hope to reap spectacular payoffs from the few that do, in other words they're looking for the next Google or Amazon. Romney has never been a venture capitalist. He and his pals bought existing companies, usually old and tired ones, and made money however they could -- sometimes by chopping them up and selling off the pieces, sometimes by breaking their existing deals with workers and suppliers, sometimes by shutting down less profitable parts and buffing up the balance sheets. That's not venture capital.

A headline on the CNN web site a few days ago said that six NATO "peacekeepers" had been killed in a helicopter crash in Afghanistan. There are no NATO peacekeepers in Afghanistan. The NATO forces in Afghanistan are combatants.

The NPR newsreader yesterday morning, referring to the prosecution of ex-CIA agent John Kiriakou for leaking classified information, said that the Obama administration has cracked down particularly hard on "breaches of national security." They've cracked down hard on leaks of information, alright, but whether those constitute breaches of "national security" is a matter of opinion, at best. Kiriakou revealed information about the torture of Abu Zubaydah. Is our national security harmed because we know that?

Of course, Politifact will never label any of these statements as lies, or even half truths. They're just the ordinary perversion of discourse.

Common Sense

2012-01-24T14:00:00.000-05:00

You may feel that all taxation is theft, and that the nanny state should not be trying to influence us to do what's good for us, and that the corporations who sell us flavored sugar water are people. Okay, fine. But let's inject some facts into the discussion and see where that leads us.

As these folks point out in Health Affairs, Americans consume on average 45 gallons of sugary beverages every year. (That's soda, sugar sweetened tea, fruit punch (with minimal fruit, of course) "sports" drinks -- which are nothing of the sort -- all of that. It's all the same. Sugar, water and flavoring.) A 20 ounce drink contains 17 teaspoons of sugar. Those 45 gallons add up to 70,000 empty calories per person. So what, you say? Women who consume just one of these per day have been found to have an 83-98% increased risk of diabetes. It's partly because it makes them fat, and it's partly because it causes a glycemic spike. Put another way: that shit is poison.

So, these people figured out, based on estimates of how price would affect demand, that putting a one penny per ounce tax on these drinks nationwide would result in a reduction in the obesity rate of 1.5%, which means 867,000 fewer obese adults. It would reduce the incidence of diabetes over 10 years by 2.6%. This is even assuming that people would make up 40% of the calories by eating or drinking other stuff. If they didn't do that, we'd save $20 billion in medical costs. That would also mean 95,000 fewer cases of heart disease, 8,000 fewer strokes, and more than $17 billion in medical expenses averted.

Now, there are all sorts of caveats and reservations and what ifs behind all this, but the basic conclusion is clear. The price of these beverages does not reflect their cost to society -- the "externalities" of the transaction. We haven't even mentioned the cost to individuals of poor health, disability, and premature death. But those medical expenses are mostly paid by Medicare, which means you are paying.

So under which situation do you have more freedom? The situation where you can still choose not to poison yourself and save the extra 20 cents on a drink, while not having to pay as much for other people's health care not to mention your own? Or the situation we have now, where corporations are aggressively marketing poison to children and nobody is doing anything about it, but you have to pay the cost?

Freedom. It doesn't mean what Ron Paul thinks it means.

False consciousness

2012-01-23T13:41:00.000-05:00

It's not exactly a news flash that we're living in a new gilded age. As human civilization reaches ever greater heights of accumulated wealth and power, it concentrates in fewer and fewer hands. This essay in the NYT by Chrystia Freeland puts our present plight in the perspective of economic history. The technological revolution in the developed world eliminates many of the white collar and pink collar jobs that kept the middle class afloat despite de-industrialization. At the same time, the industrial revolution in the formerly poor countries, combined with the rise of global transportation and information infrastructure, has allowed many of the remaining jobs that would have been stuck here to move to those emerging economies.

While our working and professional classes have suffered from this double whammy, our politics has turned in precisely the wrong direction. Market forces have created the decline of the middle class and the grotesque inequality we now endure; yet the public has turned against the activist government it desperately needs to correct the problem. The wealthy don't care about "creating jobs," and certainly not for people in the United States. On the contrary, it is precisely their decisions over the past 30 years which are to blame.

I won't go into the whole argument here about the fiction of the Free Market, I've been there before. But assuming readers are with me on this -- that we need to tax the rich and invest the money so as to give our people, not to mention our planet, a future -- the question is why so many Americans of modest means have been convinced to vote against their own interests and to direct their rage and precisely the wrong targets.

Or I might better say, non-existent targets. Who or what are the "liberal elites"? Elites are not liberal. Mitt Romney, Newt Gingrich, and the Koch brothers are elites. They are also not liberal. But they are the very people who are screwing you.

College professors do tend to be more liberal than average -- I maintain that's because reality has a liberal bias -- and we are kind of elite in that it takes a lot of luck and effort to get one of these jobs and keep it, but believe me we a) aren't rich and b) aren't running things. All we do is blather. You can dislike my philosophy and values if you like, but I'm not causing you any problems and I certainly don't have any way of forcing you to think the way I do.

I don't know if doctors and lawyers and other professionals particularly tend to be liberal but again, they only way they get to be elites in any sense other than a bit of social status is if they become fabulously wealthy, and those examples, I'm pretty sure, are not generally liberal. (Viz. Bill Frist.)

Nevertheless, the right wing propaganda machine has managed to channel people's cultural resentments and insecurities against this mythical "establishment," and thereby insulate the real establishment from popular wrath. That Newt Gingrich, the ultimate Washington insider and wealthy grifter could become a populist champion is truly bizarre. But there you have it -- the real, shadowy establishment will spend a billion dollars this year on television advertising to drive that transparently ludicrous lie deep into the collective consciousness. They just might succeed.

The most corrupt Congress ever?

2012-01-20T11:49:00.000-05:00

I don't know for sure, Mark Twain famously said that "It could probably be shown by facts and figures that there is no distinctly native American criminal class except Congress." But this latest attempt to sell us out to our corporate overlords particularly frosts my pumpkin because, as long-time readers know, I'm obsessed with open access publishing.

Science, especially science that is funded by the taxpayers, as most basic medical research is, belongs to all humanity. But right now, subscriptions to scientific journals cost hundreds of dollars which means that people without library privileges at universities can't read them. Universities in the poor countries can't afford them which means nobody there can read them. Even here in the U.S., academic libraries -- including the library at my institution which is one of the wealthiest universities on earth -- are being forced to prune their subscriptions. And guess what? The biggest academic publishers are for-profit corporations.

So, in 2008, NIH made it mandatory that research it financed become free to access through the National Library of Medicine 12 months after publication. Remember -- you paid for it. So comes now the Research Works Act, heavily promoted by the Association of American Publishers -- the scholarly and professional publisher's lobby -- to reverse the policy and put government funded research back behind the paywall. Elsevier, the biggest academic publisher, and the AAP have spent $6.3 million lobbying over the past three years, writes Keith Epstein in the new BMJ. (Ironically, behind the paywall -- they make their research articles open access, but not their news and commentary. Yeah, I have a beef with that.) By the way, Elsevier is highly profitable -- their profit margin, even in the recession, is 36%. And the publishers have, of course, contributed heavily to the campaigns of the Act's sponsors, Darell Issa (natch, one of the worst tools in congress) and Carolyn Maloney of New York, who really ought to know better.

You know what to do -- let your Congresscritter know that you oppose the Research Works Act. The scientific knowledge that you pay for belongs to you.

They aren't in business for their health . . .

2012-01-18T13:36:00.000-05:00

. . . or yours, necessarily. Mike Mitka, in the new JAMA, discusses recent findings on what happens when physicians have a financial interest in medical imaging services. (I think you aren't allowed to read it because you are mere commoners, so I've linked to the extract.)

It is common for orthopedists to invest in MRI scanners and such, and it has long been observed based on insurance data (what we in the biz call "claims" data) that they tend to send more of their patients to have pictures taken of their insides when they get a piece of the action. However, the docs who do this claim that their patients just happen to be sicker or in more pain than other doctors' patients. I agree that doesn't seem highly plausible, but they say it anyway. Mitka reports on research done at Duke that finds a group of orthopedic surgeons who had an interest in MRI scanners had 86% more negative scans than a group with no such interest. Put another way, 42% of patients from the financial interest group had negative scans compared with 23% from the group without a financial interest.

A meta-analysis (pooling data from various studies) of claims data finds that physicians who do such "self-referral" do more than twice as many imaging tests as physicians who refer out to an independent radiologist, in all sorts of conditions.

I tell you all this because it is just one more way in which the mythical "free market" does not work in health care. It is what we call provider induced demand. Patients don't decide whether they need an MRI, doctors do. And if doctors are getting paid to do them, they'll do more of them, whether you really need it or not. And no, it wouldn't work to have you pay out of pocket because you have no idea whether you need an MRI or not and chances are, you wouldn't get one if you really did need it.

The solution is to make sure that doctors make these decisions untainted by financial interest, one way or the other. In other words, this just doesn't work as a market transaction. There are lots of other reasons why it doesn't but this one ought to be obvious even to Ron Paul (although I doubt that it is).

The most straightforward, best and smartest solution is universal, comprehensive, single payer national health care. That's what we need.

Here we go again

2012-01-17T11:07:00.000-05:00

Yet another prominent, highly productive "scientist" has been caught making it all up. This time it's Dipak Das, who was director of the Cardiovascular Research Center at UCONN. His research focused on resveratrol, which you have probably heard of -- it's a compound found in red wine that has been thought to have anti-aging properties, although unfortunately it's not looking so great lately. This doesn't help, so if you have been using the whole resveratrol thing to rationalize getting schlozzed every afternoon, you'll need another excuse.

Anyhow, if you're interested (and you probably aren't), you can look at the university's investigative report here. The whole thing is (literally) 60,000 pages long but it's summarized up front. Basically, the university concludes that he was photoshopping his western blots. (That's a method for detecting specific proteins in samples.) His entire program of research was evidently fraudulent. They're stripping him of tenure and firing him. Oh yeah, they're giving up $890,000 in NIH funding. And there are more than 100 published papers which are now either shown to be fraudulent or suspect.

This and other recent cases are not starving post-docs desperately trying to compete for the few available faculty spots. You could understand that even if it's sad and bad. (Plenty of Ph.D.s are driving cabs these days.) These are very senior people with fancy titles and big time salaries, and plenty of money with which to do honest science. The moral depravity of this conduct is just astonishing. It's not just stealing money, and obstructing scientific progress. It's harming patients, maybe even killing people; and it's potentially ruining the careers of the students, fellows, post-docs and junior faculty who worked under him, not to mention the more diffuse damage to the institution and everyone connected with it. The swath of destruction is just incredible. I simply cannot believe that anything like that could happen where I work but I'm sure that's what people thought in all the places where this has happened.

So, comes now the obvious question. Why? I honestly cannot tell you. Sure, when you set out on an investigation you may have hypotheses that you cherish, that if proven true will open up a road you really want to go down. But it's nonsensical to think of a rejected hypothesis as a failure. You hear that language all the time -- the experiment "failed" -- but that's completely wrong. The experiment showed what it showed. Ruling out a hypothesis is just as much a contribution to knowledge as confirming it. Okay, that didn't work, try something else.

One problem that probably does contribute is publication bias. For reasons which are not entirely clear to me, it's usually harder to get negative results published. That never made any sense, and it is starting to change, but it's still there. Another problem is that it may be harder to get the next round of funding if you can't build directly on previous work. Proposal reviewers like it if your work so far leads logically to the proposal they are seeing now, and that may be harder to argue if you've had negative results. However, in my own work at least, I've had no problem making lemonade out of my negative results, it just takes the imagination to see their implications.

So I can only conclude that this behavior must have started way back, before the guy made it big, and it's actually been the basis of his whole career. It came to be the thing to do, in for a dime, in for a dollar. Think Bernie Madoff. Anyway, it is just enraging.

Oh yeah, I forgot to mention the damage to the reputation of science itself. With one of the two major political parties in the U.S. running against science as an institution and a philosophy of knowledge, we really can't afford that.

All the roots grow deeper when it's dry

2012-01-16T10:06:00.000-05:00

I grew up in the Sixties -- which lasted from 1964 to 1974. To place myself more precisely, I graduated from high school in 1972, so I missed the SDS and the stolen FBI files and all that stuff at Swarthmore but still got swept up in enough momentum to spend my 20s and early 30s as a full time activist. Yeah, I was an ACORN organizer, among other $80 a week movement jobs. Poor people voting and demanding decent services in their neighborhoods and jobs and housing is not actually contrary to American values, by the way. Martin Luther King and the civil rights and poor people's movements were obviously a major inspiration for me.

In spite of the inexplicably popular presidency of Ronald Reagan, we still maintained that vision of a more just and humane future. It was just going to take a little longer than we had expected.

So looking back on the past 40 years this MLK day, what do I see? That the fundamental trajectory of the era would be plutocratic ascendancy, reactionary religious revival and resurgent militarism is astonishing, preposterous, nearly inexplicable. Here we are trying desperately to hold on to the basic social infrastructure forged over 50 years, from FDR to LBJ. Even voting rights and basic values of secularism are in retreat; and the hardest times and greatest economic inequality since the Great Depression have produced, not a mass movement for justice and equality, but an uprising of moderate income people on behalf of wealth and privilege. Our hard won scientific understanding of the biosphere and our relationship with it has been simply rejected, by political consensus, and we are destroying the very world that enables our existence to satisfy the immediate greed of the wealthiest.

The title of this post is a song by David Wilcox.

It looked so easy, we change the weather
We would turn this world ourselves, our world so small.
But slower rhythms still unheard of
Said that every blessed summer someday has to fall.

Prosperity will have its seasons
Even when it's here it's going by.
When it's gone we pretend we know the reasons,
And all the roots grow deeper when it's dry.

Sympathy for the devil

2012-01-14T09:38:00.000-05:00

Or rather, for some minor demons who might prefer to be cherubs but they are what they are. That would be our modern class of journalists.

Yes,it seems utterly ridiculous for the purported representative of the readership at the New York Times to be asking whether reporters should bother to point it out when politicians lie. But it compels us to ask how the culture of journalism could end up in a place where that actually seems problematic to its practitioners.

They must inhabit and transmit the political culture, and the fundamental problem of our age is that we have had a breakdown of epistemological consensus. To me, it is a fact that burning fossil fuel increases the atmospheric concentration of CO2 and makes the climate warmer; it is a fact that increased federal deficit spending counteracts recessions and that the stimulus package of 2009, however inadequate, saved millions of jobs; it is a fact that Barack Obama has never "apologized for the United States" and that he has not "slashed military spending" but increased it; it is a fact that taxes have been cut, not raised, under the Obama administration; the health care reform act is not a "government takeover" of health care. And so on.

But conservatives repeatedly, relentlessly, say otherwise. Just about everything they say is objectively false (except for normative statements such as "abortion is murder," which are another category). So, if you are a reporter covering the Romney campaign, for example, every story would have the headline "Mitt Romney lies about X, Y and Z." I believe that would be objective and balanced, but half the country would see it as advocacy journalism and confirmation that the New York Times has a liberal bias. The Times doesn't want to be perceived that way, so what can they do?

Satire is obsolete

2012-01-12T12:25:00.000-05:00

I caught this via Atrios. The New York Times "Public Editor" asks readers to weigh in on whether reporters should point out when politicians tell lies, instead of just transcribing the lies as they normally do.

Apparently he finds that an odd concept -- of course that isn't their job -- but he's been getting all this puzzling mail complaining that they don't do it, so please explain it to him.

I'll retire to Bedlam.

Where was I yesterday?

2012-01-12T11:04:00.000-05:00

Answer: I was transferring my driver's license and motor vehicle registration from Massachusetts to Connecticut. It turns out this is approximately like getting a top security clearance. Because my passport gives my name as Cervantes, Jr., and my birth certificate lacks the "Jr." it became a federal case. I was there for 3 1/2 hours before I finally managed to avoid getting sent to Gitmo. After all that I didn't feel like doing a blog post.

Anyhow, I owe the world one so here are two essays in the new JAMA that have something to do with each other, one on patients who request interventions their physicians believe are useless or potentially harmful, the other on court involvement in disputes about end-of-life care, focusing mostly on families who refuse to pull the plug when their doctors want to (the other category being disputes between family members, a la Terry Schiavo, but that's another kettle of fish).

What both of these discussions highlight is the evolving conception of the physician's ethical obligations and the physician-patient relationship. We have experienced a major shift in cultural expectations since I first studied medical sociology some 20 years ago. On the one hand, from Talcott Parons's conception of the "sick role," in which one of the obligations of the sick person was to obey "doctor's orders," we have moved to an ideal of "patient centered" medicine in which patients make informed choices on their own behalf. (I said that's the ideal -- it isn't so much the reality. I will have a good deal to say about that down the road.)

On the other hand, while we once presumed that the physician's sole ethical responsibility was to the individual patient, given the unsustainable growth in medical spending, physicians are increasingly expected to be stewards of society's, or at least the health plan's resources. They are expected, and in some cases paid, to limit medical spending. Now, that doesn't necessarily conflict with the individual patient's interest. In fact, it's generally maintained that the obligation is to maximize both efficiency and patient welfare, and that there is no paradox because right now, much medical intervention is not justified by the balance of risk and benefit.

This is certainly true, but as these essays indicate, conflict does often arise between the ideal of appropriately limited medicine and patient autonomy. Whether they are husbanding society's resources or interpreting patients' interests according to their own calculus, physicians may conclude that beneficence conflicts with patient choice. This puts them in an uncomfortable position. Many simply acquiesce, as by prescribing antibiotics for cold symptoms or ordering imaging or other tests that patients demand, but for which no benefit is expected.

While the authors of both pieces say that physicians should take the time to have better discussions of these issues with patients and families, they don't address the reasons why this doesn't happen. There are at least two. One, they don't get paid to do it. They get paid a standard (and inadequate) amount for an office visit, whether they take extra time for a discussion or not; and they get paid to do procedures -- which is exactly the wrong incentive. Second, they don't know how to do it. Physicians are taught the biological science of medicine, but the interpersonal art gets short shrift.

We can't solve this problem just by writing about it and exhortation. We need basic change in both the organizing and financing of medicine; and the culture of medical training and practice. That's like sweeping the beach. But we must do it.

News of the (Instructively) Weird

2012-01-10T13:55:00.000-05:00

I caught this little item from the AP today in the Paper of Record. I'd like to just paste the whole thing but in fear of the copyright police I'll just give the lede:

Disability groups in Greece expressed anger on Monday at a government decision to expand a list of state-recognized disability categories to include pedophiles, exhibitionists and kleptomaniacs.

No, it's not The Onion, this is evidently real. It seems that in Greece, pyromaniacs, compulsive gamblers, fetishists and sadomasochists are already eligible for disability. The main advocacy organization for people with disabilities is outraged because this will dilute the pool of money available for them.

I was a student of the late Irving Kenneth Zola, a founder of the sociological study of disability and of the Self Help Movement; and I consulted for and worked with the Massachusetts Coalition of People with Disabilities, among other relevant experiences. I strongly support the basic philosophy that there is much to be gained in both productivity and justice if society can adapt -- architecturally, culturally, economically -- to be more inclusive and empowering of everyone, rather than creating a physical and social environment that many people cannot navigate and that fails to value the abilities that everyone has. After all, in one way or another we are all disabled, and will grow more so -- it's a matter of degree and of kind. (For example, watching an NBA game, I know I'm disabled.)

But, as a fairly simple matter, I fail to see how pedophilia or kleptomania or pyromania are economically disabling conditions meriting a pension. Yes, if you've been convicted of a crime you will have difficulty getting a job, but that just raises the broader question of our policy toward ex-offenders. The diagnostic label seems irrelevant. All of these are behavioral proclivities, in other words, which our modern fashion is to categorize as "diseases," which is a matter of some philosophical contention but there you are.

However, if the Greek policy strikes you as bizarre, what about schizophrenia or severe bipolar disorder? These can qualify you for disability in the U.S., as could substance abuse disorders at one time (although that has been greatly restricted). That seems to make sense, to most people. And the vast majority certainly support accommodation and assistance for people who are blind, who cannot walk, who have cognitive limitations, and other more classic categories of disability. So where is the line, exactly?

I actually am not sure. This is a bit of puzzle.

Mitt Romney Endorses Obamacare!

2012-01-10T10:12:00.000-05:00

Actually, what the headlines are actually saying is Mitt Romney Likes to Fire People! Yes, he did say that, and people are taking it totally out of context in order to completely change the meaning, but that's fun to do! And Romney himself already said it was okay when he did it to Barack Obama! And it fits with a pre-existing narrative! So it's the thing to do.

Okay. But I'm going to put his remark in context for a really radical new approach to journalism, and take a look at what he actually said and its relationship to public policy! Now I know that's strange and unethical and would ruin my career if I were a real journalist, but just for kicks. . .

What Romney actually said is that he wants to be able to choose his health insurance plan and pick another one if he doesn't like the one he already has. What a coincidence. If he waits until 2014, when the Patient Protection and Affordable Care Act takes full effect -- unless, of course, he becomes president and gets it repealed, as he has promised to do -- he'll be able to go to his state insurance exchange. There he will easily see all the health insurance plans available to him, and their various features, and pick the one he likes! Then, if he isn't happy with his experience, he'll be free to change it! That's Obamacare! He's for it!

So, what a reporter might ask him, if the reporter was interested in public policy instead of the horse race and gotchas and gaffes, is why, since he actually likes the key feature of the bill, does he want to repeal it? But that would require the reporter to know something, and be able to think one move ahead. That's unreasonable.

BTW: When a person publishes in medical journals, a person often gets strange e-mails, like this one:

I can use telepathy, you can easy find me online, my telepathic brain scan is on [URL redacted] What I find most fascinating my telepathy is nearly identical what Schizophrenics experiences or it manifest itself exact like "Schneider's first-rank symptoms". I can exchange voice, video, smell, people can read my mind, stalk on me, people can move small move muscles on my body from distance up to few kilometer and much more and all messages from me are transmitted to big number of people so I am a Mental Radio. One of the most advanced things I can do is to talk brain to brain and it is very fascinating, works 100% all the time and it is really talk direct to brain.

And it goes on. Why am I not surprised that his telepathy is nearly identical to what schizophrenics experience? Anyway, I mention this because of the anniversary of the shootings in Tucson. The perpetrator is, from all publicly available information, as deranged as it is possible for someone to be and was very clearly inhabiting an alternate universe when he did his awful deed. So my question is, why is the DoJ so intent on prosecuting him? That just seems pointless.

Does anybody remember public policy?

2012-01-09T14:17:00.000-05:00

I am finding the TV news shows completely unwatchable because all they ever talk about is the ridiculous crap the Republican candidates for president are saying to and about each other.

And the way in which they are talking about said ridiculous crap is not to analyze why it is ridiculous (or not, if any of it happens to qualify as non-ridiculous), but rather simply to repeat it and speculate about how it will all resonate with Republican primary voters. Will Gingrich going negative on Romney backfire because people will think he isn't being nice? Will Ron Paul's failure to support bombing Iran make him seem soft? Is Romney parsing his support for the Massachusetts health care reform act and his abhorrence of the nearly identical federal act finely enough to convince people that there's no contradiction?

Which brings me to the real point of this post. Republicans know they're supposed to hate the Patient Protection and Affordable Care Act, but they don't know why they're supposed to hate it. Something to do with socialism and death panels, but exactly what it has to do with those things, no-one can say.

The stenographers recently reported that Rick Perry said he met a woman with cancer who implored him desperately that if the Affordable Care Act wasn't repealed soon, she'd be doomed. These news stories were correct -- Rick Perry did say that. And I'll even give the benefit of the doubt that the woman exists and said to Rick Perry what he says she said. However, this is not journalism, because what they did not bother to point out that there is no conceivable set of circumstances under which said woman could possibly be worse off with the Act than she would be without it. Yet there is no point in even asking what she might have been thinking and what the point was of Perry's anecdote.

If she doesn't already have insurance, and she does already have cancer, she will not be able to get insurance until 2014, when the Affordable Care Act takes effect. Then she will be able to buy affordable health insurance and she'll be taken care of! If she does have insurance, she will simply keep it, exactly as it is now. In fact, she might even be able to get a subsidy and pay less. Yet she's doomed, doomed! To what? Being forced to buy health insurance even though she'd prefer to die?

What is lacking so far is any clear explanation and defense of the Act by its chief exponent. I presume that as he shifts into re-election mode we'll hear more, but meanwhile the Democrats in congress need to be doing much more to tell people what's really in the Act and why it's not the work of Satan after all. No-one, it seems, is bothering to do that, ceding the floor to Rick Perry's deranged (imaginary?) interlocutor. Surely we can do better.

The un-winter

2012-01-07T09:38:00.000-05:00

After a very rough year -- from last winter's relentless, roof crushing snow, through two consecutive tropical storms that left Connecticut in the 19th Century for a week and went on to destroy the road network in Vermont, to a bizarre October snowstorm that wiped out the electric grid for the second time in two months, we figured we were headed for climate apocalypse. Then came the winter of 2011-2012. Or rather, it didn't.

Yeah, it gets below freezing at night but, except for a two day cold spell where we had basically normal January temperatures, it's been downright balmy in the afternoons. There has been no snow since October (sic), there is no snow on the ground, and there is rain in the forecast for next week. If you'll take a look at the snow cover map you'll see that there is basically none in the lower 48 except for the lake effect region of upper New York and northern New England. (Why would anyone choose to live in Buffalo?)

This may be convenient for homeowners and municipal budgets, but it is actually bad for agriculture. Snow insulates the soil and keeps it warm. It hides the voles from the hawks, and when it melts, it saturates the soil to get spring off to a good start. I'm sure the deer and turkeys are happy, but I'd like to slow down their depredations. (Yesterday, heading to work, I discovered the biggest flock of turkeys I have ever seen in my field. There may well have been 100 of them -- dozens, anyway.)

I'm sure winter will come eventually, but at this point, it will already be short. Does this have to do with global climate change? As with all weather, sorta kinda. This year, in sharp contrast to the past two, we've had a polar oscillation that has kept the arctic air bottled up. But it is fair to say that given this pattern, we're averaging a couple of degrees warmer than we otherwise would have. And when that's the difference between snow and rain, it means bare ground and that, in turn, means warmer temperatures on sunny afternoons.

The reason I go off on all this is that as you may recall, when we had all that snow in previous years, Rush Limbaugh and James Inhofe were chortling about how ridiculous the whole anthropogenic climate change thing was. Of course that was nonsense then -- the planet as a whole went right on warming, the arctic was very unusually warm,and the temperatures in the continental U.S. were normal. It's just that there was a lot of snow. But this year, with unusually warm weather in D.C. and everywhere else from Montana to North Dakota, I hear nothing from them.

So what's it going to take to get our rotten to the core political system to function and begin to respond to the greatest crisis humanity has faced since our unexplained population bottleneck 400,000 years ago? You tell me.

Hey Indeedy

2012-01-05T11:16:00.000-05:00

Lawyer Einer Elhauge, in NEJM, explains why the individual mandate in the Affordable Care Act is indeed constitutional. Go ahead and read it but in case you're too lazy, he throws the kitchen sink at this question.

Most broadly, once you engage in commerce, then Congress can regulate you. And it is not the case that Congress can only regulate commercial activity -- Congress can regulate any activity that affects commerce, as it did when it limit wheat growing for self-consumption back in the 30s. (Yep, it did that, and the Supreme Court said it had that power in 1942 and re-affirmed it in 2005.) In 1790, Congress required ship owners to provide medical insurance to sailors; and in 1798, it required sailors to buy it for themselves. (Really!) In 1792, Congress required every able bodied citizen to buy a firearm. Furthermore, the distinction between the mandate -- buy insurance or pay a tax penalty -- and an actual tax -- e.g. the Medicare payroll tax -- is purely semantic. It amounts to the same thing. And he goes on and on.

This is pretty much what every dispassionate observer says -- there is no constitutional problem with the Affordable Care Act. But as we have already seen, lower courts have been divided on the question and guess what? It's Republican judges, exclusively, who have ruled against the Act. So what do you think the highly partisan, highly politicized Supreme Court majority will do? Uphold the Constitution and more than two centuries of precedent, or make an indefensible and deeply harmful decision in order to serve its political objectives?

I'm not real hopeful about this. By the way, I don't like the kludgy individual mandate, as you well know. It is not the best public policy, but we know why it happened -- to get the insurance companies on board with the legislation, because it's corporate lobbyists who run Congress. However, Congress has the constitutional power to make bad law.

There would be no constitutional problem whatsoever with universal, comprehensive single payer national health care. We know that because Medicare has already been upheld. Just extend it to everyone. We're done.

More on the mythical center

2012-01-04T13:33:00.000-05:00

Continuing my recent musings, suppose I were to tell you that the midpoint between Honolulu and Nairobi is in Philippines Bay. (I believe it is, approximately.) Would that suggest a way to resolve the "controversy" over Barack Obama's birthplace?

Tom Englehardt, as usual, does a good job explicating the utter pointlessness of the recent adventures in Iraq and Afghanistan. (He's written the same essay about 97 times but you can never get too much of a good thing.) Now think about it. Who is the only prominent U.S. politician -- someone whose words are actually noticed by the hairhats on teevee, not a non-serious person such as Bernie Sanders -- who says this?

That would be the otherwise completely wacko Ron Paul. (And no, there are no other exceptions to Paul's wackoness. He says he wants to end the War on Drugs but he doesn't really mean it, he just wants to transfer it to state control. Ditto for all of his other libertarian pretensions. He's actually inimical to individual rights because he rejects the 14th amendment, which means that he does not believe that any of the rights enumerated in the Constitution need be respected by the states. So all of you Cheetoh-dusted Pepsi swillers can scrape the Ron Paul sticker off your parents' basement door.)

And this is the real problem with our politics. The Constitution, with its winner-take-all presidency and similarly modeled state governments, creates barren ground for third parties; while dissent on any one issue cannot bring down a government as in parliamentary systems. The result is that we perpetually have only two competing coalitions, and voters have only a choice between two complete menus, each of which is likely to contain 49% inedible swill.

I can't vote for Ron Paul's foreign policy, and the specific limitations he wants on the federal government, without getting abolishing the federal reserve and repealing the Civil Rights Act. And, now that I'm a citizen of Connecticut, I can't vote for Sen. Blumenthal's support for renewable energy investment without getting his gluttonous appetite for high tech military hardware. And you can no doubt think of your own conundrums.

There are many other big flaws in our Constitution -- not least the grossly unrepresentative Senate. The requirement that we treat it with religious reverence is preposterous. It really doesn't work very well. And we're seeing that right now, with a vengeance.

Parallel Universes

2012-01-02T13:58:00.000-05:00

Of late there has been no point, for me at least, in watching TV news or any of the political chat shows such Ed or Rachel that I might ordinarily use to dispose of an hour so of unwanted consciousness. All they ever talk about is how the Republican candidates are likely to fare in the Iowa precinct caucuses, about which I give not a FFOARD.

This would be a pointless waste of airtime in any case, because when it's over, it will be what it will be, and 50,000 hours of speculation about it ahead of time will be completely meaningless and forgotten. But in the specific case of January 3, 2012, it's also bizarre, because there is one absolute guarantee: whoever wins will be either delusional, a cynical psychopath, or a little bit of both. The candidates are competing ruthlessly to prove that they are the most radically wrong they can possibly be about everything. The prize goes to the most profound, consistent, and unabashed ignoramus or liar.

I am quite sure, however, that Republican primary voters have a similar opinion of me and the godlesshippiecommiefaggotfreaks I hang out with. That I am a professor at an Ivy League university is an even graver insult. That this situation bodes ill for the future of our country and our planet is obvious.

What does not follow, however, is the fetishized conclusion of many a pundit that the way forward lies somewhere in the "middle" between what in my view is insanity and reason. There is no middle. There is no planet in which anthropogenic global warming is simultaneously a scientific fact and a massive conspiracy to defraud the National Science Foundation and destroy capitalism. There is no universe in which drowning the federal government in the bathtub causes economic collapse by ending necessary investment in public goods such as economically essential infrastructure, education, public health and scientific research; and simultaneously unleashes the heretofore enchained forces of the Job Creators, forced to leave us wallowing in underemployment by regulatory uncertainty and a 15% marginal tax rate. There is no universe in which allowing gay people to marry simultaneously respects individual rights and promotes social harmony; and calls down the wrath of God upon us.

There is no "center." There is no way to split the baby, even if baby splitting were a good idea in principle. We have nothing to talk about when we don't exist in the same world of facts.

Donning the Turban

2011-12-30T08:29:00.000-05:00

Okay, I promised I'd get around to looking ahead to 2012 in the U.S. and I guess it's now or never. I've been procrastinating because it seems an unpleasing prospect.

I try to avoid the pundit's occupational hazard of presuming magical predictive powers. But I do hereby declare there is a 95% chance that our national conversation will completely miss the point on just about every important subject. That's the basis of my gloom. It's not that we can't make real progress toward solving our problems, it's that we won't even recognize them or talk about them. We'll talk about other problems that we don't have.

Everybody has noticed that we have extreme economic inequality in the U.S., the kind we used to deplore in what were once called Third World dictatorships. Some people on the right don't think this is a problem - those folks with the loot are the "job creators" and if you want a job, you want them to have even more money. Apparently there's a guy who only has $5 billion right now, and once he gets $6 billion, he'll give you a job. The way to achieve this is to stop making rich people pay taxes and to eliminate environmental, worker safety, food and other consumer safety regulations, and allow banks and investment management companies to steal from you.

On the other side we have people who want to increase marginal tax rates on income over a million dollars a year by 2%, and slash federal spending on stuff like health and other scientific research; technology investment; infrastructure maintenance, repair and construction; health care for the poor and elderly; education; and basic needs for poor children, in order to reduce the federal budget deficit in 2030. Oh yeah, meanwhile they want to give you a break by underfunding Social Security. Those are the liberals.

What we won't talk about is the absolutely critical need to invest everything we can right now, while we still have the resource and time, in a post-fossil fuel energy regime; to dismantle our globe girdling military empire; to prepare our young people for the demands of the knowledge-based economy; to save the ecosystem services of forest, grassland and ocean; and to destroy the power of the psychopathic, soulless corporations that are running the world right now. Because we won't even talk about any of the above . . .

We will continue our national decline. Our economy is controlled by people who have no loyalty to the United States or its citizens, who will extract whatever they can from the public infrastructure without paying for it, and send the proceeds wherever in the world they can loot at an even higher profit.

Our remaining national strength is squandered on a useless military behemoth designed to fight World War III on its own against the rest of the planet combined, but unable to defeat a few hundred men with homemade bombs. (Why we want to defeat them in the first place is a profound mystery.)

More and more of our children will go hungry. People who have worked and saved all their lives suddenly find themselves with their savings and careers destroyed, architects and engineers taking the jobs their teenage children would have had ten years ago. Higher education will be impossibly out of reach for more and more of those kids even as their elementary and secondary schools deteriorate.

And almost in the background, noticed only to be denied, the weather will grow more and more destructive, whole regions of the country will become essentially uninhabitable, agriculture will decline, mass extinctions of plants and animals will continue, and the ecology of the world ocean will collapse.

What do you expect the political campaigns next year will be all about?

Odd thoughts

2011-12-28T13:20:00.000-05:00

I came into work today, even though the university is closed, because of some pressing duties. Providence is a college town, so downtown seems to have been hit by a neutron bomb. I was the only person in the restaurant where I ate lunch. This week generally has a slow, subdued, and slightly lonely quality, a suspension of normal time.

In fact there is a great deal of consequence going on in nation and the world right now, but for whatever reason, the TV news focuses on a disconcerting polarity of heartwarming holiday tales and horrific tragedies. I don't expect there are more deadly house fires and auto crashes this time of year, but we certainly hear a lot more about them. One such was a fire in a Victorian mansion in the tony New York suburb of Stamford CT that killed three children and their grandparents.

It turns out that before retiring for the night, somebody removed the hot coals from the fireplace and put them out in the mudroom in a bag. This behavior is so daft that I thought there must be some deeper meaning to it. The proper place for hot coals, of course, is the fireplace. It is built to contain fires. Just leave them there.

Could it be that the Martha Stewartian perfection of the home seemed impaired by the thought of -- shudder -- ashes in the fireplace? Whatever the case, the fireplace was once as essential to the functionality of a house as indoor plumbing and electricity are today. I grew up in a farmhouse built in 1835, which had two big stone fireplaces on either side of a central chimney. The fireplace in what is today the dining room has a steel rod on a swivel built into one wall, which was used to hang cooking pots over the fire; and a dutch oven on the side. You put coals in the bottom half of the oven and baked in the top half. That room was both kitchen and dining room. The room that is today the kitchen was a transitional room, an unheated anteroom which undoubtedly held firewood and whatever tools and gear were needed to venture out of doors, and probably a well pump. (The only surviving well from those days is out of doors, so I'm not sure about that.) Beyond that, fully attached to the house, was a stable where animals spent the winter.

Imagine, not just the utility, but the meaning of that fireplace. In winter, obviously, it would have burned continually, as not just the focus but the essential source of family life. Here was the one truly warm place in winter, where food was prepared and consumed, water was heated for cleaning and bathing, illumination was available in the evening for reading, the bedwarmers were filled before everyone retired for the night, and everyone huddled together continually in the cold and lean months.

Nowadays, fireplaces are just toys -- dangerous toys, as it turns out, for people who don't understand them. I suppose they are more than toys. They retain symbolic power from the old days, as a symbol of the household community, which is still captured in the word hearth. We have sat around fires for a million years, so the appeal must be built into our nature. But it's just for old time's sake.

People are Stupid

2011-12-27T08:16:00.000-05:00

That was the opening line of a talk I heard by Isaac Asimov back when I was in college. He was predicting the kind of world we would have in the 21st Century and no, it wasn't about intelligent robots and space travel. It was about how we would have equality for women and limits on population and resource depletion and stuff because if we didn't, we'd be well and truly screwed.

He was right of course but unfortunately we're leaning more toward the latter alternative. "People are stupid" is also what I take to be the core message of this useful handbook on debunking BS from Skeptical Science. (It's a PDF but not huge.)

The basic problem we face in going up against the Limbaughs and Hannitys of this world and their devil-spawn in the Republican primary field is that you don't beat liars by trying to stuff people's heads with more and better facts. If your headline is "It's a myth that climate scientists don't agree about human-caused global warming," the phrase "climate scientists don't agree about human caused global warming" actually has a more powerful effect than the phrase "it's a myth." If you provide 7 arguments as to why you should believe that burning fossil fuels does cause global warming, that's too many, because people don't want to think that hard. If you tell them that the Vulgar Pigboy doesn't know what he's talking about, that's just going to make them hate you because they know and trust the Vulgar Pigboy. (VP=Rush, BTW.) Also, words - too hard to follow. Show them a picture.

And so on. It's well worth a read if a bit depressing, not least because the liars already know all of the above and are highly skilled in implementing it. But the authors hope that if real experts can learn these lessons, the truth can win on a more level field. I hope so.

It's been a decent interval . ..

2011-12-24T08:08:00.000-05:00

So I can repost this, which I wrote a few years back.

Christopher Hitchens, like Lyndon Larouche, used to present himself as a leftist. For many years he had a column in The Nation in which he vied with Alexander Cockburn for the “Most Acerbic” award (a magnificent scarlet inkwell filled with sulphuric acid). Things started to get a little weird in the 1990s when he developed an obsessive hatred of the Clintons. His reasons were partly respectable (triangulating, Dick-Morris-employing betrayers of the revolutionary vanguard) and partly insane (Bill’s serial sex crimes made Ted Bundy look like a boy scout; Whitewater [in which they were guilty, Guilty, GUILTY!) was the financial scandal of the century; Hillary not only murdered Vincent Foster, but conspired with her lesbian lover to seduce, rob and kill dozens of wealthy young fops whose mutilated bodies turned up in seedy alleys all over the DC metro area . .. well, maybe I made up that last one but it’s in the spirit of the thing.) Once he could no longer demonstrate his superiority to the bleating herd of liberal sheep by cheering on Ken Starr, the Iraq war became his next opportunity. His bellicose rantings were enough to drive Dick Cheney to the Quaker meetinghouse. He finally resigned from The Nation, claiming that the refusal of the magazine’s other writers and editors to fall to their knees in grateful acknowledgment of his intellectual and moral superiority on the question of war was proof of their bigotry and hatefulness. He wrote a final hissy fit essay in which he burned every bridge from London to Lompoc.

As some people have noticed, the Iraq war has not turned out the way it was supposed to. Some of the war’s portside chickenhawk supporters have since issued mealy mouthed retractions; others have concentrated on giving Chimpoleon and his pals unsolicited advice about how to do it better. Hitchens, however, has devoted himself to escalatingly vicious and absurd attacks on the war’s opponents. It’s not unusual for polemicists to turn against their own comrades but Hitchens’s case is particularly disgusting and bizarre. I think that chronic alcoholism destroyed brain cells in his cerebral cortex that normally inhibit irrational emotional responses in the limbic system. Something ticked him off around 1994, and the anger just fed into a positive feedback loop that slowly and steadily grows more intense. Eventually, he’ll lose one too many neurons and lapse into a vegetative state.

In his last couple of years, his public face was mostly about atheism, which is fine by me. But people shouldn't forget the rest of it. The guy went seriously off the rails.

Lies, damn lies, and un-lies

2011-12-23T12:41:00.000-05:00

I'm sure I don't have to draw readers' attention to the preposterous selection by the self-styled "fact checking" organization Politifact of the "Lie of the Year." This was the claim by many Democrats that Republicans voted to end Medicare, specifically when the House voted to endorse Paul Ryan's long-term fiscal austerity plan. As many a blogger has pointedout, this is not a lie, therefore it cannot be the Lie of the Year. And it wasn't even Democrats who first said it, it was Naftali Bendavid in, of all places, the Wall Street Journal.

PolitFact is defending itself, seeming almost proud to have provoked such a firestorm among liberal bloggers and analysts. They claim that conservatives get all their info from Fox News, while liberals get all their info from Rachel Maddow, so of course we're unable to see that our treasured memes are actually lies.

Well now. Rachel Maddow is highly opinionated, but unlike Fox News, she has respect for actual true facts. That aside, I don't get my information about health policy from Rachel Maddow or anyplace else on TV. I get it from scholarly journals because, unlike the clowns at PolitiFact, I happen to be a genuine, bona fide expert on the subject. I even have a fancy degree in it and everything and I am a professor at one of those pointy headed elitist fancy pants east coast universities.

So here's the genuine information, unfiltered by Rachel Maddow. Medicare is a government sponsored health care plan which covers everybody in the U.S. over 65, and some other folks as well. It's essentially a single payer plan -- Medicare pays for health care services, giving everyone who is eligible a bundle of guaranteed benefits with very low, subsidized premiums and copayments. (People who can't even afford those get extra help from Medicaid.) (Now, you can choose to have Medicare use the funds otherwise allocated to you to buy private insurance. It's called Medicare Advantage. But it turns out to be no advantage at all, because it actually costs the government more.)

That's Medicare. That's what the word means.

The Republicans would instead give you a voucher that you could use to buy private health insurance, but it would not be enough money for most elders to actually afford the same level of benefits they get from Medicare. And it would just get worse and worse over time. And it would be much less cost effective because those private insurance companies would spend a big chunk of the money on marketing, profits, executive salaries, and trying to find ways to stop older and sicker people from doing business with them. (There are plenty of sleazy ways to do that, even if it's supposedly illegal.)

That's not Medicare. It's something else.

There are many other implications of this difference that I won't go into here, mostly having to do with all the ways that Medicare could be even better and would be if the insurance, pharmaceutical and hospital industries didn't own Congress.

The people who run PolitiFact don't understand all that because they are not experts. They have been bamboozled in the name of "balance." They are useless.

2012

2011-12-21T14:08:00.000-05:00

I have a probably unfortunate habit of looking ahead to the new year here. As far as I can remember I have tended to be mostly right but I don't claim any special powers of prognostication. Anyway, in case anybody cares, here's what I'm worried about, which, alas, is plenty.

Starting in Europe and moving generally eastward:

Don't look now (and few people are) but Greece is already in the midst of a total economic collapse. I mean the kind where refugees flood into the rest of Europe, civil order disintegrates, food rioters break into warehouses, and the country's hard won democracy founders. Really. It's that bad. Greece has long had a dysfunctional economy and political culture, it's a special case and economically, it's basically a minor appendage to Europe, but Europe as a whole is heading into a less dramatic, but still painful recession and its leaders seem collectively insane. They're doing the best they can to make matters worse, while squabbling with each other like schoolchildren who didn't get lunch. In the past -- i.e., for the better part of 2,000 years -- their squabbles have tended to get extremely ugly. I'm not expecting World War III but I do know that the experiment of European unity is in peril. Meanwhile this can't be good for their biggest trading partner, that would be us.

Meanwhile, and again Americans long ago lost interest, but Iraq is skating perilously close to breaking into three pieces -- which will not happen peacefully. The brewing civil war in Syria just exacerbates sectarian tensions in Iraq, since the Shiite government is much more sympathetic to Assad than the Sunni Arabs who are increasingly feeling oppressed and have lost faith in Iraq's democracy. If Iraq does fall apart then it won't be a surprise to see Iranian and Saudi forces enter the country and then, hoo boy. Oh yeah, Iran is hurting big time from the sanctions regime and its own population is simmering while it's elites are increasingly fractious. There is no limit to the amount of shit that might hit the fan in the whole region, and uhh, oh yeah, oil.

Proceeding on to Pakistan, it is very likely that the pretense of civilian rule will dissolve. Pakistan's military and security services are riddled with highly ideological religio-nationalists who have shown themselves perfectly capable of creating irrational provocations to India and which have designs on wielding influence in Afghanistan through precisely the people who we now call the insurgency and who are blowing up our fine young soldiers. Oh yeah, they have a large nuclear arsenal.

I'm actually not particularly worried about North Korea but I don't like to see millions of people starve. China will probably see some economic difficulties but they'll muddle through.

Before I cross the Pacific, I'll just say that Africa, for all its troubles, is actually doing okay compared to previous decades. And, proceeding to Latin America, they're doing quite well these days. The big players, Argentina and Brazil, are actually doing jes' fine, with stable democracies, strong economies, and steady progress against their long standing problems. (Not so much the Amazon rain forest, however.)

Now, proceeding north from Brazil . ..

To be continued

Stuff

2011-12-20T10:15:00.001-05:00

I'm sorry for not posting for a few days. As I may have mentioned before, I'm selling my home of more than 20 years in Boston and finally have an imminent closing, so that's made me very busy, not least of all with getting the last of my stuff out of there. In the process of closing down the old homestead and moving, I think I've gotten rid of about 50% by volume of all the crap I had. As much as possible, I talked the thrift store into taking stuff or found a way to give it to someone directly, but the piles of trash are still immense.

How did this happen? How did I end up with mass quantities that I don't need, don't want, don't even want to store? And why, since I actually have more crap than I want, do family members insist on giving me yet more crap that I probably don't want every December 25? For years now I've been trying to break them of this habit. I make a contribution to charity -- specifically Oxfam but it could be any charity that gives to people who actually need it. I send everybody a card saying I did that. They all seem happy with that and not offended by it, but they still just have to give me something.

I asked my mother what she wants for Christmas and it turns out she's as sensible as I am -- she said she wants people to come to her house and take stuff away. But even the combined influence of the two of us can't overcome the deeply felt need to have a mass celebration of buying and having stuff, more and more stuff, more and more useless and superfluous stuff, every December.

With the planet in peril from overconsumption, and literally billions of people who actually could stand a little of your generosity, this makes no sense at all. Including if you are a Christian. Lillies of the field and all that, remember?

So let's win the war on Christmas. Enough stuff.

Update: Almost forgot to share Tom Lehrer's Christmas Carol. (Full lyrics here.) Final verses:

Relations, sparing no expense'll
Send some useless old utensil,
Or a matching pen and pencil.
"just the thing I need! how nice!"
It doesn't matter how sincere it
Is, nor how heartfelt the spirit,
Sentiment will not endear it,
What's important is the price.

Hark the herald tribune sings,
Advertising wondrous things.
God rest ye merry, merchants,
May you make the yuletide pay.
Angels we have heard on high
Tell us to go out and buy!

So let the raucous sleigh bells jingle,
Hail our dear old friend kris kringle,
Driving his reindeer across the sky.
Don't stand underneath when they fly by.

End of an era

2011-12-16T13:32:00.002-05:00

As those of you who have checked out the sidebar know, I have for many years contributed to the blog Iraq Today. When I first started, it was called Today in Iraq (it's a long story why we had to change) and it was one of the most heavily trafficked blogs on foreign affairs. We were linked from Atrios and Riverbend and I regularly got e-mails from everyone from Iraqi officials to U.S. army publicists to reporters and pundits complaining about stuff I had said about them. We also heard from military, military spouses and war widows, usually to thank us but sometimes to accuse us of disloyalty because they didn't think it was possible to simultaneously support the troops and oppose the war.

As Iraq faded from the consciousness of Americans, so did the attention people paid to Today in Iraq. But we kept it going, because we felt it still ought to matter to English speaking readers, particularly Americans (although we have had contributors from Europe and readers from all over the world).

Today, the U.S. handed over its last remaining base to Iraqi control and ended its military operations in the country. I still care as much as ever about the long-suffering people of Iraq, and I still believe that the United States bears some responsibility for their future, but our armed forces will no longer be involved. That's what we've been advocating for from the beginning. I am very glad about it, although I look to the future in Iraq with great concern. There's not much good news these days so I'll take what I can get.

So this marks a bit of a change in my life as well. The blog will become Today in Afghanistan, and I will henceforth spend more time studying that country and its troubles. I am not abandoning Iraq -- I'll check in on it every Sunday -- but it will be a weaker tie, something like a friend who has moved out of town, I suppose. Anyway, I hope you'll look in on Today in Afghanistan as Whisker and I develop the site and our style of aggregating and commenting on the news from that country.

This should be obvious . . .

2011-12-15T13:34:00.001-05:00

But it still bears repeating because it doesn't seem to live comfortably in the political consciousness. A major point of Lawrence Lessig's new book is that as important as the corrupting influence of money in politics is to determining the outcome of the political process, it's just as important in determining what we talk about. One of his big examples is the major focus by Congress this past winter on whether banks could charge transaction fees on debit cards -- while spending less time on unemployment, global warming, health care, the various wars in which the country was engaged, or the deficit. I would add that we wouldn't be talking about further cutting wealthy people's taxes either, and we never would have cut them in the first place back in 2002.

I would also add that while all of the above is important, the simple fact is, as Tom Murphy explains so even a historian can understand it, civilization as we know it is doomed. It will not be possible to produce enough liquid fuel to sustain the existing society, let alone the growth anticipated in India, China and elsewhere, within a very short time. Even if we want to do shale oil and tar sands and coal liquification, climate be damned, those resources cannot be developed fast enough. and we face the Energy Trap no matter what we do -- it takes energy to develop renewables or unconventional oil sources or infrastructure that promotes conservation such as mass transit. No matter what direction you want to go, we need to use the fossil fuels we have no in order to get there, but if we don't start investing now, if not yesterday, those fuels will get more and more expensive and will be in too short supply to support that development.

So we need to deal with this immediately, radically, and with full commitment. But all we're talking about is financial deregulation, repealing the Affordable Care Act, and lower taxes for billionaires. See you 'round the apocalypse.

Ooooghh: Tangential but, Revealed: huge increase in executive pay for America's top bosses. From The Guardian:

Exclusive survey shows America's CEOs enjoyed pay hikes of up to 40% last year – with one chief executive earning $145m. Chief executive pay has roared back after two years of stagnation and decline. America's top bosses enjoyed pay hikes of between 27 and 40% last year, according to the largest survey of US CEO pay. The dramatic bounceback comes as the latest government figures show wages for the majority of Americans are failing to keep up with inflation.

The guy who scooped up $145 million? That would be John Hammergren of McKesson, which is a pharmaceutical and medical supply distributor. Now you know why we can't have single payer national health care.

Hillbilly heroin

2011-12-14T10:20:00.000-05:00

I've kinda changed my mind -- kinda -- about opioid prescribing. I used to lean toward emphasizing that doctors are often too reluctant to prescribe opioid analgesics, that they can be a tremendous boon to people in chronic pain, and that a) short term use for pain relief seldom leads to addiction and b) if people who need them basically forever technically become addicted, who cares? Biologically, maintenance on a steady level of opioids can have some side effects, such as constipation, but people can function perfectly well and in fact better than they would in chronic pain.

But, as CDC reports here, we have a large and growing problem with prescription opioid abuse and the ultimate manifestation, that we can't look away from, is death by overdose. It turns out that by 2008, death from prescription drug overdose rivaled death from motor vehicle crashes, the leading cause of unintentional injury death (36,450 vs. 39,973). Since motor vehicle deaths are declining (due to socialist fascist nanny state regulations such as air bags, antilock brakes, etc.), and prescription opioid ODs are increasing, those lines will probably cross soon if they haven't already. (By the way, it's non-Hispanic whites who are at by far the highest risk. African Americans and Hispanics have much lower rates of death from misuse of opioid pain relievers. They're much more likely to end up in jail for drug offenses, but they commit them less often. This is another national scandal.)

However, I've only kinda changed my mind. As the linked report also states, it has been found that 3% of physicians account for 64% of opioid prescriptions, and there's plenty of evidence that most of this epidemic is linked to "Pill Mills" -- unscrupulous operations that hand out scrips without appropriate medical indication, evaluation, or follow up. Astonishingly, the governor of Florida, the state with the highest concentration of these operations, long resisted efforts to crack down. It's still likely that many physicians are withholding relief from some people who ought to get it. But we need to stop these criminals.

Buzzy

2011-12-13T10:49:00.000-05:00

Bissinger that is. He was Buzzy in prep school but he's dropped the diminuitive now that he's all grown up and he's just Buzz. (I was acquainted with him but didn't know him well. His real given name is Harry BTW.) He's very well known for documenting the culture of sports in the U.S. so Tweetie* has been having him on the program regularly to discuss the Jerry Sandusky/Penn State child rape mess.

Buzz is the veritable paradigm of repressed fury. I keep expecting his hair to burst into flames. And I can understand why, it's how a lot of people feel. Mr. Sandusky is of course entitled to due process, but the disposition of his personal case is not really the point in all this. Whatever the underlying facts, many people in positions of authority, with weighty responsibilities, failed to act appropriately and adequately when presented with credible information that required that they do whatever was necessary to be sure that children were safe. We already know this.

So what do I have to add to the maelstrom of mostly fairly obvious reflections? Just that if we view the sexual exploitation of children as a public health problem, we can think about etiology and epidemiology instead of just foaming at the mouth and having our hair burst into flames. Yes, moral condemnation and righteous fury are essential to reinforcing the social consensus, not to mention they're human nature, and I don't begrudge indulgence in them, but it's even more useful to understand why this happens and how it manages to continue.

I'm not a psychologist so I can't offer any particular expertise in the psychological roots of sexual attraction to children or sexually exploitative behavior. I do know that there is a risk of people who are abused as children becoming abusive themselves, although most of course react in the opposite way and become fiercely angry toward people who do this. (Joshua Komisarjevsky, who was recently sentenced to death in Connecticut, put on a defense based on his having been repeatedly sexually assaulted as a child. It didn't convince the jury but there is undoubtedly something to it.) While many children are resilient and overcome such traumas, others do not and, in one way or another, the consequences ripple out through society and down through time, unto generations. So preventing one incident can have multiplying benefits, while failure is a catastrophe that can extend far beyond a single child.

What is uniquely interesting in the Penn State case, as in the case of the Catholic church, is the sociological dimension. Whatever the reason that many priests and (allegedly) Jerry Sandusky engaged in this behavior, powerful cultural forces protected them. The church is an insular society unto itself, whose transcendent value is institutional aggrandizement. Football is a more complicated phenomenon. Yes, there are little subsocieties of team and university, but they are much more fluid and diffuse than the church -- people come and go, with the exception of Joe Paterno Penn State football and Pennsylvania State University are not life-long commitments, nor are they singular identities. And this scandal leaked well beyond those two institutions to include not only the campus police but also the police of the town of State College, apparently (from what we are starting to hear) a high school principal, charity executives and social workers, and probably many other people who were overawed by the charisma of the football team. Unlike the bishops, they weren't part of the institution they were protecting.

So this story also has resonance pertaining to the role of athletes and sports in our society. Athletes have an expectation of entitlement, which they get from the same wellspring as coach Sandusky. Sports are a public spectacle that stands for accomplishment and virtue. That symbolism largely obscures the reality that what you are watching and passionately adoring is just a bunch of ordinary, flawed people who happen to be skilled at a fundamentally useless enterprise. Many sports, including football, in fact institutionalize and glorify violence, which seems a wrong thing to worship, although I grant it is fun and exciting. (I wrestled in college -- there's nothing more essentially violent than that. The whole object is to physically force your will on the opponent.) But we are strongly committed to the illusion and just can't stand to shatter it.

*For those who are not aware of all Internet traditions, that's Chris Matthews. Some people feel he resembles the cartoon canary. (I tawt I taw a puddy tat!)

Another window into the libertarian paradise

2011-12-09T10:59:00.000-05:00

Jerry Avorn, in NEJM (and mad props to them for continuing to make their public affairs material open access) looks back on the thalidomide disaster. The younguns may not know about this (I'm often befuddled when I discover you whippersnappers don't now what Vietnam was all about) so to review briefly:

Fifty years ago, drug manufacturers didn't have to prove that their products were safe and effective in order to sell and market them. Sen. Estes Kefauver introduced legislation to require that they do so but, as Avorn tells us, "Kefauver was accused of trying to unnecessarily expand the power of government, threatening the viability of the pharmaceutical industry, and inserting Washington bureaucrats between patients and their doctors, limiting the freedom of both. His legislation seemed doomed."

Damn right and Don't Tread on Me! I will give up my unstudied drugs when they pry my cold dead fingers from the pillbox.

So it turns out that at about the same time, there was a mysterious epidemic in Europe and Australia of babies being born with their hands and feet attached directly to their torsos. It took some freelancing investigators to figure out that their mothers had been prescribed a drug, marketed heavily for morning sickness (not to mention insomnia, premature ejaculation, menopause, alcoholism, depression . ..) sold under various brand names. Because it was called by so many different names in so many different places, it took a while to get it off the market. In the end, more than 10,000 children were born with devastating birth defects.

But . . .

The drug, generically called thalidomide, was never sold in the U.S. because an FDA employee named Frances Kelsey took it upon herself to conclude that evidence of safety was inadequate. Once this story came out, Kefauver's legislation passed. We still have a long way to go -- the deficiencies in the FDA approval process, even today, have been well-covered here. But, after a few more disasters in recent years, we've made some progress.

Listen up Dr. Paul. The drug companies, if left to their own devices, would be selling us arsenic. Liberty does not emerge from the mist if you take away government. On the contrary, we will find ourselves at the mercy of ruthless, greedy, powerful forces that we have no way to resist or even understand. Freedom is a product of democratic government, there is no other way for it to exist.

In case anybody wanted to know what I do for a living . . .

2011-12-07T13:41:00.000-05:00

Right now I have funding to do a study called Explanatory Models if Illness and Decision Heuristics in HIV Care. What I'm doing in this first stage is having semi-structured interviews (that means essentially a guided conversation, no check boxes or fill in the blanks) with people living with HIV, in which I ask them what their concept is of HIV, HIV disease, and treatments, and how they work, and why they should or should not take the pills, etc. This is actually very important because over the years I've found that a lot of people have theories about all of the above which don't correspond to the theories their doctors have, and which cause them not to take the pills regularly, which their doctors think is a really bad idea.

I am also involved in a project where we are training physicians in a counseling technique called Motivational Interviewing, to see if they can't learn how to do a better of job of counseling their patients about taking pills and other health related behaviors. Mostly, before we train them, they just scold people, which doesn't work.

I have also developed methods for coding and analyzing clinical communication. We're steadily publishing papers from that work, and they tend to prove what I said in the preceding paragraph.

I'm curious, in case anybody wants to play this game. How would you explain what a virus is? How does it reproduce? How does it make people sick? That's in general. How about HIV? (Hint: It's different from most viruses. Do you know why?) Why can't your body get rid of it, as it does with a cold or flu? How do the drugs work to control it? Why do you have to take them right on schedule?

If you don't have a clue, that's okay too. If you think your idea is probably wrong or dumb, don't worry about it -- believe me, most people don't know the technical details, it's just interesting how folks think about it given that they weren't biology majors.

Knowledge is good?

2011-12-06T09:55:00.000-05:00

You may not have caught the news about a Dutch virologist who has cooked up a genetically engineered strain of influenza which he claims could kill half of humanity. I was tempted to say that how I feel about that depends on which half, but on second thought, I'd call that a bad idea regardless.

What he has done, as I understand it, is to marry the lethal properties of the H5N1 avian flu virus that has been bouncing around Eurasia for a while with properties that make the virus highly contagious among humans. He's just guessing what the consequences would be of letting it loose but nobody wants to find out for sure.

He thinks he should publish his work so that people who want to come up with defenses against bioterrorism will have a heads up. Others think that would be not smart. I tend to agree with Others. We already grok the concept, which is about all you need to know to think about preparing. Publishing the details would make it easier for the Gingrich administration to actually make the stuff to use in the War on Terror, as any smart historian would do.

All that said, there are too many people in the world, and there will be way too many more in due course. For the past 20 or 30 years, it has been unfashionable for environmentalists to focus on the size of the human population. This is because it was considered more philosophically correct to worry about the other factor, the net negative environmental impact per person. Supposedly if we could make that low enough it would be cool for there to be zillions of people.

I say pish tosh. Of course we need to live more sustainably, but you have to multiply the burden each of represents by how many of us there are to get to the total problem and frankly, we're heading in the wrong direction on the first factor. The International Family Planning Conference just concluded, to exactly zero interest on the part of the U.S. corporate media. The truly bizarre, ugly and evil religious fanaticism that says giving people, notably women, control over their own reproduction is immoral must be relegated to the netherworld of ideas where racism and fascism now reside.

Otherwise, we will indeed experience a major reduction in the human population, the hard way.

This really frosts my pumpkin

2011-12-05T14:58:00.000-05:00

Let there be no doubt whatsoever. Donald Berwick was, is and ever more shalt be the best person to head CMS. He is the most qualified, has the best ideas, and has the strongest resume to be in charge of making medical care in this country better for patients, cheaper for payers -- including the taxpayers -- and more satisfying for providers. If you don't understand why, or what the man is all about, please do read the linked article.

As Harris Meyer writes, "[I]t's difficult to find any health care stakeholder groups that express anything less than glowing praise for Dr. Berwick's performance at CMS." But, president Obama had to put him in office through a recess appointment because the brain dead Republicans in the Senate threatened to filibuster his confirmation on account a he's a soshulist and he's for rashuning. Then they wrote a letter saying don't even come back and try for a regular appointment.

Evil idiots. That's all they are. Why anyone would even contemplate voting for Republicans candidates, who all hate America, I cannot begin to fathom.

Yeah, it's personal

2011-12-02T14:34:00.000-05:00

An important twist in my long and winding road was when I resigned from my job at United Way in Boston, at the same time as my friend Wayne S. Wright, and for basically the same reasons. (No reason to go into that, it's a good organization that's worthy of your support.) I set up a consulting practice to work my way through grad school, and Wayne became the first real executive director of the Multicultural AIDS Coalition in Boston. (I say "real" because there was a caretaker exec appointed to guide the nascent organization while they sought a permanent incumbent.) Wayne started referring me to various community based organizations involved with HIV prevention and services.

At that time -- the early 1990s -- there was no effective treatment. HIV meant you eventually get AIDS and then you die, in a very unpleasant way. And that was happening to a whole lot of people including, ultimately, Wayne. Unfortunately, I can't find his full obituary free on line but but this is the lede and it should give you a pretty good idea of what a great fellow he was. I was luckier than many people, I just had a few friends die of AIDS, but I've talked with a lot of gay men for whom the plague years meant one funeral after another and the destruction of entire communities -- very much like the Black Death and other plagues must have been before real medical science came along.

Effective treatment for HIV became available just the year after he died, and everything changed. One of the most prominent AIDS-related service organizations, the Hospice at Mission Hill, closed because HIV was no longer about death. In its place rose the Boston Living Center, where people go to help themselves do just what the name says. As a matter of fact, people who were in the hospice, weighing 80 pounds and ready to die the next day, rose from their beds and their bodies astonishingly reconstituted and they suddenly had to contemplate the sorrows of life as vigorous and healthy young men once more. We call this the Lazarus syndrome.

So when I read that the Global Fund to Fight AIDS, Tuberculosis and Malaria is too broke to make any new grants for three years my blood boils. We've given up on the goal of treating everybody because, well, we just can't afford it apparently. There's something else we need to do, although I'm not clear what that is. And in case you hadn't heard, people who get treatment and have suppressed viral loads are not infectious. That means, if we treat everybody, we can end AIDS forever. We can eradicate it. But it just isn't worth it.

Hey indeedy

2011-12-01T12:57:00.000-05:00

James Michael Crotty discusses the Republicans' elevation of ignorance and stupidity to a virtue. His basic explanation is that it's the only way to preserve ideological purity, especially when your ideology is entirely counterfactual. Fair enough, but obviously it begs the question.

Why are so many Americans passionately committed to absurd beliefs? Obviously they are continually exposed to propaganda, but wealthy greedheads and religious con artists have the same opportunities in Europe Canada that they do here -- Fox News is huge in the UK BTW -- but the worship of idiocy is much less common elsewhere. If I tried to engage a Republican primary voter in a discussion about health care policy, it would be a big mistake for me to mention that I have a Ph.D. in the subject, and study it for a living. It's even worse -- I do that at an Ivy League university and I got the doctorate from Brandeis which is, well, you know. (It rhymes with U.) All that means is that I have no standing on the subject whatsoever, because I'm a pointy headed elitist.

I don't know the full explanation, but one hypothesis is that it's partly because higher education in this country is a luxury good largely reserved for the children of the affluent. The reason Scott Brown can attack Elizabeth Warren for her association with Harvard is that Harvard really is a marker of privilege. It makes sense intuitively for non-privileged people to doubt that people associated with ruling class institutions are actually on their side.

(So how do you explain George W. Bush? Well, he did go to Harvard (and Yale) but it obviously didn't rub off on him. He had a phony cowboy accent, had difficulty producing syntactically well formed sentences, and didn't believe in that ungodly science baloney.)

It would help a lot if higher education was free to everyone, with admission based on credible measures of people's prior preparation and potential to make good use of their education, and no account whatsoever for their parentage or financial resources. That would do a lot, I think, to change the cultural dynamic.

On another note, I should say something about World AIDS Day, even though it's basically a marketing tactic like National Pickle Week. It's still an occasion to reflect and take stock. I'll probably get around to it a day late.

Ezekiel Emanuel is half right . . .

2011-11-30T14:50:00.000-05:00

But there's a bit more to the story. He points out that 10% of the population account for almost two thirds of health care costs. As a matter of fact, based on data from the Medical Expenditure Panel Survey, the top 5% account for more than half, while the bottom 50% account for 5%. (Abstract only for the unwashed. This data is 10 years old but it had been stable since 1970. It doesn't change.)

Dr. Zeke wants to make the care of those people more efficient using bundled payment instead of fee for service and care coordination strategies. That's fine, it might save a few percent and make those folks lives a little better. I'll let his argument about that speak for itself if you care to read the article.

But here are some points he doesn't make.

First, you've heard all that yackety yack from conservatives about how if we had to pay for more of our health care out of pocket, people would choose more wisely and we'd save a lot of money. Pish tosh. These people are soaking up tens of thousands of dollars a year in health care expenditures because it's free to them so why not go for it. They are seriously, chronically sick. They have kidney failure, heart failure, complications of diabetes, cancer, or serious congenital diseases. (No, they aren't all elderly, only about half.) People don't get kidney dialysis because they feel like it, they do it as the only available alternative to dying. Making the rest of the people pay fifty bucks to see the doctor isn't going to save diddly, but it is going to make them more likely to end up in the top 5% where they are costing real money.

Second, suppose we could save a few percent on the care of these really sick people. That's better than nothing but it's still only a dent -- and the underlying trend of increasing costs would continue, it would just be set back a couple of years. The problem would not be solved.

Unlike Ron Paul, I am not in favor of abandoning the unfortunate. So what do I propose? A few things that Emanuel doesn't want to talk about because of politics.

First, we need to do cost effectiveness analysis and we need to set limits. This doesn't actually have to hurt people. Do people really benefit if they get three or four weeks of extra life semi-conscious in a hospital bed? I don't think so. That's not where most of this money is going, but it's a chunk. A bigger chunk can come from just knowing what's most effective and setting up enforceable guidelines that prohibit wasting money on useless or harmful treatments, such as angioplasty for people who haven't had heart attacks. People are making money off of this stuff, which is why Republicans won't let us even study the question. Well screw 'em.

Second, we need to invest much more in public health. We'd have a lot fewer people in this situation if we really made the effort to combat obesity, tobacco addiction, and other preventable harms. There's net social benefit from reducing particulate pollution from motor vehicle exhaust, chemical contamination of food (such as BPA from can liners), mercury in fish, food-borne infectious diseases. And a lot more. But that requires spending government money to improve the social and physical environment, and regulating powerful industries. Again, Republicans think that infringes on the freedom of rich people to rob us. See final comment above.

Third, we need to use the buying power of Medicare, Medicaid and public employee health care -- and eventually the buying power of the single payer program that will cover everyone -- to reduce the incomes of overpaid medical specialists and the price of drugs and medical devices. And no, using the promise of obscene profits as the basic mechanism to finance drug development is grossly inefficient. Yes, that costs a lot of money, but it would be cheaper for the government to finance the research directly, which would direct the research in the most socially beneficial, as opposed to the most profitable direction; and then buy the drugs cheaply, instead of having most of the money go to profits, executive salaries, and marketing costs.

In other words, we can't get there by mucking around on the edges. We need fundamental reform.

We need universal, comprehensive, single payer national health care. Nothing else. That's what we need.

Dr. Murray

2011-11-29T13:56:00.000-05:00

I don't think I need to provide a link, but in case you haven't heard, Dr. Conrad Murray, physician to the late Michael Jackson, has been sentenced to four years in prison for involuntary manslaughter. I certainly agree that his actions were egregious, and that in principle, bad doctoring can constitute criminal behavior. But, it's always a tough call and it seems like a very slippery slope.

The essence of the problem is that physicians have a license to take actions that are ordinarily crimes. They can slice us open, remove body parts, and feed or inject us with powerful toxins that might just end up killing us. If we aren't conscious or competent, they don't even need our permission. Although you may have heard that it's a principle of medical ethics dating to Hippocrates to "First, do no harm," it is not. Just about anything substantial that doctors do carries a risk of harm -- all medical interventions represent a tradeoff of uncertain benefits, predictable harms, and serious risks. Not only that, but a medical degree does not confer superpowers -- doctors make mistakes, even the best of them, and those mistakes harm people.

I once made the acquaintance of Gilbert "Punky" Mudge, the cardiologist who treated Reggie Lewis, who told him it was okay to play basketball. It wasn't. Lewis had a cardiomyopathy that caused him to die of cardiac arrest when he took to the practice floor. Lewis's widow sued, but ultimately Dr. Mudge was found by a jury not to be responsible for Lewis's death. In a sense, of course, he was -- his advice was wrong. But that's the tough thing about being a physician. If most people make a mistake in their work, it's not a big deal, or it's correctable. But we can't start making physicians criminally responsible for their human frailties or, obviously, nobody will do the job. In Dr. Mudge's case, his judgment may have been affected by some personal history which I won't go into because that wouldn't be fair, but in any case, he wanted very much to save Reggie Lewis's career and give such a promising, talented, and likeable young man a chance to realize his dreams. After Reggie Lewis and his widow, I doubt anyone was more damaged by the matter than Dr. Mudge.

So what are the factors that ought to make bad doctoring criminal? Malicious intent is presumably one. For example, doctors who operate opioid prescription mills are intentionally working against their "patients'" interests out of purely venal motives. On the other hand, whether somebody legitimately ought to get a prescription for opioids is a matter of judgment and there have been prosecutions that seem inappropriate. Addicts are often very skilled at deceiving doctors, and not only that, but some of them are also genuinely in pain and maybe it's just as well for them to get the drugs.

Dr. Murray appears to have been trying to serve what he understood to be his patient's best interest. Jackson was a tormented soul who could not sleep, and evidently Murray kept resorting to stronger and stronger measures until he finally started anesthetizing his patient. That seems like very poor judgment already but doctors can legally prescribe off label and again, poor medical judgment is not a crime. He apparently left his patient unattended while he was in a propofol-induced coma. That is the sort of negligence that would support a malpractice suit but is not ordinarily prosecuted. (We had a surgeon in the Boston area who left a patient on the operating table so he could cash a check and buy drugs. He lost his license and got sued, but he was not prosecuted for that specific act.) Finally, Murray apparently did not immediately call for an ambulance when he discovered his patient in respiratory arrest, and that could be what pushes this over the line. I suppose if I were a juror it would be the fact upon which I would focus, although in fact it was probably too late anyway.

So what I'm saying is that I suspect most physicians, not out of self interest since few imagine themselves behaving so inappropriately, but out of a general interest in protecting professional judgment from unseemly second guessing, would prefer to see this situation handled in civil court. Murray would no longer be able to practice, he would be ruined professionally and financially, the world would be safe from his professional poor judgment, and either way, Michael Jackson is already dead. But it's a tough call.

Credit where it's due

2011-11-28T11:18:00.000-05:00

Every morning and evening, I am strapped into a chair and forced to listen to NPR against my will. (Well okay, maybe I could listen to something else . . . ) I am not often kind to them here -- lately they've featured a fairly steady diet of long, sycophantic interviews with insane Republican power brokers, apparently in a craven and obviously futile attempt to save their federal funding -- but they finally give us a piece on climate change, occasioned by the hopeless Durban conference, in which they do not feel compelled to "balance" truth with ideological hallucinations.

As Richard Harris reports, "The United States is second only to China in emitting gases that cause global warming." Yep, he said it. Also, he quotes Kevin Kennedy of the World Resources Institute: "'Nowhere else in the world do you see a political debate about whether climate science is real, whether or not the climate is actually changing,' Kennedy says. 'That political climate makes it very difficult to move forward in a comprehensive way. And that is something we need to address in this country.'" And he doesn't make room for a rebuttal from climate science experts such as James Inhofe or Rick Perry.

The Durban conference is hopeless, of course, precisely because the United States will not support any effective action on climate change. And that is because the corporate media, in general -- and that includes the New York Times, by the way -- continues to treat the question of how much it matters, whether it's worth doing anything about, and even whether it is even happening, as a political controversy rather than a question of scientific fact; and because public discourse is largely controlled by wealthy psychopaths who are perfectly happy to destroy civilization in order to keep a few more millions in their pockets.

I don't write about this much because it terrifies me too much and I really don't know what I can add. I will, however, add Climate Progress to my sidebar, and I hope you all will visit and educate yourselves. Then take action -- no politician who won't commit to making this a priority deserves your vote.

Donald Berwick

2011-11-25T08:47:00.001-05:00

Just a quick note that, to no-one's surprise, the corporate media has pretty much ignored the Republican filibuster which prevented the appointment of Donald Berwick to head the Centers for Medicare and Medicaid Services (known for historical reasons as CMS) from becoming permanent.

They claim it's because he once praised the British National Health Service, which makes him a commie, but Brian Beutler does an excellent job of explaining what's really going on. Berwick is a proponent of comparative effectiveness research and cost effectiveness analysis -- as well as being darn right radical in his advocacy for patient centered care and the empowerment of patients as the decision makers in their own health. But the Republicans ignore the part of the previous sentence after the dash and focus on the first part, which of course makes him a death panelist.

What they are really afraid of is that he can prove that public insurance, and especially a single payer system like Medicare, can deliver better health care with happier customers for less money than private insurance. If they let him get away with proving that, their corporate owners won't be happy.

Repealing the Enlightenment

2011-11-22T11:27:00.000-05:00

I have said it before, but Naomi Klein says it at greater length, and maybe even a bit better. Climate change denialism is an example of thinking backwards. Since we already know that unregulated markets maximize human welfare, it is impossible for carbon dioxide emissions from burning fossil fuels to cause any serious problems. That would imply a need for some sort of intervention by government to reduce those emissions, and that conclusion is logically impossible, right?

Klein goes on to show how anthropogenic climate change implies many other conclusions which are not permitted in conservative ideology, but that's the basic idea. Anyway it's worth reading so go ahead. (I get the dead trees Nation so I got to read it sitting on the sofa and then do the puzzle.)

Tom Levenson at Balloon Juice is generally taken aback, nonplussed and aghast at what appears to be a growing global rejection of science as in any way authoritative. It's antivaxers trying to get their kids infected with chickenpox that sets him off, but then he broadens out. "The tyranny of facts undermines privilege . . ." The Republican War on Science is motivated by greed -- tobacco industry greed, coal and power generation industry greed, oil company greed.

And it's not just environmental catastrophe and selling people addictive poison. Have you been wondering why the heck Newt Gingrich has suddenly called the Congressional Budget Office a "reactionary socialist institution? It's because the CBO won't agree that gigantic tax cuts for wealthy people increase government revenue. (What the heck is a reactionary socialist, anyway?) Economics isn't really a science, but if we're living in this universe we can agree that the Obama stimulus did save millions of jobs and that the reason we have these big federal deficits stretching over the horizon is because of the Bush tax cuts and wars. If we're Republicans, however, we can't agree with those propositions, because they conflict with our axioms. Adam and Eve must be real historical characters because without original sin, Christ's sacrifice couldn't redeem us. (Not that the whole thing makes any sense in the first place.)

Thinking forward means observing what is out there in the real world and then trying to explain it. Thinking backwards means deciding what we already believe and then trying to force reality to look that way, which means ignoring evidence and making stuff up. Thinking backwards is what conservatives do. We need to laugh them off the stage, but if we don't, what happens won't be funny.

The NYT gets maybe half way there

2011-11-21T11:29:00.000-05:00

The Editors, glorying in their anonymous collectivity, take on Medicare spending. They frame the issue correctly -- we need to rein in the growth in the cost of Medicare because we need to keep it universal and comprehensive. If the cost of Medicare continues to grow faster than the economy, it will grow harder and harder to convince the public to continue to pay for it. (Of course, this is a matter of degree. The Editors point with alarm to the projection that Medicare will account for 16% of federal spending by 2021, which Is Just Unpossible! Well no, it isn't, we could do that. But maybe we won't.)

So, The Editors think we should carefully examine proposals to raise the eligibility age, make higher income seniors pay higher premiums, and introduce more "cost-sharing by beneficiaries to deter unnecessary use of medical care." They think all that might be good but they are cautious. Wrong, wrong, and wrong.

Raising the eligibility age would not save any money at all. It would mean that people age, say, 65-67 would still be paying for their health care some other way, or not at all. Since a lot of people are out of the labor force by then, not at all would be a very popular option. But what happens when people that age don't get any medical care is that as soon as they hit Medicare eligibility, they come right in and now Medicare has to pay for all the bad stuff that wouldn't have happened if their health care hadn't been on hold for a few years -- heart disease and kidney disease due to uncontrolled hypertension and diabetes, for example. Baad idea.

Making higher income people pay for their Medicare sounds reasonable, but it would be politically suicidal. The appeal of Medicare is that it's universal. If it becomes a program for low and moderate income seniors only, wealthy people will turn against it -- it will just be "welfare," and we know that's evil.

Cost sharing is an even worse idea because your average senior citizen obviously does not know which medical interventions are worth it and which are not. They'll consume less medical care and medications, but at least half the time, they'll make the wrong choices. Which could end up costing more in the long run.

Then The Editors say that "So-called premium-support or voucher plans come in many flavors — some good, some bad — and would need to be carefully vetted." What all of these plans mean is abolishing Medicare and giving people money to buy private health insurance. Exactly none of the flavors of this disgusting idea are good. Medicare -- a single payer system -- is much more efficient than private health insurance and costs far less to deliver the same benefits. It always will, because it doesn't make a profit for shareholders or multi-millions for its executives, doesn't have to market itself to compete with other payers, and has the market power (should it ever care to use it) to make the medical system behave more efficiently and deliver the goods for even less.

Having tepidly endorsed or at least tolerated all of the really awful proposals that are out there, they are all for payment reform to the extent of moving away from fee-for-service to some form of capitated payment. That's okay although we have a long way to go to prove that it can work well. But, here's what they don't say.

We need to support cost effectiveness analysis and we need to direct resources away from doing stuff that just isn't worth it. Nobody wants to touch that because a former half-term governor of a state with a smaller population than metropolitan Boston will scream about death panels. That's a really stupid reason not to tell the people the truth.

Communicative action

2011-11-18T10:14:00.000-05:00

For those not familiar with the philosophy of Jurgen Habermas (Stanford Encylopedia of Philosophy article is here), one of his central interests is in how we go about constructing knowledge together, through discourse.

To crudely summarize (and these conventional English translations of the terms may not be the best) we can engage in either communicative action, or strategic action. The latter is basically when I'm trying to get over on you -- I have a desired outcome, I want you to do something or believe something that's going to get you to do what I want, and I engage in speech or other forms of communication to bring about that end. Communicative action is when we talk with each other, openly and transparently, to discover how we might come to agree. Any one of us may engage in strategic action at one time or another, but it is pretty much impossible for the institutional interests labeled by Habermas as "the system" to do anything else. Corporations try to sell you stuff, political action committees try to get you to vote for the interests of their donors -- you're never going to have a dialogue with them.

I expect Habermas must love the Occupy movement -- they are totally committed to communicative action, at least internally. It does have the downside that they can't state exactly what they want to happen, but then again, maybe we'll all get there together some day.

But, if I may abruptly change the subject, what about doctors and patients? You might think, since the whole point is that the doctor is looking out for your well being, that you and your doctor would be having a lot of conversations about what, exactly, you think that is, and sharing thoughts about how to get there. Well, you may not have thought about this much, but you probably aren't really doing that. I could go on about this at great length, but here's a quick story.

I met the other day with some people who are living with HIV. I was interested in how they would explain what a virus is, and basically, none of them could say much about it. A virus is something that causes disease, that's about all they knew. Now, all of these people thought their doctors were the greatest thing since oxygen, and had been living with HIV and getting treatment for it for years. But the doctor had never bothered to say how she understood the nature of a virus and the way the drugs work to control it.

So, in about two minutes, I explained it, like this. As you know, your body is made up of billions of cells, and in the center of each cell -- the nucleus -- there's a molecule called DNA. That consists of very long strings of smaller molecules which spell out the instructions for making the proteins that carry out the functions of the cell and make up the tissues of your body. The instructions are carried from the DNA into the cell by a molecule called RNA, which directly controls the assembly of the proteins.

Well, most viruses are just little pieces of DNA that contain the instructions to make more of the virus. One way or another, the viral DNA gets into a cell and its instructions take over, turning the cell into a factory that just makes more and more of the virus. HIV is a little bit different because it consists of RNA instead of DNA. Same instructions, just in a different form. You have cells circulating in your blood called T-cells, that are part of the immune system that combats viruses. Some of these T-cells have a so-called receptor -- a channel for getting stuff in and out of the cell -- called a CD4 receptor, and when HIV bumps into one of those, it injects its RNA into the cell. The RNA immediately causes a protein to be made which causes the cell to write the instructions for making HIV into the cell's DNA. At some point, that DNA will be activated and the cell will turn into an HIV factory. Over time, as more and more of these CD4+ cells are destroyed, your immune system becomes less and less effective and you start getting weird infections.

That was it. They got it. They were all astonished. It's really that simple, they understood it, and we went on to understand drug resistance and how the various drugs work, among other things. Oh yeah, exactly what those T-cells do when they're working correctly. Other stuff. In about 5 minutes. So why, in maybe 10 years, had their doctors never told them this?

Some disorganized chatter

2011-11-16T10:11:00.000-05:00

Yesterday I was in Boston all day for meetings, slept in my old house for what I hope will be the last time -- it's under agreement, just waiting to close -- then drove back to CT, didn't have a chance to blog. So . . .

The main point of my last post is really that we don't know what the consequences will be of technological developments. They often have huge effects that no-one foresees. The automobile wasn't just a faster horse that didn't need farmland to feed it -- it created the suburbs and a whole lot else, including becoming one of the leading causes of death, particularly for young people, and making the world warmer and stormier. We can try to imagine a world with on-the-spot manufacturing and driverless cars, but we'll probably get it wrong. Whatever happens, almost nobody will spend any time worrying about possible bad effects, however. If it's possible, we'll do it, pretty much mindlessly, because it is by definition progress.

Another completely unrelated issue that is on my mind is the prevalence of insane lawyers. To be sure, I'm not one, and I don't know what I would do if I were handed the assignment of defending somebody who doesn't have a chance in hell and probably doesn't deserve one. However, when I was a kid I read Clarence Darrow's "Attorney for the Damned," and he managed to find a way.

I have commented before -- not here I think -- about the lawyer for Joshua Komisarjevsky, whose particular acts of depravity we don't need to mention again. The guy's pretrial strategy was to relentless attack the sole surviving victim, whose family his client murdered; and along the way to hold a press conference on the courthouse steps in which he recited specific details of how his client had raped an 11 year old girl, which he apparently considered somehow exculpatory. Komisarjevsky has now been convicted of 6 capital offenses and his trial is in the penalty phase. The lawyer is trying to convince the judge to allow him to call his client's daughter, who is about the same age as the girl his client raped and murdered. I'm sure that will engage the jury's sympathy. Sheesh.

Now we have the almost equally popular Jerry Sandusky, whose lawyer let's him give a prime time interview to the sportscaster Bob Costas. Mr. Costas is not to be underestimated just because he covers fun and games. He's a smart guy, which Sandusky and his lawyer clearly are not. In the process of denying the allegations against him, Sandusky proved beyond a reasonable doubt that he is El Creepo, and should never be allowed within sight or sound of any boys. All prospective jurors will have a pretty good idea of the most effective way to achieve that.

There is a substantive point to take from this. If our culture did not view the criminal justice system principally as an instrument of retribution, we wouldn't be subjecting the public to these repulsive sideshows. Komisarjevsky was not allowed to plead guilty to a capital offense, so we had to endure a trial, and now this. If the deal had been life in prison to begin with, his lawyer would have haggled over the terms of his confinement and that would have been all there was to it. As for Sandusky, he probably would have been dealt with more appropriately a long time ago, but he wouldn't be resorting to such preposterous and desperate tactics if he wasn't looking at spending the rest of his life in so-called administrative segregation, which is the only place he's headed with a guilty verdict. He wouldn't last ten minutes in a prison population, obviously.

Most people probably think that's just fine, and I know I'm not going to talk anybody out of it. But in both of these cases, subjecting the public, the victims, and the jurors to trials is a major evil. By the way, the TV news stations in Connecticut and the Hartford Courant posted Komisarjevsky's confession on their web sites, accompanied by disclaimers to the effect that you really don't want to hear this. No, you don't.

Tea, Earl Grey, Hot

2011-11-14T13:45:00.000-05:00

Prediction is very hard, particularly about the future. But I've been hearing a lot of low-key buzz lately about astonishingly transformative technologies that are not far off. 3-D printers are already not so uncommon. In fact the elementary school where my sister teaches has one. They can make any object you like out of metal, plastic or ceramics, and no doubt we'll soon have more sophisticated models that can use combinations of even more materials, such as made-to-order clothing on the spot. (Books can already be made and sold this way.) Cars that drive themselves are also on the horizon. As a matter of fact, they exist today. When it will be legal to let the car drive you to Grandma's house on the public roads I don't know, but it may well be the case very soon that robocars are safer than human drivers.

While we are oohing and ahhing over cool stuff, we often don't stop to think that technology drives major social transformations. When I was a youngster, my grandfather was a college professor and my grandmother was the secretary to a college professor. My grandfather's job still exists but my grandmother's doesn't. My secretary is Microsoft Office. Even low-level corporate managers who didn't rate their own secretaries would write their letters with a pen on yellow legal sheets or dictate into a tape recorder and send them to the typing pool, then they'd proofread the result and send it back for a final product. No more.

And in case you're agonizing over the decline of U.S. manufacturing, don't. The U.S. still has a robust manufacturing sector, but what we don't have is a robust manufacturing jobs sector, because the way to stay competitive in manufacturing in the U.S. is to replace labor with machinery as fast as possible. Of course people have to make the machinery and write the software, but that requires far fewer jobs than the products displace.

So imagine a world in which, instead of walking into a store and selecting from among the available coffee mugs or dinner plates, you look at samples on a touch screen, pick the one you want, and a machine makes a set for you while you wait. And no, you didn't get in your jalopy and drive to the store. You entered your destination into your smartphone, and the computer (which already knows where you are, obviously) dispatched the nearest car to pick you up and take you there.

Living that way is much cheaper than owning your own car. Cars are constantly in service so the world needs many fewer of them. They just about never crash, and they always know when they need maintenance and get it on time. Everyday manufactured goods are also much cheaper because they don't have to be shipped -- the materials to make them are shipped in bulk instead, which is a lot less expensive. Also you don't have to pay a truck driver. And there are no unsold surpluses -- every object that is made is sold, immediately.

Sounds great, huh? Could even have environmental benefits -- saves energy and waste. Or so it seems. Can anyone think of a downside?

Follow up on psychology research

2011-11-11T10:51:00.001-05:00

We had a guest who is planning to get a graduate degree in psychology inquiring about my drive-by comment that some people consider the whole field of social psychology to be "dodgy." This isn't my specialty and I don't know a whole lot about it, but here's Benedict Carey in the NYT reviewing the issue:

In recent years, psychologists have reported a raft of findings on race biases, brain imaging and even extrasensory perception that have not stood up to scrutiny. Outright fraud may be rare, these experts say, but they contend that Dr. Stapel took advantage of a system that allows researchers to operate in near secrecy and massage data to find what they want to find, without much fear of being challenged.

“The big problem is that the culture is such that researchers spin their work in a way that tells a prettier story than what they really found,” said Jonathan Schooler, a psychologist at the University of California, Santa Barbara. “It’s almost like everyone is on steroids, and to compete you have to take steroids as well.”

I'm afraid I'm not getting the distinction between "outright fraud" and telling a "prettier story than what they really found." When you publish research findings, the only story you are permitted to tell is what you really found. It is true that research reports normally end with a "Discussion" section in which the authors often speculate, going beyond the findings to adduce possible implications or further hypotheses. These can be tendentious, to be sure, but at least an alert reader will be able to spot that, if the "Results" section is accurate and presents the information needed to correctly interpret the observations. Abstracts are often misleading, as are titles, and that's a problem because many readers never look beyond them.

But Schooler obviously understands that using steroids is against the rules in athletics, and telling a prettier story than what you really found is against the rules in science. The analogy is imperfect, not least because the consequence of using performance enhancing drugs is that somebody wins a game, which doesn't actually matter; whereas the consequence of falsely reporting on research is that the world is misled, careers and money are spent chasing down the wrong path, and quite often, people -- likely in their role as patients -- are directly harmed. I don't know whether this is available to the public -- I don't think so, but unfortunately I'm using a computer that has privileges to read BMJ whether I log in or not -- but they have much more this week on the Andrew Wakefield fraud. It turns out that a) not only did the kids not have autism, they didn't have inflammatory bowel disease either; b) the pathologist whose name was on the paper as a co-author had in fact found them not to have bowel disease but signed onto the paper anyway; and c) the institution - University College London -- has refused to do any investigation of the whole matter.

Although I have never seen anything but integrity among my own colleagues, recent publicly reported scandals are making me wonder how widespread the corruption of science may be. It's disconcerting, to say the least.

These kids today . . .

2011-11-10T11:28:00.001-05:00

Oh my God, am I becoming a curmudgeon? No, I really don't think so. The NYT sent a reporter to State College, who had a front row seat as students set fires, trashed a TV van, attacked police, and otherwise vandalized their campus in their outrage over the firing of the football coach. I don't know if reporter Nate Schweber went out of his way to find morons, but he evidently didn't have much trouble.

“I think the point people are trying to make is the media is responsible for JoePa going down,” said a freshman, Mike Clark, 18

Demonstrators tore down two lamp posts, one falling into a crowd. They also threw rocks and fireworks at the police, who responded with pepper spray. The crowd undulated like an accordion, with the students crowding the police and the officers pushing them back. “We got rowdy, and we got maced,” Jeff Heim, 19, said rubbing his red, teary eyes. “But make no mistake, the board started this riot by firing our coach. They tarnished a legend.”

Justin Muir, 20, a junior studying hotel and restaurant management, threw rolls of toilet paper into the trees. “It’s not fair,” Mr. Muir said hurling a white ribbon. “The board is an embarrassment to our school and a disservice to the student population.”

Paul Howard, 24, an aerospace engineering student, jeered the police. “Of course we’re going to riot,” he said. “What do they expect when they tell us at 10 o’clock that they fired our football coach?”

Now listen up. Yeah I'm old now but I went to college. We even had a football team, and it almost became famous. Swarthmore was at one point poised to break the all-time NCAA record for consecutive losses. CBS even sent a crew to cover the historic event. The student body was behind them 100%. The stands were packed and the roar deafening. Well, you could hear something, anyway. The Swarthmore College marching band (which featured an amplified cello) performed its famous amoeba formation at half time for the benefit of national television. But our heroes blew it. They scored a touchdown as time expired to win the game. We were all really bummed out, even more so because it was a bad call. The ball never made it over the goal line.

So yeah, we were 100% behind the coach and players. But in spite of our passionate loyalty, if it turned out that one of the assistant coaches had been raping boys in the locker room and the head coach, athletic director, and college president all covered it up and merely told the guy to do his child raping elsewhere, I'm pretty sure we'd have started the rioting before they all got fired and only would have stopped once they were fully and unceremoniously canned.

Does this signal the decline of the West? Or am I overinterpreting?

Too much going on at once

2011-11-09T13:29:00.001-05:00

Well, you can't call this a boring week in the news, that's for sure. Let me get the obligatory comments out of the way on a few of the stories that are trying to drive each other off the front page.

I think the religious fanatics actually made a big mistake with the Mississippi "personhood" amendment. I understand they're trying to do this in a few other states and it ain't over (officially) yet but if you can't do it in the country's most benighted state (sorry to our fans from the land that gave us the blues but you know it's true) where can you do it? Their mistake was to confront the public with the logical conclusion of their claim that "human life begins at conception," that an embryo is morally indistinguishable from a baby. It turns out that lots of people who define themselves as "pro-life" can't actually go there when they have to take it literally. It's a reductio ad absurdum of the anti-abortion position, which they deliberately presented. If people are careful and wise, they can build on this moment to fundamentally shift the terms of the debate.

Next, Joe Pa.(It turns out there's a distant and meaningless connection -- he's an alumnus of Brown University.) Lots of people are pointing out that this is similar to the Catholic Church. Not so much, I think. They have in common the moral failing of putting the perceived good of the institution ahead of the child victims, but the context is otherwise quite different. Penn State and its football program weren't involved in the lives of the victims and weren't actually perpetrating the rapes. And it's pretty clear to me that the culture of the Catholic priesthood is deeply imbued with repressed and twisted sexuality. The guys at Penn State didn't actively protect Sandusky or enable his actions, they just couldn't be bothered to stop him. You may not agree, but it seems to me that along one dimension, anyway, that's even worse, because the cost of acting, and the potential damage to the institution, were far less in the Penn State case. It would have been easy to turn Sandusky in, and while people would have been shocked, it would not have reflected poorly on Penn State or Penn State football. So their actions are not only inexcusable, but rather inexplicable, in my view.

Next, I'm sure you're at least as sick as I am of hearing about Herman Cain, but I'll make one last comment. It's just plain weird that Vulgar Pigboy and the rest of wingnuttery are rallying around him and blaming the liberal media. It would cost them next to nothing to dump him, but it's costing them a whole lot to keep loving him. They're just pathologically incapable of admitting error, I guess.

Finally, as coastal Alaska gets wiped out by a snow hurricane, I wonder if it will have any impact on the climate change denialism that rules in a state where the oil industry mails a check to everybody once a year? We'll see. But no, I don't care what a former half-term governor has to say about it, and neither does anyone else.

The Bernie Madoff of Social Psychology

2011-11-08T11:08:00.000-05:00

That would of course be Diederik Stapel of Tilburg University in the Netherlands. I compare him to Bernie because he committed an astonishingly bold, massive fraud over many years that included gross betrayal of friends and colleagues. Oh yeah, he should have been caught many times but his prestige and power protected him. If you want the full story from the university investigating committee, it's here.

In case you haven't read about this and don't want to bother, basically the guy would chat up post docs and faculty colleagues to find out what research questions and hypotheses they were thinking about. Sometimes he would then work with them to design a study, write questionnaires, get funding, etc. He claimed to have relationships with high schools and universities that allowed him to recruit their students, or in a couple of cases faculty, as subjects. He'd go off to ostensibly collect the data, come back with it in a couple of months, and whaddya know, the hypothesis would be confirmed. Sometimes he didn't even bother with all that, he just said he had an old data set that was suitable, which he hadn't gotten around to analyzing, here it is. Only, he never collected any data. At all. He made it all up. Oh yeah, he also supervised dissertations based on phony data.

The really strange question is why? Bernie could have invested the money, and Stapel could have actually done the experiments. Madoff wouldn't have made 12% a year come hell or high water, and Stapel wouldn't always have found what he was looking for, but they still could have been perfectly successful. In Stapel's case, in fact, probably equally successful -- there's nothing stopping us from publishing findings we don't expect.

Just as Bernie brought about financial ruin for his customers, Stapel has brought career ruin on his students and collaborators. Even though they were perfectly innocent of the fraud, their programs of research are now destroyed and their publications will have to be retracted. Although the university says his students can keep their degrees, they are forever tainted and will no doubt find it very difficult to advance their careers. Everyone's CV will shrivel up like bacon.

He has also damaged the university, and the entire field of social psychology, which some people already consider to be a bit dodgy. (Think Marc Hauser.) The psychopathology here is really inscrutable. Yeah, the guy is some version of a psychopath but he seems to have been generally empathic and reliable in other contexts. This is just weird.

Sometimes it is worth proving the obvious . . .

2011-11-07T13:43:00.000-05:00

Or at least I'll concede it might be. It's big national news, it seems, that a survey of 7-12 graders finds sexual harassment is pervasive.

Well duhh. Did the majority of adults somehow skip adolescence? We were there, remember? Well, okay, we probably don't, unless somebody gets our attention and makes us think about it. The world of children and adolescents is often cruel, even depraved. Kids can do a pretty good job of keeping their secrets from adults and within their own world, to the extent it manages to evade oversight, they're in the struggle of all against all, nasty and brutish -- also short since it ends, at least for most of us, with adulthood.

But we have a cognitive bias toward seeing the past with a rosy glow, remembering the good parts much more than the bad. That's good, in that it helps us feel better, but it isn't helpful if we want to look out for young people, really appreciate what they go through, and help to shape their worlds for the better. So I'm very glad that we're seeing a real trend now toward paying attention to bullying -- of which this is a subset, obviously, maybe the biggest piece.

I think it's happening in large part because of real changes in cultural norms about gender, sexuality, and the associated dynamics of power and vulnerability. We're talking about boys who are gay or perceived to be gay being targets of relentless abuse; boys who feel entitled to take what they want from girls, whether physically or symbolically; masculinity defined as cruelty and domination.

It does get better, unless you happen to be a libertarian, in which case Lord of the Flies is your paradise.

Never speak ill of the dead

2011-11-05T18:02:00.000-04:00

Hi, I'm Randy Ooney.

Here's a random collection of banal objects. This is a box of cereal. Why can't cereal come in a canister? Who made that rule?

This is a roll of toilet paper. Who invented toilet paper, anyway? We know who invented the telephone and the light bulb, but what's more important? Was it Scott? I don't know.

These are double A batteries, and triple A batteries, and D batteries. What ever happened to B and C?

Somebody sent me this eyebrow trimmer. Who ever trims their eyebrows? I certainly don't.

For CBS News, this is Randy Ooney, good night. And why the heck is anybody sitting and watching this inanity? That's what I'd really like to know.

Hermania!

2011-11-05T08:34:00.002-04:00

Last night Rachel Maddow posited -- nay, all but concluded -- that the ever more bizarre Herman Cain presidential campaign is in fact a clever work of performance art. She pointed to various sly allusions and other clues that reveal the true intention.

Okay, that seems the most sensible explanation to a sane outside observer. But why would the Koch brothers sponsor a satiric performance that aims at revealing the absurdity and ignorance of the very constituency they manipulate for their nefarious purposes? Conceivably, their hubris is so great they believe they can simply enjoy the joke and get away with it. Maybe this is a message to current and future Republican candidates to respect the depravity of the Republican primary electorate.

Whatever it is, I'm impressed.

Human life ends at birth

2011-11-04T14:35:00.000-04:00

Apparently. The Governor of Mississippi has come out in favor of the so-called "personhood" amendment, which will amend the constitution of the nation's most poorly educated and least healthy state to declare that "every human being from the moment of fertilization, cloning or the functional equivalent thereof" is a "person" with full legal rights. So, apparently, has former abortion rights champion Multiple Choice Mitt. (In some of what follows, I plagiarize myself, which I believe is legal.)

Of course, these people despise human life. They couldn't give a stale communion wafer about sick and dying children in poor countries, or right here in the US of A, where their leading domestic priority is to repeal legislation to provide health care to kids whose families can't afford it.

The entities to which they impute "sanctity" are not human beings, but anything that's kind of like a human being, in having human DNA, but is otherwise unlike what most of us think of us being human in having no ability to survive independently, and no consciousness. And where do they get the idea that lives of microscopic balls of cells, fetuses with unformed cerebral cortexes, and former humans whose cortexes have been destroyed, are somehow "sacred"? They obviously don't get it from the Bible. There is not one word about abortion anywhere in the Bible, Old Testament or New, even though abortion, and for that matter infanticide, were widely practiced in the Biblical world.

For that matter, the Bible certainly does not put forth any concept of the "sanctity of life." The Hebrews are commanded at various times to slaughter people, steal their land, rape their women, and enslave their children. God himself massacres innocent children in Egypt and elsewhere. God commands the Hebrews to stone a man to death for gathering sticks on the sabbath.

And of course, the Bible could not possibly assert that "life begins at conception" because people in Biblical times didn't have the slightest idea what conception was or how fetuses developed. In fact, if you believe in God, then you also have to believe that God is the most prolific abortionist in history, by many orders of magnitude, because something like 2/3 of "human lives" -- the zygotes created at the moment of conception -- never successfully develop. Most of the time, the woman is not even aware that she was ever pregnant. If abortion is murder, this is the death of tens of millions of innocent children every year. Should it not be the absolutely highest priority of medical research to save those babies' lives? But you never hear a peep from these people about it, because they know it's completely illogical.

Christian prohibition of abortion is an entirely modern phenomenon, dating at its very earliest to the 19th Century. And what happened at that time to suddenly provoke the concern of the Pope? It wasn't any scientific discovery -- understanding of the nature of conception and the zygote did not come until about until considerably later. No, what got the Christian fathers riled up was the women's movement. The idea that sex could be uncoupled from reproduction, or that women could choose not to become mothers, was appalling to the (putatively) celibate old men who ran the Catholic Church, and later to the Evangelical "Christian" conservatives who share their views on the semi-human status of women, although they otherwise think Catholics are heretics who God intends to torture for all eternity. And vice versa.

The reason I bring all this up, although you already know it, is because nobody in public life seems willing to take this issue on at the fundamental level of morality and logic. The most assertive anyone is willing to be about it, including NARAL, is to say that people differ in their views of the morality of abortion and that the law should not impose one view on everyone. I say it's time to get serious about this and expose the hypocrisy and fundamentally nonsensical basis of "pro-life" activism. Answer these lying bigots who would lead the world back into darkness. Explain to people why their views and public discourse makes no sense. Reveal their true agenda, to oppress women and for that matter all of humankind. To rule the world through terror and deceit.

Not a damn thing Christian about them.

Speaking of denialism

2011-11-03T10:42:00.001-04:00

Henry Aaron - not Hammerin' Hank, but the Brookings Institution economist -- makes it so clear even a Republican could understand it. Whatever savings may be available from making Medicare and Medicaid more efficient, or squeezing providers and beneficiaries, aren't going to cut it:

Whichever approach is followed — repeated modest reductions or a single huge one — if all cuts come exclusively from spending, it will be impossible to sustain anything approximating current commitments under Medicare and Medicaid (and under Social Security) as we know them. Resistance to defense cuts, beyond those already included in the legislation to boost the debt ceiling, is already hardening. A concern about undermining the nation's capacity to meet its international obligations may prevent the repeated allocation of half of spending cuts to national defense. Interest spending will inevitably grow sharply as today's recession-induced, near-zero real interest rates return to normal levels. Outlays other than those for defense, interest, Medicare, Medicaid, and Social Security today constitute only one third of the budget and have been cut deeply already. Following the Willie Sutton principle, Congress would have to “go where the money is” and slash the major social insurance programs, including Medicaid and Medicare.

To avoid this outcome, tax increases must account for a sizable fraction — perhaps most — of any deficit-reduction plan.

That's it. If we want to keep the promise made long ago that elderly people will not have to fear dying uncared for in the cold and dark, the Koch brothers will have to pay more taxes. There's no way around it. That's the cold truth.

Priorities

2011-11-02T13:31:00.000-04:00

This brief update on the coming era of the cyborg has gotten some blogospheric attention, but I have my own take. Basically, in case you didn't know, developing technology now allows human brains to be connected directly to computers, via implanted electrodes or scanning devices such as magnetic resonance imaging. Much speculation and alarm concerns the possibility of mind reading, which may sound implausible but is actually already in early stages of actually happening.

For the foreseeable future, this will require sticking your head in a big, expensive device for a considerable period, so it won't be invading your privacy as you walk through the shopping mall. However, it could do interesting things to criminal investigations and who knows, maybe even job applications some day.

But I'd like to focus on the other application, which is prosthetics. The major direction of this research is to enable people who are paralyzed or missing limbs to control replacement limbs or even entire bodies directly with their brains. That could certainly benefit people who have a very tough lot in life. Another example of science fiction becoming real is the field of so-called regenerative medicine. Yes, this also happens to be where all the religious nuts are having fits of moral idiocy over the use of embryonic stem cells. Leaving that aside, amputees may not even need to become cyborgs because they'll be able to grow new limbs. We might also be able to grow new organs -- hearts, livers, kidneys, even brain components. (And therein lie some philosophical conundrums, for another day.)

This isn't happening tomorrow but it might be happening soon enough that we need to think about it hard, starting yesterday. Here's what troubles me.

Of the world's 7 billion people, how many do you think will have access to these technologies? If we invest hundreds of billions of dollars to learn to grow new hearts, the only people who will get them are rich people, who will then have shiny new hearts that keep on pumping till they're 120 years old. It will never be cheap until some time after war and injustice are eradicated.

It's astonishing and wondrous and it has great commercial potential -- the latter being the real reason there's funding for it. It seems wrong to speak against finding ways of healing the sick, but we don't yet offer the astonishing and wondrous medicine we already have to the vast majority of the earth's people. It just doesn't seem right.

I've got a baaad feeling about this

2011-11-01T11:22:00.000-04:00

I normally leave the economic gloom and doom to the experts, e.g. Atrios, Krugman, and DeLong. And I do so now, but I refer you particularly to Professor K, who explains it all to you.

The semi-comforting story we always hear is that the current extraordinary rise in economic inequality in the U.S. has to do with rising returns to education. The high school grads just can't make a middle class living bolting cars together any more, but with a master's degree you can scoop up coin like beach sand.

Not. The truth is that the money isn't flowing to the college grads, or even the top 20% of income earners. It's flowing entirely, all of it, to not even the top 1%, but the top .1%. And no, they aren't "job creators," and confiscating their wealth isn't going to put anybody out of work. On the contrary, they are parasites who provide no socially useful services whatsoever. Some, such as Bill Gates, got wealthy by making shrewd and/or fortunate investments in productive enterprises early on, but even in that exceptional instance Bill Gates doesn't need to have billions of dollars in personal assets in order for Microsoft to be a successful business. (To his credit, he knows this, and he's working at giving away his money. So far that hasn't destroyed any jobs to my knowledge.)

Most of them, however, got rich by skimming from the financial markets or, as in the case of Mitt Romney, buying up companies, firing much of the workforce, siphoning off as much cash as they could, and then selling them to somebody else. Or, as in the case of the Koch brothers, they inherited the money. But what can we do about this situation? They can buy all the elections they want and pollute the public discourse with a Niagara of lies. How can we possibly get rid of them?

It's great that people have finally taken to the streets but what happens next? I have a hard time foreseeing anything good.

I admit it, I'm totally spoiled

2011-10-31T10:01:00.001-04:00

For the second time in two months, bizarre weather has knocked out my electricity supply, and apparently it's going to take a week to get it back once again. Big deal, right? People got along just fine without electricity for a million years or whatever (depending on when you want to start calling the critters people), I can certainly make it for one week.

Think about it -- electricity delivered to the home from central generating stations has been the general way of life in the United States for only about 100 years. It didn't make it to rural areas until much later -- the Rural Electrification Act was passed in 1936. I'm reading Daniel Yergin's biography of petroleum (I think that's a fair description), The Prize, and you may not have thought about this before, but John D. Rockefeller grew rich selling kerosene for lighting. Petroleum burst onto the scene as a substitute for tallow candles and whale oil. Powering engines came, including electrical generators, came much later.

In this brief historical moment electricity has completed transformed our society, and our daily lives such that it is indispensable. I happen to have heat without electricity, because I have a Vermont Castings Defiant wood burning stove, but I don't have running water, and I'm reduced to reading by candlelight. No way to take a shower, vacuum the floor, charge my computer or cell phone, watch television -- getting news of the outside world, if I didn't have a nice well-powered office to go to, would require purchasing a bunch of wood pulp with ink on it. I can cook a meal on top of the wood stove -- and I did, actually, on Saturday. But I couldn't wash the dishes. If I decide to tough it out, I'll have to carry a bucket down to the stream to haul up water, and heat it on the stove top, all by candle light since it's basically dark shortly after I get home.

Well yeah, that's what people used to do. They must have been miserable, right?

The final nail in the coffin . . .

2011-10-28T14:29:00.000-04:00

of AIDS denialism. A multitude of Brits has completed a prospective cohort study of people living with HIV from 1996 through 2008. This is the most powerful, persuasive study design possible. It's Da Bomb of studies of HIV treatment. 1996 is basically the year when effect antiretroviral treatment became available. Here's the bottom line:

1) Life expectancy at age 20 of people living with HIV increased from 30 to 45.8 years over the period.

2) Life expectancy at age 20 was 37.9 for people who started therapy with CD4+ cell count less than 100; for people who started therapy with CD4+ count above 200, it was 53.4, getting up there pretty close to normal.

This "life expectancy" number is artificial, of course - I've explained it here before. But it's the best estimate of what a person age 20 can expect based on the experience we have with people of all ages with HIV since 1996. For those who don't know, CD4+ cells are a particular type of immune system cell, also called "helper T cells," that HIV preferentially infects and destroys. It's the loss of those cells that causes the immunodeficiency characteristic of AIDS.

So this is what we keep telling the AIDS deniers: if you have HIV, and you don't take the pills, you get sick and die. Even if you take the pills starting fairly late, after your T-cells are depleted, the numbers will come back but you aren't likely to live such a long healthy life, probably because you no longer have the variety of T-cells needed to confront the variety of pathogens you're likely to experience, and possibly because of other damage as well. But if you take the pills, take them regularly, and stick with it, you can look forward to a reasonable life span. Fact. Done.

That doesn't mean it's okay to get HIV. The pills have side effects, they're expensive, and you won't likely live as long or be as healthy as you would be without the infection. You'll do okay, but you really don't want it.

That said, and given that prevention is still the far better alternative, this does show that what I learned in school about the fairly small contribution of medical intervention to health and longevity is no longer true. Medicine has gotten better. It can pay real benefits. It's still true that it's even more important for people to have good diets, maintain healthy weight, not be assaulted by environmental contaminants or violence or poverty, not smoke or otherwise poison themselves, and so on. And it's also still true that too much medical intervention can be as bad or worse than too little.

But even if you're lucky enough to have all the good stuff and do all the right stuff, you're still gonna want a doctor.

And that's why we need universal access to high quality, evidence based medicine. And that's why we need universal, comprehensive, single payer national health care.

The last place you want to be when you're sick . . .

2011-10-27T13:04:00.000-04:00

is in a hospital. Hospitals are very dangerous places for several reasons. The most obvious is that there are a lot of debilitated people there with tubes going into their orifices, and often extra holes with extra tubes, that are full of all kinds of nasty bugs that eat antibiotics for breakfast, and then eat people for lunch.

But that's not the only reason. I'll pass briefly over the risk entailed by being in the clutches of doctors who are often overeager to do really radical stuff to you, although I happen to think that's quite dangerous. As Covinsky and colleagues discuss in JAMA, an extraordinarily high percentage of older folks who are hospitalized for one reason or another leave the hospital with brand new disabilities having nothing specifically to do with the original reason for hospitalization. Quite often, they never make it home again. Among the reasons:

Excessive confinement to bed. This can happen due to inappropriate bed rest orders, or because they are essentially tied to the bed by a urinary catheter or IV line. If you can walk, dress yourself, make it to the toilet, etc. when you enter the hospital, you should insist on keeping on doing it. When people who are already frail become inactive for even a couple of days, they often can't get their strength back.

Poor nutrition. Again, people may be placed on restrictive diets inappropriately, but they also may just find it very hard to eat the swill placed in front of them. And, as with the above, when you lose strength due to a bout of malnutrition, if you're getting on in years, it may be hard to get it back.

Falls. The hospital is an unfamiliar environment and believe it or not, regular hospital wards aren't necessarily set up so as to be safe for people prone to falling -- there's a lot of weird furniture on rollers, slippery floors, often the odd piece of paper or linen lying on the floor, not necessarily railings where they should be, etc.

Delirium. The environment is bizarre, noisy, chaotic. People may be drugged or sleep deprived. The result is often loss of contact with reality. Sometimes people never fully recover their cognitive chops.

So . . .

A) Try not to go there, and deal with issues on an outpatient basis if at all possible.

B) If you do have to go there, as I say, be feisty and a pain in the ass and insist on getting out of bed, getting dressed, getting yourself to the loo, keeping to your usual routine of newspapers and crosswords or whatever, as much as you possibly can. Eat. Don't take any crap.

C) The people who run hospitals need to learn how to do it better.

That is all.

The denialism puzzle

2011-10-26T15:34:00.000-04:00

I've been hearing ads on National Pubic Radio - oh excuse me, not ads, "underwriting" -- for this new film that claims the Earl of Oxford wrote Shakespeare's plays. Here's Joe Romm comparing this absurd nonsense to climate change denialism. I came across it after a visit to Seth Kalichman's blog, where a commenter issues a veiled death threat because Dr. K maintains that HIV causes disease. As you may have noticed, it is now an official requirement for Republican candidates for office to deny evolution, anthropogenic climate change, and the toxic effects of air and water pollution.

Many questions are legitimately controversial and every once in a while, some pretty well-settled beliefs get overturned. But that's actually less common than it used to be, because unlike folks in the past, we have a vast and growing accumulated store of knowledge on which to build our conclusions, ever better methods of observing and measuring, and more powerful deductive tools and ways of testing hypotheses. We actually do know more than people knew in the past. So yeah, Galileo was right and the prevailing belief was wrong but guess what? There's zero chance Galileo will be overturned and we'll find out the earth is at the center of the universe after all.

The same goes for evolution. We know that the broad outlines of evolutionary theory are correct and that life on earth diversified over billions of years from a common ancestor. It's just a fact, like the earth going around the sun. It's been proved beyond any shadow of a doubt by an overwhelming body of evidence. Same with HIV and AIDS. Everybody who has had anything to do with HIV care knows that if you give people who are at death's door from AIDS anti-retroviral drugs, they get better. People who weigh 80 pounds, whose bodies are wracked by fungal infections and bizarre viruses, who vomit up everything they swallow, suddenly get up off their death beds and start chowing down and dancing the cha cha. They stop taking the drugs, they get sick again. They take the drugs again, they get better again. QED.

And so on. Homeopathy. Vaccines cause autism. Dick Cheney masterminded the 9/11 attacks.* Yet these people are absolutely beyond hope of convincing. No possible evidence or argument could sway them. I'm proud to say that I've changed my mind on quite a few issues after studying the evidence. But it seems a badge of honor right now for people to refuse to do so and not only to hang on fiercely to nonsensical beliefs, but to demonize and threaten people who are rational. See Rick Perry claiming that the entire enterprise of climate science is a conspiracy to steal grant funding by falsifying data, and the Virginia AG trying to prosecute Michael Mann.

And the corporate media, as we well know, is resolutely committed to avoiding sorting out truth from falsehood at all costs. "Shape of the Earth: Views Differ," as Paul Krugman imagined the headline. Our civilization is in peril. I'm at my wit's end.

* Yes, the Bush administration failed to act on information urgently provided to "president" Bush. There's probably a lot more we should know about the whole thing. But we know who proactively did it and why the buildings fell down.

Good problem statement, anyway

2011-10-25T10:50:00.000-04:00

Lawrence J. Schneiderman offers up plenty of most excellent zingers regarding our cultural blindness about the nature of medical services and the ineluctable limits thereon. It's the sort of thing I keep saying here but he's more famous. A sampling of the good bits:

Throughout their exertions, members of Congress have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination as to what health outcomes should receive priority in a just society. "Priority in a just society”—those five words are encompassed and eclipsed by one word that was excoriated or indignantly tossed aside: rationing.

We will have to make tough choices, of course, but the choices will be based not on capricious gated communities of eligibility for limited, expensive, high-technology, life-sustaining treatments—for example, simply by reaching age 65 one suddenly becomes entitled to Medicare, which will provide substantial coverage for all sorts of organ transplants but sadly not a penny's help with walking, eating, bathing, and other daily tasks by qualified home health care workers, or even by family members who may have to give up their job to attend to these far more common elderly needs. These costs are a major source of bankruptcy and can amount to 10% of household income, causing severe economic, social, and psychological burdens on caregivers. Recognizing that there has to be a limit to the otherwise boundless demands that can be made on medical care, we must accept that medicine cannot serve every personal need, desire and good. Everyone is not entitled to everything. Everyone is entitled to a decent minimum level of medical care.

[T]he R-word, rationing, the proverbial third rail in the halls of Congress: Touch it and you’re dead. At least your legislation will be; witness the instant defeat of the mild effort to have Medicare reimburse physicians’ time to discuss end-of-life treatment alternatives, including advance directives. “Death panels,” shouted the opposition. “Pulling the plug on grandma!” “We cannot have rationing!” declare politicians who complacently enjoy their own medical insurance and overlook the irrational rationing that takes place all around them. Yet everyone who spends any amount of time thinking about this problem knows that rationing is ongoing and inevitable. As noted even in that champion of the libertarian free market, The Economist, “Every health system rations in some way or other; the demand for health care is always greater than the resources available. The question is whether rationing is done openly and as sensibly as possible—or done implicitly, through murky pricing, bureaucratic fiat or denial of care."

Alas, his solution I fear is too full of fuzzy logic and complex ethical judgments to advance the cause. Indeed, after reading the article carefully, twice, I'm not sure I understand it, and I don't consider myself a dolt. He attempts to apply a utilitarian ethic that weighs a combination of urgency of need, personal functional status, and social benefit. He tries to wiggle out of the accusation that his proposal values people's lives and health differently depending on somebody's evaluation of their relative worth to society, but alas, as far as I can tell, he wiggles futilely. Such judgments do appear to be lurking in the weeds of his garden, and he offers no clear and consistent way of making them, beyond a call for "transparency" and an appeal process. Not going to happen.

But, we sure as hell need to do something. The Republican solution is to champion injustice, exploitation, expropriation, waste and abuse. The Democratic solution is to wimp out and do nothing meaningful - including being too frightened even to make a clear statement of the problem. At least Schneiderman tries to give us that.

The deadly gift

2011-10-24T10:44:00.000-04:00

That is our self-awareness, and the psychological and social complexity which it contemplates. This makes being human extraordinarily interesting, but sometimes unendurable. As Christabel Owens and others note in their very interesting paper, Recognising and responding to suicidal crisis within family and social networks (British spelling there, not a mistake), almost one million people take their own lives every year.

Suicide is a surprisingly significant cause of death, but it's obviously a far greater tragedy than most more prevalent causes. It takes the lives of many young people, and it often leaves survivors feeling guilt as well as the pain of loss -- not to mention the pain the decedent must have been feeling, often completely unknown to others, or misunderstood.

Owens et al interviewed the loved ones of people who had killed themselves, and they find much that may not only be of practical help to people in similar situations, but also enriches our understanding of our shared condition. It seems to many of the survivors that the deceased had great difficulty, for various reasons, in communicating his or her distress; that the ambivalence that possibly suicidal people often feel is likely to be interpreted as meaning that the suicidal intent is not to be taken seriously; that it is often difficult for us to understand the inner lives even of people with whom we are intimate; that people do not want to be intrusive or seem to compromise the autonomy of loved ones; and that they also do not want to violate privacy or disrupt other people's relationships.

In fact, there is no harm in asking someone who seems deeply distressed whether they have contemplated suicide, or in inquiring about ambivalent or conflicting signals. There is no harm in encouraging people to get help. At the same time, people should not punish themselves with guilt for missing the signs which, as it turns out, can be difficult to interpret and act upon. I hope that this research, and other information which is available (e.g., American Foundation for Suicide Prevention) will reach more people.

As far as I know, only we, among the sentient creatures, feel our way in the world keenly enough that continuing sometimes becomes intolerable. Let's try to make the world a little less cold.

A really tough call

2011-10-20T11:12:00.000-04:00

I'm writing just a few minutes after Al Jazeera posted video conclusively proving that Muammar Gaddafi has been killed by revolutionary fighters. (There's no particular sense linking to the video, which is ephemera, since the fact of his death will soon be generally accepted and you don't need to look at that anyway. However, here's the link to the Al Jazeera home page for your bookmarks.)

As readers know who have checked out my side bar, another of my blogospheric projects has been helping to document and excoriate the illegal war of aggression waged by the U.S. in Iraq, and more recently the pointless, destructive ongoing occupation and aggression in Afghanistan. I was for many years on the Steering Committee of Boston Mobilization for Survival and I helped organize demonstrations in Washington and Boston against Reagan era intervention in Central America and against the Iraq atrocity. I've helped to organize and promote talks by everyone from Noam Chomsky to Howard Zinn to Cynthia Enloe to Fr. Robert Drinan, condemning U.S. imperialism and militarism. I have a drawer full of anti-war memorabilia.

But sometimes these hard cases come along. I found myself at odds with much of the anti-war community in the Boston area over the U.S. intervention in the ethnic conflict in the former Yugoslavia. In fact it was so contentious -- and back then I wasn't very good at managing conflict -- that it caused a major falling out between me and some old friends. Specifically, I saw the air campaign to protect the Kosovars from the genocidal campaign of Slobodan Milosevic not as an imperialist aggression but as a moral imperative. I felt that my comrades were reacting reflexively based on our long history of opposing proxy wars during the Cold War and campaigns to protect U.S. corporate interests in Latin America. This was really different. The memory of our failure to stop the Rwandan genocide was still fresh. I could not see how, when we had the power to stop something similar from happening, we could just sit and watch.

Yes, there were innocent people who died from U.S. bombs. But many more would have died had we not acted. And there was no evident U.S. interest in the intervention other than promoting stability and the preservation of international norms in Europe. I could discern no important ulterior motives.

The Libyan situation is more difficult to characterize. Gaddafi, for all his crimes, was the internationally recognized head of state and he was, without a doubt, putting down an insurrection. That's the legal fact. The moral fact is that his rule was illegitimate and was recognized by the U.S. and European powers out of purely cynical motives. To be sure, there are others like him who we continue to stand by. But as purely pragmatic matter, there was an opportunity here, because there was a massive, adequately led and reasonably well-armed uprising that could depose him if NATO acted as its air force; and there was a quite broad international consensus for action, including UN and Arab League cover, if not exactly support. Remember the horror that ensued when George Bush the First encouraged the Shiites in southern Iraq to rise up, and then failed to support them?

The Libyan civil war has resulted in the deaths of many innocent people. There's no telling how many but certainly the number is above 1,000. Many more have been displaced and are homeless. We don't know what will ensue, whether Libya will ultimately have a more just and open society. But I just couldn't decide that I needed to condemn the intervention. I believe there is a morally respectable case for it. What do you think?

Is everybody out of step but me?

2011-10-19T14:49:00.000-04:00

Unfortunately, it's off limits to you common rabble, but I'm going to discuss this medical news essay by Bridget Kuehn in the new JAMA anyway. (This is the sort of thing NEJM makes open access -- but so far JAMA has not succumbed to the awesome power of Stayin' Alive.)

As you may recall from previous episodes, the FDA sometimes requires medical device makers to conduct post-marketing safety studies of medical devices as a condition of approval. The only problem is, this "requirement" is not, in fact, a requirement. The companies often don't do it, or they sort of kind of start the studies but never complete them, and the FDA doesn't do anything about it. As Kuehn puts it, "Critics argue that tougher sanctions from the agency or greater collaboration from government agencies to ensure collection of the necessary data may help resolve this problem."

My only comment on that is, "Well, duhhh."

However, what I'd really like to discuss here is the specific issue of silicone breast implants. The drama around this was pretty well publicized a few years back. Concerns about silicone leaking into the body and causing disease led to a 14 year ban on plastic boobs but the FDA approved two products in 2006, with the condition that the companies conduct post marketing safety studies. They were required to follow at least 40,000 women for 10 years, but after 3 years, the follow-up rates are only 60.2% for one company and 21.8% for the other. At this rate, the FDA concludes, they won't have enough statistical power to detect uncommon, but possibly very serious, outcomes.

Okay, that's bad, but here's what we already know:

There are frequent "local" complications such as implants rupturing or contracting into a hard mass, wrinkling, scarring, pain, asymmetry and infection. Remember that the only point of these implants is cosmetic.
20-40% of women who got boob jobs for cosmetic purposes had them removed within 10 years; 40-70% of breast reconstruction patients had them removed.
There appears to be a small increase in the risk of anaplastic large cell lymphoma. It's rare, but if it does happen, you'll be lucky to live 5 years.

Ladies, listen up. Some guys like big bazongas, it's true. But believe it or not, some guys, probably just as many, don't, even if they aren't supposed to admit it. I don't know, given the above facts -- plus what we don't know due to the companies figuring that what you don't know can't hurt them -- whether these really ought to be approved for sale. Personal choice and all that. But knowing what you know now, is this something you really want to do? Just to appeal to a sub-set of men who happen to have a specific fetish and don't love you for your beautiful mind after all? Just askin'.

Those eccentric Brits

2011-10-18T10:16:00.000-04:00

The American Medical Association is much too serious to do something so radical and political and hippieish as the leaders of the British Medical Association have just done. They've issued a statement calling for urgent action on climate change. I mean, what does that have to do with the profession of medicine?

Climate change poses an immediate, growing and grave threat to the health and security of people in both developed and developing countries around the globe.

Climate change leads to more frequent and extreme weather events and to conditions that favour the spread of infectious diseases. Rising sea levels, floods and droughts cause loss of habitat, water and food shortages, and threats to livelihood. These trigger conflict within and between countries. Humanitarian crises will further burden military resources through the need for rescue missions and aid. Mass migration will also increase, triggered by both environmental stress and conflict, thus leading to serious further security issues. It will often not be possible to adapt meaningfully to these changes, and the economic cost will be enormous. As in medicine, prevention is the best solution.

Action to tackle climate change not only reduces the risks to our environment and global stability but also offers significant health co-benefits.[i] Changes in power generation improve air quality. Modest life style changes – such as increasing physical activity through walking and cycling - will cut rates of heart disease and stroke, obesity, diabetes, breast cancer, dementia and depressive illness. Climate change mitigation policies would thus significantly cut rates of preventable death and disability for hundreds of millions of people around the world.

Oh, I see. Of course, this won't do anything to increase doctors' incomes. So there's no reason for the AMA to get involved.

Live long and prosper?

2011-10-17T14:54:00.000-04:00

Inspired by RA's comment on the previous post, I would say it's still an open question what health status and longevity will be like in rich countries like the U.S. of A. as the 21st Century staggers on. It's already conventional wisdom in the public health community that life expectancy will decline a bit because of the obesity epidemic. It's very difficult to say whether there is any signal from chemical exposures, such as pesticides and industrial effluent, for the mildly paradoxical reason that people are living longer. If these exposures do increase the risk of cancer and metabolic diseases, we can't exactly tell because these diseases are also associated with age, and it used to be that not a lot of people lived long enough to get them. Also, obesity is a risk factor, while smoking rates have been declining. Etc. In other words, hard to sort all that out.

But, in fact, probably the biggest threat to our health as a people is the rise in inequality. Inequality makes us sick. If we can't provide decent opportunity, security, and a supportive social environment for everyone, then we won't be as healthy and we won't live as long. Yes, clean air, clean water, a healthful food supply, all matter. But only at the margins. The impact of these sorts of environmental insults on people who are well nourished, psychologically whole, and well cared for, is much less than on people who are otherwise disadvantaged. And disadvantage reproduces itself throughout and across communities, and down through time and generations.

As for the long-term human population, however, it doesn't matter what happens to people past child bearing age. If everybody dropped dead at age 50, it would have no effect on the number of children born in 2050. (At least not directly. It would reduce pressure on resources, obviously, in the interim, but might prove economically costly because we'd lose all those experienced, wise people such as myself.) And actually, the male population barely matters either. The only question is how many girls survive through their reproductive years, and how many babies they have, and how many of those girl babies in turn survive. So unless we want girl babies to die, women need to have fewer children. That's the bottom line.

Nine billion of my closest friends

2011-10-16T09:11:00.000-04:00

That's the widely accepted mid-range forecast for the human population in 2050, with the number expected to stabilize at about 10 billion by century's end. The stabilization is expected to happen because of the long-term trend toward declining birth rates as societies become more prosperous, the status of women rises, and infant and child mortality declines.

As Robert Engelman discusses at Climate Progress, all this projecting assumes no increase in the death rate. In fact it assumes continuing increases in life expectancy and declines in early mortality. People are very reluctant to go there, it seems, but what if it doesn't happen that way?

Engelman points to climate change and rising sea levels. He doesn't have much to say about the possibility of emerging infectious diseases, which worries some people quite a lot. He also apparently wrote before news of an analysis, about to appear in the journal Nature, which finds it might be barely possible to feed 9 billion people, but only if humanity makes several major changes, none of which are happening now. The most important is for people to eat less meat. Most cropland is devoted to growing animal feed, which turns into about 1/8th as much human food. However, the current trend is the opposite: people are eating more and more meat, particularly as China becomes more affluent.

But we don't have to wait until 2050 to know that we have a problem. We have a problem right now. As John Schoen reported earlier this year, the global food supply is stretched to the limit. Rising food prices contributed to the social unrest that created the Arab Spring, and the UN now expects food prices to remain high forever, basically. Reserves are at the lowest level in 30 years and still falling. Weather anomalies as well as rising demand, and diversion of crops to biofuels, are behind the shortages. All of that is just going to get worse.

So no, there can't be 9 billion people. That can't happen. It can not happen the hard way, or it can not happen the easy way. Unfortunately, "Christians" who oppose contraceptive services want to make sure it happens the hard way, because you know, Jesus wants children to starve. Meanwhile, however, please eat less meat.

Apologia

2011-10-14T14:55:00.000-04:00

PZ has solicited people to write "Why I am an Atheist" essays which he is selectively posting. I'm not going to enter the competition because a) I wouldn't be a winner and b) it doesn't really make sense to me to apply an affirmative label to myself based on what I don't believe. True, I'm not religious but I don't believe in Santa Claus either, and neither fact constitutes my identity or serves to explain or describe me.

What I do believe is not simple to explain. To begin with, there are various senses of "belief." I could say that I believe Shakespeare was a great writer, for example. One true fact about me is that I am an admirer of Shakespeare. Some people are either unfamiliar with Shakespeare's work, or don't care for it as much as I do. Our lack of shared belief in this case does not entail any contradiction. You can feel any way you want about Shakespeare as a writer, including having no opinion at all, without in any way calling into question my feelings about the Bard.

I also believe that the plays were written by the son of a local official and glove maker from Stratford-upon-Avon. Some people don't believe that. Therein does indeed lie a contradiction. We cannot both be right. This is what is called a truth claim as opposed to a personal preference or taste. However, we might have these opposing beliefs while sharing pretty similar criteria for evaluating truth claims. Perhaps we have not seen all of the same evidence, or make different judgments about probabilities. We might argue passionately but the fundamental nature of reality is not at stake.

Next, I believe that Shakespeare was the descendant of creatures that lived in Africa around 6 million years ago whose descendants also include chimpanzees. You might believe that he is the descendant of people created magically from dust by a supernatural being less than 10,000 years ago. These opposing claims cannot possibly be based on similar criteria for judging truth, because the kinds of evidence that exist for them are completely different. The evidence for my conclusion consists of an overwhelming body of observations about the remains of ancient creatures preserved in rock; the biology of chimpanzees, humans, and other creatures including their DNA and everything having to do with genes and gene expression; geology; cosmology; and observations about the distribution of all sorts of creatures around the planet and their interactions with their environments and in many cases, their observable evolutionary change over time. And more. It's based on a broad, complex picture of reality built up painstakingly, piece by piece, from evidence.

The supernatural being making the man from dust, however, is based entirely on the contents of an ancient book written by people who had no evidence whatsoever for the story they told. They were just imagining it. And it is full of both internal contradictions and contradictions with observable reality. Believing such a story is just silly. We know more than they did because we have been studying the world, and writing down our observations, and passing them on to the next generation, so each knows more than the last.

So the question is not why am I an atheist. I'm an atheist because there is no meaningful evidence whatsoever for the existence of God; and because the concept of God is both internally contradictory and contrary to readily observable reality. That isn't really even worth an essay. I find it trivially obvious. The question is why so many people cling fiercely to silly stories. That requires an essay.

The twilight of democracy?

2011-10-13T10:45:00.000-04:00

In the 1930s, the last times as hard as what we're in now, the state stepped in to write a new contract between capital and labor that saved capitalism, whether the plutocrats whose greed caused the Depression and the devastation of the working class appreciated it or not. Today, we're back where we were in 1929, and people are finally taking to the streets in anger and desperation -- but with an astonishingly sunny disposition about the whole thing, I must say.

(For those of you who haven't seen it yet, former Schtickdreck Henry Blodgett, who helped pump up the Internet bubble, is now telling it like it is. Don't miss it. I believe I recently mentioned that inequality in the U.S. is now making Third World kleptocracies look benign, as Blodgett's colleague Gus Lubin illustrates.)

However, the response of the GOP (Grand Old Plutocracy) is to propose raising taxes on the bottom half of income earners in the interest of "fairness," while further cutting taxes on the ultra-wealthy -- which are by the way at the lowest level since 1930. That ought to seem really weird, but in fact the polling numbers right now show Plutocracy Party candidates running neck and neck with the president, who has cut taxes on workers and for that matter middle income professionals, and wants to raise taxes on the wealthy, while spending money to create jobs and pull the economy out of the quicksand -- all of which makes him a socialist who hates America.

There's false consciousness, and then there's insanity. The problem is that the corporate media refuse to explain any of this clearly, and instead choke the public square with obfuscating smoke. The 6 trillion dollar question is what's going to happen when those folks out in the streets just get mocked by the corporate media, their plight belittled by the political class, and they're still out of work, and it just keeps getting worse.

Less continues to be more ...

2011-10-11T14:31:00.000-04:00

. . . or is it More continues to be less?

We should probably distinguish between two components of the so-called dietary supplements industry. Component number one, which gets a continual trashing at such worthy locations as Respectful Insolence and Science Based Medicine (which are not wholly separate entities, but that's by the way), is the "herbal remedy" or more accurately snake oil industry. This consists of companies that sell worthless products which they insinuate will cure your ills, but don't need to have any actual evidence because Congress has forbidden the FDA from regulating anything that's called a "dietary supplement" until and unless it comes to their attention that the stuff is actually killing or harming people, and they can prove it.

These are the people who claim to have the secret knowledge that "they," meaning mostly the pharmaceutical industry, don't want you to know about. Why these evildoers can't be prosecuted for fraud is unclear to me. Homeopathic remedies are in that class but so are echinacea, saw palmetto, etc.

Then there are products that really are dietary supplements, in the sense that they contain concentrated amounts of nutrients, such as vitamins and minerals, that we really do need in our diets. The purveyors of these products are usually more circumspect in their claims, partly because they are often big mainstream corporations some of which also produce FDA-approved pharmaceuticals. You'll see multivitamins advertised on TV, but the idea that they might do you some good is not as outlandish as the claims for shark cartilage and whatnot.

However, the claim largely seems to be untrue, at least for Americans who are almost universally adequately nourished. Just because a deficiency of a vitamin causes problems doesn't mean that more than enough is better. At one time there were indications from epidemiological studies that antioxidant vitamins might prolong healthy life but the more the issue has been studied, the less likely it seems. In fact, studies as time goes on and studies of higher quality are done, it has started to appear that most supplements may actually be harmful.

You may have heard about a recent publication by Jaakko Murso and colleagues in the Archives of Internal Medicine. This is helpful not only because it reports on new findings from a large-scale epidemiological study, but also because it contains a good review of the current state of knowledge to which this adds. The study included only older white women, so maybe it's different for other categories of Homo sapiens although it's not clear why it would be. And, like most previous studies of this question, it's purely observational. Randomized controlled trials of dietary supplements would be very difficult to do because you need decades of follow up and since they're sold over-the-counter there's really no way to control who takes them and who doesn't.

The difficulty with such studies is that whether people take supplements is not independent of other factors. Maybe people who take them are more health conscious generally, eat better, exercise more, don't smoke, drink only in moderation, yadda yadda. So they appear healthier but it's not because of the supplements. Or maybe people take supplements because they have health problems, so it looks like they're less healthy, but again it's not because of the supplements.

Sigh. All you can do is get as much information about the people as possible and throw it into a multivariate model. If you control for the smoking and obesity and pre-existing illnesses and what-not, you can at least argue that you might have been able to shake out the independent effect of the supplements.

What this study finds is pretty much in line from the picture that has already been emerging. It looks like calcium might be beneficial, but not if taken in excess. It looks like iron supplementation is harmful. This is actually the strongest finding because there is a consistent dose-response relationship, it's been observed in previous studies, and there is a plausible biological explanation for it. Anti-oxidant vitamins, it appears, are more likely to be slightly harmful than they are to be beneficial.

Again, this is all assuming you don't have a nutritional deficiency, but you almost certainly don't. We get everything we need, and usually more, from our diets. Can we absolutely rule out that multi-vitamins and mineral supplements might benefit some people under some circumstances? No, but there's no reason to believe it either. So why spend the money?

But for me, the point is not to give medical advice, which I am not doing. You should talk to your doctor. Rather, the point is that this stuff is heavily advertised, both to old people and to parents of young children (in the form of empty calorie cereal products with a vitamin pill thrown in, as well as actual pills), they're vacuuming up money, and it's essentially a scam. It shouldn't be allowed but the Supreme Court and Congress thinks corporations have a First Amendment right to lie to you. I don't think that was the Original Intent, Justice Roberts.

Just so you know . . .

2011-10-10T14:27:00.000-04:00

I'm back in business at Windham County. Expect to continue.

I'm getting out the popcorn for this

2011-10-09T09:44:00.000-04:00

It had to happen. The "Value Voters Summit" (the rest of us don't have values, or course) has become an occasion for people to start talking about how Mitt Romney is not a Christian. Reporters, for whatever reason, feel they have to tip toe around this and not actually discuss Mormon theology.

Not that I care, but obviously, Mormons are not Christians. The distance between the Latter Day Saints and any Christian denomination is vastly greater than the distance between Southern Baptists and Catholics. I don't know how many voters will care either, but this does mean that a major problem facing the Republican Party and the contemporary conservative movement in the U.S. has finally come to the surface. When you base party and movement identification on religious identification and theological commitment, you are building a foundation of rubble.

Faith unites the particular people who subscribe to any given version, but it divides them from everyone else. In the U.S. today, we have a secular society in which this doesn't matter to most people in daily life. Our friendships and workplace relationships generally ignore religious affiliation. There is prejudice among some people against Muslims, obviously, but we're on our way, I think, to ultimately integrating Islam into the tapestry as we have done with Judaism.

In politics, obviously, we have not gotten as far toward true secularism as we have in other spheres. Muslim candidates don't have a chance in most places, Keith Ellison being the exception that proves the rule. We elect Mormons and Jews to office quite commonly nowadays, but it's unclear whether either could be elected president. (I hope we don't get an affirmative answer the hard way, with Mitt Romney.) Atheists, however, have no chance, according to polls. We are disqualified in the eyes of more voters than are Muslims or homosexuals. (Truth.)

But, the Republicans are doing everything in their power to make this situation worse. By claiming that the U.S. is a Christian nation, they not only isolate themselves from non-Christians, they also poke the hornet's nest of who actually counts as a Christian. It works to stir up a certain segment of the electorate as long as those people think you're talking about them and saying they are the special, chosen people who should rule. But it means real trouble when they start quarreling with each other about who exactly is in and who isn't.

Enjoy the show.

I told you so

2011-10-07T12:56:00.000-04:00

In accordance with my wishes (and once again the awesome power of Stayin' Alive to shape the culture is proved), the U.S. Preventive Services Task Force is about to recommend that we knock it off with the prostate cancer screening. The predictable truckloads of excrement are already hitting the fan. If you want to get informed about this issue, there's no better resource, if I do say so myself, than Stayin' Alive, here, here, and here. (The last one was written before the verdict was in on whether there is any mortality benefit from prostate screening. Basically, there isn't.)

There are two outraged constituencies, between which it is essential to distinguish. One is men who consider themselves prostate cancer survivors, often speaking for advocacy groups. They are absolutely convinced that prostate cancer screening saved their lives and ipso facto, if other men are not screened then lives will be lost.

However, it does not follow. What we do know is that they were screened for prostate cancer, they tested positive, they were treated, and they are alive. What we do not know is whether they would be alive if none of the preceding had happened and the answer is, most likely, yes. In fact, based on autopsy findings, about 70% of men over 70 have prostate cancer when they die, and never knew it. These men would very likely have been among them, had they not been screened, and they would also have retained their urinary continence and erectile function.

A few of them would have died of prostate cancer had they not been screened, but more likely, the cancer would have been detected after it became symptomatic and their chances of survival wouldn't have been all that different. And some men who are screened, and undergo treatment as a result, will die sooner than they would have if they weren't treated.

But, men who are so invested in their survivorship and who have dedicated themselves to saving the world from the terrible fate they avoided just aren't going to give that up easily. It's very hard to accept after the fact that such a momentous decision, and the pain and sacrifice it entailed, might have been a mistake. Especially when you are grateful to your doctors and all that. It's just demanding too much cognitive dissonance for them to change their minds.

The second constituency that's howling is of course all those people who make money from prostate cancer screening. Oncologists, radiologists, drug and device companies. No mystery there. Less screening stops the gravy train. All these people will scream and yell but you had best ignore them -- they have an irreducible conflict of interest.

One more piece of good news -- you don't have to let the doctor stick his finger up your ass any more. Just say no. If this causes more guys to show up for appropriate medical care, so much the better.

Yes Sarah, there is a death panel

2011-10-06T13:11:00.000-04:00

Like many people, I find this quite disturbing. I understand that the War on Terra provides certain (what shall I call them?), ah, conceptual challenges to our ordinarily largely thoughtless process of suspending morality in the service of war. In order to make war seem like a morally endowed realm, over the centuries people have developed rules.

For example, it's okay to kill people with projectiles or explosives, but not with poison gas. That seems utterly nonsensical to me but it's extremely important to some people who get quite passionate about the distinction. It's okay to attack a target knowing full well that non-combatant bystanders will be killed or maimed, but it's not okay to intend that they be the target. Again, the distinction largely escapes me, but it's important to some people. Within such constraints, it's fine to kill people, but if you happen to capture them, it's no longer okay. It's also not okay to torture prisoners, or otherwise treat them inhumanely, unless the perpetrator happens to be the United States. And, obviously, you can only kill or maim people using explosives or projectiles if they are combatants of a nation with which the country doing the killing is at war, or happen to be collateral damage of efforts to kill or maim said persons.

In the case of the War on Terra, we have, perhaps perforce, extended the definition of an entity with which we are at war beyond the nation state, but the U.S. has never declared war on Al Qaeda, nor the Taliban, nor is it clear who is and is not a member of either group. Al Qaeda, in particular, is not really an organization but just a label which various people and groups with various degrees of organization and coherence apply to themselves, or have applied to them by others. Osama bin Laden, who U.S. forces recently killed, was a citizen of Saudi Arabia (I believe they revoked his citizenship, leaving him stateless), with which we are not at war; and was killed in Pakistan, with which we are also not at war.

Anwar al Awlaki was a citizen of the United States, with which we are not at war, and was killed in Yemen, with which we are not at war. He also happened to be a citizen of the United States, and therefore constitutionally protected by the following language:

No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a Grand Jury, except in cases arising in the land or naval forces, or in the Militia, when in actual service in time of War or public danger; nor shall any person be subject for the same offense to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation.

Plain enough. So it would seem that the president of the United States would be exceeding his authority by ordering that a United States citizen be killed, if said person had not been convicted pursuant to due process of law and sentenced to death. In fact the president would be a murderer.

As the Reuters article linked above explains, the president did not issue such an order. In order to "protect" him, such orders are first promulgated "committee of mid-level National Security Council and agency officials. Their recommendations are then sent to the panel of NSC "principals," meaning Cabinet secretaries and intelligence unit chiefs, for approval." All of this is done entirely in secret, without any possibility of judicial review. The president can object, but does not proactively order the person killed.

Evidently I'm supposed to trust these unidentified people to kill only people of whose death I would approve. But why should I? What if the president happened to be someone who appears on the same stage with Bryan Fischer, and agrees that the Bill of Rights does not apply to non-Christians, or homosexuals? Now that we have a functioning death panel, and it's evidently perfectly legal and requires no public justification or accountability of any sort, it's officially available to the next president. Not that I'm down with this one either, but just in case you are, I'm just sayin'.

A good death

2011-10-05T10:59:00.000-04:00

The fact is often bandied about that 1/4 of all Medicare spending is on people in their last year of life. Some people are misled into thinking that this implies more futile and wasteful spending than it really does, because we only know that these people were in their last year of life retrospectively. Generally, doctors are not able to predict how long a person will live, and much of that spending represents appropriate efforts to give people additional years of meaningful life that just didn't work.

Nevertheless, we know that there is a lot of money spent on so-called "heroic" efforts to rescue people who have very low quality of life and/or no hope of living very long, and who do not want the treatment or would not want it if they were able to express their wishes. Furthermore, both the dying and their loved ones generally much prefer to die at home, or failing that in a nursing home, than in a hospital.

It turns out there is huge regional variation in the amount of Medicare spending in the last year of life, which is highly correlated with the percentage of people who die in hospitals. The movement to encourage people to make end-of-life plans, and sign advance directives or appoint a proxy -- a spouse of child, most likely -- empowered to make end-of-life decisions should the person become mentally incompetent -- has increased the number of people making such documents. The number would be even greater, of course, if the proposed Medicare benefit for consultation about end-of-life care had been included in the Patient Protection and Affordable Care Act. Alas, as we all know all too well, Sarah Palin's psychotic screaming about Death Panels put a stop to that.

While advance directives sound like a great idea, unfortunately there has been mixed evidence about whether doctors actually pay attention to them and whether they are effective in reducing unwanted and wasteful expenditures. LH Nicholas and colleagues sort some of this out for us in the new JAMA. The story is a little bit complicated but the main takeaway is fairly simple.

In regions where spending is generally high and more people die in hospitals, treatment limiting advance directives* do seem to make a difference. They reduce average spending by an estimated $5,585 per patient; decrease the probability of dying in a hospital from 47% to 38%; and may reduce the probability of receiving life support by a bit although this difference failed to reach the conventional p <.05 level of statistical significance. The message seems to be that in places where the culture generally promotes heroic measures, advance directives do make a difference. In other places, the norms are already consistent with less futile treatment so they have less impact.

But, the second takeaway is that a) not enough people have advance directives (just under half); and b) they still don't seem to be honored as much as they should be.

Anyway, if you haven't done it yet, please do. It's something we don't want to think about but it is a great favor to your loved ones to have everything clearly understood ahead of time. And to yourself, of course. Your primary care doctor should be able to help you with this even if Medicare won't pay for it.

*You are free, by the way, to make an advance directive calling for everything possible to be done to extend your life, even by one minute, and even if you are a vegetable. However, too few people actually did this to analyze the effect.

Pain, doubt and doom loom . . .

2011-10-04T09:52:00.000-04:00

and, to quote Pogo, "Bazzfazz." The Economic Cycles Research Institute joins some other reputable forecasters in foreseeing really, really bad stuff. To wit:

More than three years ago, before the Lehman debacle, we were already warning of a longstanding pattern of slowing growth: at least since the 1970s, the pace of U.S. growth – especially in GDP and jobs – has been stair-stepping down in successive economic expansions. We expected this pattern to persist in the new economic expansion after the recession ended, and it certainly did. We also pointed out – months before the recession ended – that because the “Great Moderation” of business cycles (from about 1985 to 2007) was now history, the resulting combination of higher cyclical volatility and lower trend growth would virtually dictate an era of more frequent recessions.

So it comes as no surprise to us that, with the latest expansion only a couple of years old, we’re already facing a new recession. Actually, such short expansions are hardly unheard of. From 1799 to 1929, nearly 90% of U.S. expansions lasted three years or less, as did two of the three expansions between 1970 and 1981. In other words, such short expansions are unusual only with respect to recent decades.

It’s important to understand that recession doesn’t mean a bad economy – we’ve had that for years now. It means an economy that keeps worsening, because it’s locked into a vicious cycle. It means that the jobless rate, already above 9%, will go much higher, and the federal budget deficit, already above a trillion dollars, will soar.

Okay, we already have people taking to the streets (and why did it take them so long?) but they don't know what they want, except for times to get better and nihilistic greedheads to stop ripping everybody off. But where will our politics go when it just keeps getting worse? That's really worth worrying about.

Rats, I missed it

2011-10-01T08:32:00.000-04:00

It seems yesterday, Sept. 30, was Blasphemy Day. I don't know how I could have left that off my calendar.

Well, okay, I don't really need a special day for it. But as much as I enjoy blaspheming, the challenge is that the more intensely religious a person is, the more likely that person is to commit blasphemy. It's an almost perfect correlation. If I say Jesus is the son of God, I'm committing blasphemy as far as every Muslim, Jew and Zoroastrian is concerned. If I say Muhammad is God's prophet, I've committed blasphemy in every Christian dominion. If I say Rebe Menachem Scheerson was the Messiah and he will be reincarnated . . . well, you get the idea.

I don't go around saying stuff like that. On the other hand my occasional references to the 4.65 billion year antiquity of the earth, the common ancestry of humans and slime molds (I was about to say Chimpanzees but that's too obvious), or the dependence of consciousness on its biological substrate are no doubt blasphemous to some people, but each of these are facts that I touch upon only when they come up in some exigent context. I don't just ritually repeat them as a periodic duty. So I'll pass on Blasphemy Day after all. It's just superfluous.

We're mad as hell and we aren't going to take it any more

2011-09-29T13:16:00.000-04:00

I'm not the world's biggest fan of Matthew Yglesias, but He gets my endorsement for this. This Occupy Wall Street theatrical production that's going on right now is just absurd. Yes, it's good that we're seeing some folks out protesting who are mad about some of the right things and aren't demanding that the federal government keep its hand off of Medicare.

On the other hand, even if they're ridiculous when they aren't offensive, teabagger demands actually exist. The protesters down in New York obviously don't like to see parasites suck up billions while good honest folk can't get a job. I'm with them on that. So what do they want to do about it? Maybe if they just got some giant puppets or Wavy Gravy showed up it would all make more sense. Or maybe not.

Yes, we need a movement in this country. We need people to channel their anger into political action. We need to wrestle politics away from the billionaires behind the curtain and their Jesus talking marionettes. But that means people have to come together around an agenda for real change. The only concrete demand that's come out of this action is that a New York City police inspector be investigated for gratuitously pepper spraying some people. I'm for that, but it wasn't the original problem.

Yet one more disappointment

2011-09-28T15:05:00.000-04:00

You may have seen news coverage of this study which finds that saw palmetto extract is utterly useless for benign prostate enlargement. (You only get to read the abstract, but I read the whole thing. Na na na na na.)

I can tell you that this was a very high quality trial, it's got all the right randomization, blinding and assessment procedures, and the results were as negative as you can possibly get. Actually placebo turned out to appear very slightly more effective, but that's probably just chance. If you believe this, saw palmetto absolutely does not work.

What's interesting about this is that saw palmetto for benign prostate enlargement was one of the examples of a traditional herbal remedy that was believed to work, based on previous trials. (Obviously, willow bark works for pain, it's aspirin; poppy resin contains opium, which does what opium does; etc. Many drugs are derived from plants, nothing unusual about that.) However, more recent trials and meta-analyses had called that conclusion into question. One reason they did this was to clear up the confusion, and also to try a higher dose than has been used in the past to make sure they had maximum chance of finding a benefit if the stuff really does work.

So why the fairly steady trajectory from initial positive findings to this disappointing result? Actually, that's pretty common. Early trials of a compound are typically not of the highest quality, in part because there isn't a lot of money for them. People just want to get a first look, and nobody's going to put big bucks into something highly speculative. Lower quality trials are more likely to get positive results because of inadequate blinding and other design flaws, and furthermore their sponsors are usually engaged in selling the stuff. On top of that, trials with positive results are more likely to be published.

So, even with interventions that do ultimately turn out to be effective, it's common for the effect size to diminish as they are better studied. In this case, it went away completely. The universe is against us.

Fortunately, saw palmetto appears to be harmless, so it's just that men have wasted some money. My advice in general however -- don't be eager to take pills that have only been on the market (in the case of pharmaceuticals requiring FDA approval) a short time; or in the case of unregulated supplements, that have only been studied a little bit. Chances are those early encouraging results aren't going to pan out. By the way a good reason to doubt is lack of a known biological mechanism of action. Bayes theorem tells us that with a low prior probability, the positive findings aren't nearly as convincing.

Of course, this won't stop the "supplement" industry from marketing the stuff. Their claims don't have to be true.

Two simple words

2011-09-27T13:32:00.000-04:00

Yesterday I blew a wheel bearing on my way home from work and wound up sitting beside Route 6 for 2 1/2 hours waiting for the wrecker. (Only 70,000 miles on the vehicle, I am not at all gruntled.) Anyway, the guy finally did show up and he was quite friendly. On the drive to the Nissan dealership he asked me what kind of work I do and I told him I'm a medical sociologist, I mostly study communication between doctors and patients. Then, as is my wont (I'm a data addict) I gave him the prompt. "Usually when I tell people that they have stories to tell me."

Did he ever. I'm don't have a lot of time today to invest in literary quality so I won't try to reproduce his voice, but here's the gist of it. Fred (let's call him) had a hernia operation a couple of years ago. It's basically day surgery, I don't even think he stayed overnight. Walking to the car with his wife he felt an excruciating pain in his abdomen. They went home anyway but from there he called the surgeon and said he was in pain.

"Why? Did you fall on the ice?" Fred took his eyes off the road long enough to beam his rage at me. "I said to him, Why the fuck would you say that? Why the fuck would you say something like that to me?" Anyway, the surgeon told him not to worry about it.

So Fred tried not worrying. But he had no appetite. He kept feeling more and more bloated, like he had gained 20 pounds, but he wasn't eating anything. A couple of days later, he vomited. "I said to my wife, shit, that's food I ate three days ago." Then he started torrential sweating and the pain became unendurable, so his wife took him to the ER.

"There was a Polish doc there, a good guy. They did a cat scan, then he said to me, You're in critical condition. We're going to have to operate. I said when, tomorrow? He said no, now. Five minutes later they had me knocked out."

It turns out the surgeon had stitched the patch to his small intestine, which stopped the peristalsis -- the waves of contractions -- that move material through the system. I had to help Fred with the technical details, which he still didn't completely understand, but this is called paralytic ileus. Food and the tiny amounts of air and saliva we continually swallow were backing up above the obstruction, while the rest of the tract below had emptied out. This situation could have killed him a couple of different ways, including peritonitis if the stitches were leaky. His intestines could have ruptured. Part of the intestine could also have died. You get the idea -- this was not good. Oh yeah -- he got a C. difficile infection, which is a common opportunistic nosocomial infection which moved in when the antibiotics they pumped him full of wiped out his normal intestinal flora. It's extremely nasty. Fred was hospitalized for 11 days.

Sooo . . . Toward the end of the ordeal he saw the nice Polish doc out in the corridor talking with Doctor Badfingers, who then came into his room. But Dr. Badfingers wouldn't admit what he had done. He hemmed and hawed and spouted some BS. "Why couldn't he just apologize?" Fred demanded. "That's all he had to do. I make mistakes working on cars, you know? He could have said it was close quarters in there, he just got a couple of stitches in the wrong place, he's sorry. But he wouldn't say that."

So I told Fred that lots of doctors have been told not to apologize because the hospital lawyers think it will count against them in a malpractice suit. In fact, this question has been researched and doctors are less likely to be sued if they apologize. Most malpractice suits have less to do with the technical screwup -- if any, although in this instance there would seem at first glance to be a good case for negligence -- than they do with the interpersonal interaction surrounding it. And Fred had indeed gotten a lawyer and was indeed looking to sue, which he said he would not have done if the guy had just apologized.

Unfortunately for Fred, he probably isn't going to get anywhere with his suit, not because this is not malpractice, but because the award he could get probably wouldn't be worth it. He doesn't have long term damage, he's back at work, he's big and robust and jolly (when he isn't thinking about this experience) and jurors just aren't going to break down and weep for him. His lawyer needs to be looking at a big enough contingency to make the whole thing worth his while and he'll probably decide it just isn't there. But I'm speculating.

The problem with the whole malpractice tort system is not that it drives up medical costs, as Republicans would have it. They are wrong about everything, of course. Malpractice awards, insurance, and resultant "defensive medicine" probably contribute around 2% to overall medical costs, and of course some part of that, maybe most of it, is perfectly legitimate. However . . .

The likelihood that a doctor will get sued has little to do with whether the doctor did in fact act negligently or incompetently. Mistakes and bad outcomes happen which are not the result of negligence, but the people who suffer from them can't get compensated, and can't even get their subsequent medical costs or other care needs resulting from the medical error or bad outcome paid for. Yet people like Fred often can't sue, which means he doesn't get compensated for his lesser harms of missed work and pain and suffering, even though he probably is the victim of negligence. Finally, people whose bad outcomes are not the result of negligence often do sue anyway, and while they don't usually win, they generate litigation costs.

What we need is a no-fault system for compensating iatrogenic harms, and a separate system for holding physicians and hospitals accountable for avoidable errors. We need to sever the two problems.

And oh yeah, Doc -- say you're sorry.

Priorities . . .

2011-09-26T10:13:00.000-04:00

In my last post, I made a jest about spontaneous human combustion as a major public health problem, but a commenter wants me to get real. So here's my basic concept of the public health universe.

In every society, social and economic status is strongly associated with life expectancy, health status, and the prevalence of disability, even where there is universal and equal access to health care. In addition to these disparities within societies, it is now generally held that societies with more inequality tend to have worse population health than societies of comparable aggregate wealth but less inequality. Population health is also strongly affected by environmental conditions such as water and air quality; culturally and economically influenced behaviors such as tobacco and other substance abuse, diet, and physical activity patterns; and social conditions associated with psychological stress and violence.

The World Health Organization tends to view social determinants of health and resulting disparities in terms of inequities among countries, but it is also true that even after controlling for aggregate wealth, countries with less inequality have better health indicators than countries with more inequality. The United States is actually an outlier that contributes powerfully to this association -- in spite of our great wealth, we also have exceptional inequality. In fact, using one simple measure, the ratio of income between the top 10% and the bottom 10%, the U.S. is among the most unequal countries in the world -- we have greater inequality than Nepal, Ghana, Cameroon, Benin, and most of the poor countries. (Burkina Faso, anyone?) The same is true by other measures. (The Wikipedia table lets you sort by various indicators.)

And, we also have much lower life expectancy and higher infant mortality than would be predicted by our relative wealth. In fact our life expectancy at birth in 2007 was about the lowest among the wealthy countries, although obviously we're ahead of places like Ghana on that measure.

We don't completely understand the mechanisms that link social inequality to poor health. Obviously people in the poor countries are subject to severe malnutrition, contaminated water, and untreated infectious diseases which are unlikely to plague people in the U.S. (although it does happen). But even our poor people generally have clean water and enough to eat, and can get antibiotics if critically needed. Tobacco, obesity, occupational hazards, exposure to air pollution, and other measurable risks (including fire, BTW) are associated with socioeconomic status. We can figure out why these associations exist and work to ameliorate them, but of course it would be even better if everyone was better educated and more financially secure. That would be getting at root causes. And, even after we control for everything we can think of, there is still a residual, and substantial, socioeconomic gradient in health status that we can't really explain.

Basically, it hurts to be at the bottom. More justice means better health. So ultimately, that's my priority.

An insufficiently recognized public health issue?

2011-09-23T13:23:00.000-04:00

That would be spontaneous human combustion. It seems an Irish coroner has ruled it the official cause of death for a 76 year old man:

Michael Faherty died in his home in December 2010. His body was badly burned, but a fire in the nearby fireplace did not cause the blaze, forensic experts said. Scorch marks on the ceiling above the body and the floor below, and no trace of accelerant, led the coroner to return the controversial verdict, the first of its kind in Ireland, according to the BBC. “This fire was thoroughly investigated and I’m left with the conclusion that this fits into the category of spontaneous human combustion, for which there is no adequate explanation,” West Galway coroner Dr. Ciaran McLoughlin told a court Thursday.

Discover Magazine, which is marginally reputable, has a rundown on the subject of SHC. There is a possible explanation for some cases, which is that if an unconscious person's clothing catches fire, it could act like a wick, gradually burning the person's body fat like a candle. This process would take several hours, but it might not ignite the surroundings. The Skeptic's Dictionary is a bit less credulous, but doesn't rule it out. UK Skeptics seem to think it probably does happen.

Note, however, that the combustion is not really spontaneous. There is an ignition source, such as smoking material. And the person obviously has to be unconscious. This this is a possible explanation for some events, such as the one in Ireland; but Spontaneous Human Combustion is a misnomer.

So if this does happen, it's just an unusual way of manifesting a perfectly ordinary risk, that of falling unconscious near a source of flame. Mostly you burn the house down, sometimes you just leave a greasy soot stain. Weird, but not supernatural.

This is probably nothing . . .

2011-09-22T15:07:00.000-04:00

Cold fusion and all that. But ...

Puzzling results from Cern, home of the LHC, have confounded physicists - because it appears subatomic particles have exceeded the speed of light.

I post this because as far as I can tell it has yet to be reported in the U.S. If it's true, just wow.

Oppressive government regulations

2011-09-22T10:38:00.000-04:00

As I have mentioned before, I think, I'm currently forced to commute a good distance to work so I'm OD'ing on National Pubic Radio. Yesterday I learned that our favorite country of holey cheese, global tax evasion, and giant wooden trumpets has a law prohibiting the keeping of just a single guinea pig. It seems they might get lonely, so you must have at least two. Yep, it's perfectly legal to conspire with despots to conceal the billions they have looted from their people, but you can't make a guinea pig lonely.

Believe it or not, I have a point to make here. It turns out that government regulation doesn't actually "kill jobs," at least not in this case. It has created a unique entrepreneurial niche. Consider what happens if one of your guinea pigs dies, but you don't want to make a long-term commitment to guinea pig ownership at this particular time. You have a problem if you get a second guinea pig, because you will be trapped into permanent guinea pig ownership. When the first one dies you'll be stuck with the second one so you'll need to get a third, and so on until your heirs are burdened to perpetuity.

To the rescue comes Priska Kung, who will rent you a guinea pig. When guinea pig one goes to that great Habitrail in the sky, you just send the rental back to Priska. She has no problem because she has dozens of them.

So what happens when government, for example, tells the consolidated flange factory that it can't just dump it's toxic waste into the river? The company buys water treatment equipment, that's what happens, and somebody gets a job making it. And, just as the extra guinea pig creates jobs for guinea pig feed and supply companies, the clean river provides jobs for fishing tackle and kayak manufacturers. And, we end up with fewer lonely guinea pigs and prettier and better smelling rivers. Plus less cancer and stuff like that.

Yes, it makes guinea pig ownership and flanges a bit more expensive, but they really are that expensive in the first place, it's just that now we're making the responsible parties pay for what the things really cost. That's called responsibility and fairness.

Now, maybe you don't care about lonely guinea pigs as much as you do about toxic rivers, but you know what? That's why we have democracy, so we can vote on this stuff. And if you think you're voting against "burdensome government regulations," you're really voting for dirty air and dirty rivers and fewer jobs for people who make pollution control equipment and fishing tackle, but maybe slightly cheaper flanges. So let's have an honest discussion for a change.

And that includes you, Mr. President.

Extinction

2011-09-21T11:11:00.000-04:00

We are in the midst of what may -- likely will -- turn out to be one of the greatest mass extinctions in earth's long history, rivaling the mass extinction that ended the cretaceous period and the reign of the dinosaurs. Most people are paying no attention, but the few who are generally tend to be unhappy about it.

At the same time, however, we are trying to eradicate some species. We've already terminated the variola virus (smallpox) and we're working on polio. Whether viruses are really species, or really alive, is questionable however. They don't have any metabolism and they don't contribute to biomass. Nothing eats them. All these particular viruses could do was make us sick and sometimes kill us, so I don't suppose anyone is sorry to see them go.

We've wiped out the dodo and the passenger pigeon and quite a few other species just by carelessness, and the U.S. government tried to exterminate the North American bison in order to starve the plains Indians (which worked), but a few survived. As far as I know, though, eradication of the Guinea worm, AKA dracunculiasis, will be the first successful, deliberate, human caused extinction of a metazoan. Former president Jimmy Carter is behind this project. The worm is now extinct in Ghana, and is hanging on only in Mali, Chad and Somalia.

The Guinea worm is, from the human viewpoint, an extraordinarily repulsive creature. Again, I can't imagine many people will be sorry to see the last of them. Still, it gives one pause. The ethics of our relationship to nature are complicated. Wolves and tigers and cougars are an economic and physical threat to us, and in the old days people were happy to try to just kill as many as possible. But we don't think that way any more. Most people think it's very important to preserve them.

But can you put your finger on precisely what is different between them and the Guinea worm?

I just have to say, this day is quietly amazing

2011-09-20T13:40:00.000-04:00

Just think -- back when I was of the age to join the military, you couldn't get a security clearance if you were gay and you were likely to lose any ordinary job if you were outed. My friend Robert Belanger was the second president of the Mattachine Society, which means "mask," which was on of the earliest gay rights groups (I don't think they even had the word, they were still homosexuals) in the U.S. and which operated, our of necessity, in complete secrecy. Homosexual activity was illegal in most places and the police went out of their way to enforce the law. Obviously homosexuals were excluded from the military and it would have occurred to approximately nobody that there was something wrong with that. Just ten years ago, the horrific threat that homosexuals might get married or be allowed to serve in the military was enough to destroy Democratic chances in elections throughout the country.

Today, by law, passed by the Congress, discrimination against homosexuals in military service is illegal. If that isn't sufficiently astonishing, this has occurred with no more notice than a change in the tolls on I-93. The CNN web site right now doesn't even have a mention of it until you go 3/4 of the way down the page to a tiny text link between "Which rock killed the dinosaurs?" and "Fracking: Drilling jobs not worth it." The MSNBC front page has no mention of it whatsoever. Your local Republican member of congress is busy accusing the president of class warfare and Bill O'Reilly is threatening to stop working altogether if he doesn't get to keep at least 80% of his marginal income above $1 million, but as far as they're concerned, this just isn't happening.

It's just a normal day. Except, of course, for the people who suddenly, just like that, with no fuss at all, can lay full claim to their true identities. Wow. Just Wow.

Oh, so that's what it's all about

2011-09-19T12:58:00.000-04:00

So the New York Times did finally cover the UN meeting on non-communicable diseases! (See my previous post.) And on page A-1 no less! Yay!

However, I had to go to the skip on page 3 to figure out that they were in fact covering the meeting. The headline reads China and India making Inroads in Biotech Drugs, and the article focuses on the patent rights of U.S. biotechnology companies. It seems the reason us 'Merkins need to know about the UN meeting is because those thieving wogs are plotting to manufacture blockbuster biotech drugs and sell them to people in poor countries who can't afford the tens of thousands of dollars those poor, victimized drug companies are charging for them.

I know, it's absolutely scandalous that somebody would try to save lives in countries where people have dark pigmentation at the expense of your stock portfolio. Don't worry, even though he's a socialist, the president has your back:

Already, the Obama administration has been trying to stop an effort by poorer nations to strike a new international bargain that would allow them to get around patent rights and import cheaper Indian and Chinese knock-off drugs for cancer and other diseases, as they did to fight AIDS. The debate turns on whether diseases like cancer can be characterized as emergencies, or “epidemics.”

Now, it might occur to you that since these folks in the southern hemisphere can't afford the patented biotech drugs anyway, it's not really going to hurt Genentech in any obvious way if they turn to some other company which does provide an affordable version -- especially since those Indian manufacturers would actually pay a licensing fee to Genentech. But hey, they might lose a couple of sales to a plutocrat somewhere, and we can't risk that, now can we?

And here I thought the UN meeting was going to be about how to give billions of people healthier, longer lives. I'm so naive. It's about how to protect corporate profits. And obviously your president knows what's really important.

If you've been reading the newspapers and watching TV, you probably don't know this . . .

2011-09-16T13:55:00.000-04:00

but the UN is about to host a major international meeting on the prevention and control of non-communicable diseases. It evidently hasn't caught the attention of any U.S.-based journalists, but this is actually a fairly big deal around the world. The millennium development goals, which I used to write about here quite a bit, don't really include non-communicable diseases unless you want to put malnutrition and death in childbirth in that category. The focus is very much on poverty and infectious disease.

But the assumption that the most pressing health problems in the poor countries are infectious diseases and parasites is becoming obsolete. In fact most premature deaths around the world are due to heart disease, diabetes, cancer, transportation accidents and other causes that are not considered in the millennium development goals. More people have poor quality diets than literally go hungry; tobacco use is declining in the U.S. and finally becoming less chic in Europe, but the tobacco merchants have firmly set their sites on the developing world; people in the poor countries are far more affected by poor air quality and toxic exposures than are people in the wealthy countries; and hardly a day goes by that we don't read about an overcrowded ferry sinking or a train hitting a bus or a pipeline exploding or some other catastrophe in Africa or south Asia.

The UN meeting on HIV 2001 had major impact, leading to a massive international effort. That effort has fallen well short of what was needed, but it nevertheless averted a far worse disaster that one can scarcely bear to imagine. Perhaps this event will have comparable impact, but first Americans need to break out of their pathological self-obsession and take a look at the world around them. I'm hoping some of us will notice.

(BTW, of course, communicable diseases obviously haven't gone away and the prospect of multi-drug resistant staph, TB, and other pathogens is pretty damn scary. I'll stay on that case as well.)

This is how bad it's gotten

2011-09-15T10:39:00.000-04:00

Christopher C. Jennings, in NEJM, informs us that a "strange bedfellow" coalition has arisen among health care consumer advocates, states, health care providers and pharmaceutical manufacturers, all of whom are hoping that the Congressional "super committee" fails to reach an agreement and we get the automatic $1.2 trillion in spending cuts instead.

He doesn't specifically name any advocacy group or organization that has come to this conclusion, so we'll have to take his word for it. But the case he makes seems pretty sound. There is apparently no way that the Republicans on the committee will agree to any increased revenues. The legislation that set up the committee protects Medicaid from the automatic cuts and calls for only a fairly modest restraint on Medicare spending should the Committee fail to reach agreement. The likelihood is that an agreement would actually be far worse, in part because Democrats would have to give something away to get any of the president's middle income tax cuts and investment programs through.

I would add that the automatic cuts include a big whack to military spending, which I strongly favor and which also would not happen under an agreement, meaning even more would have to come out of good stuff. By the way, with no action by Congress, the Bush tax cuts will expire next year, also good, and no way that happens with a super committee agreement either.

The bad news is that medical research will get an 8% automatic cut, and that will really hurt. But you know what? Congress can just pass a bill that reverses it. A super committee agreement will require that the president and the Democrats in congress agree to some profound evil. If they just don't go there, they can keep their policy positions intact and keep on fighting. (Not that they are likely to do so, but they could in principle.)

So yes, I'm on board with failure of the super committee. We'll finally get to take a half decent slice out of the military boondoggle that is bankrupting our country, corrupting our culture, and terrorizing the planet. This is an opportunity we should embrace.

Holy War

2011-09-14T14:24:00.000-04:00

Andrew Sullivan can be extremely annoying, mostly because he is committed to labeling himself a conservative but he has a really difficult time figuring out what it is about his beliefs that could justify that label. He's possibly a moderate Tory by British standards but hey Andrew, you're living in the U.S.A. and it doesn't really translate. He's smart enough to know that Barack Obama is also a moderate Tory and to be a big Obama supporter, but how does that make him "conservative" by U.S. standards? He's also a gay Catholic which is even more ridiculous.

Anyhow, he does a pretty good job here of expressing how the Republican party has left him. To slice out the pith of this essay,

the GOP, deep down, is behaving as a religious movement, not as a political party, and a radical religious movement at that. . . .That's how I explain the current GOP. It can only think in doctrines, because the alternative is living in a complicated, global, modern world they both do not understand and also despise. Taxes are therefore always bad. Government is never good. Foreign enemies must be pre-emptively attacked. Islam is not a religion. Climate change is an elite conspiracy to impoverish America. Terror suspects are terrorists. When Americans torture, it is not torture. When Christians murder, they are not Christians. And if you change your mind on any of these issues, you are a liberal, an apostate, and will be attacked. . . .Think of Michele Bachmann's wide-eyed, Stepford stare as she waits for a questioner to finish before providing another pre-cooked doctrinal nugget. My fear - and it has building for a decade and a half, because I've seen this movement up-close from within and also on the front lines of the marriage wars - is that once one party becomes a church with unchangeable doctrines, and once it has supplanted respect for institutions and civility with the radical pursuit of timeless doctrines and hatred of governing institutions, then our democracy is in grave danger.

Yes indeed, our democracy (if that's what it is in the first place) is in very grave danger. What is equally disturbing is how little awareness of the peril there seems to be on the part of sane politicians and opinion leaders. In particular, the corporate media is treating these refugees from the 12th Century with profound respect. Is it really in the long-term interest of Disney and Comcast and Time Warner to operate in an atavistic theocracy? Why don't they get wise to this?

Hey indeedy

2011-09-13T14:40:00.000-04:00

I have often claimed here (and elsewhere) that economics is not a science, but a kind of theology. Economists do not set out to discover truths by studying reality. Rather they make a bunch of assumptions -- none of which are, you know, true -- and then spin out a fantasy world from the assumptions. The purpose is to tell us how we ought to behave, in particular why we should tolerate the injustices of the present day as the proper state of nature. The Free Market™, in particular, is entirely fictitious -- an elaborate delusion that never has existed and never could exist.

This somewhat arcane essay by David Graeber on the origin of money is entertaining, and concludes with the eloquence of Thoreau:

At this point, it’s easier to understand why economists feel so defensive about challenges to the Myth of Barter, and why they keep telling the same old story even though most of them know it isn’t true. If what they are really describing is not how we ‘naturally’ behave but rather how we are taught to behave by the market—well who, nowadays, is doing most of the actual teaching? Primarily, economists. The question of barter cuts to the heart of not only what an economy is—most economists still insist that an economy is essentially a vast barter system, with money a mere tool (a position all the more peculiar now that the majority of economic transactions in the world have come to consist of playing around with money in one form or another) [10]—but also, the very status of economics: is it a science that describes of how humans actually behave, or prescriptive, a way of informing them how they should? (Remember, sciences generate hypothesis about the world that can be tested against the evidence and changed or abandoned if they don’t prove to predict what’s empirically there.)

Or is economics instead a technique of operating within a world that economists themselves have largely created? Or is it, as it appears for so many of the Austrians, a kind of faith, a revealed Truth embodied in the words of great prophets (such as Von Mises) who must, by definition be correct, and whose theories must be defended whatever empirical reality throws at them—even to the extent of generating imaginary unknown periods of history where something like what was originally described ‘must have’ taken place?

Ayyyyyup.

Meatheads

2011-09-13T13:08:00.000-04:00

The Agriculture Department has issued rules banning the sale of meat contaminated with six strains of E. coli which have been found to cause severe disease in humans. You probably think that's a good idea but you're wrong, according to the American Meat Institute. (Yep, there is one.) "Imposing this new regulatory program on ground beef will cost tens of millions of federal and industry dollars — costs that likely will be borne by taxpayers and consumers. It is neither likely to yield a significant public health benefit nor is it good public policy," sayeth the purveyors of dead flesh.

It seems to me they need to hire a new PR firm. They are actually insisting on the right to sell you meat contaminated with deadly bacteria. In the name of freedom, I suppose. Do you find that comforting? If not, try eating something else.

If al Qaeda didn't exist they'd have to invent it

2011-09-12T14:43:00.000-04:00

Actually it barely does exist any more. We were treated to breathless, wall-to-wall coverage for nearly a week leading up to last Sunday about some Pakistani guys who were supposedly going to set off truck bombs in New York and DC. The people on cable with hairpieces molded from a single piece of plastic are positively disappointed, I think, about the big fat nothing. But we do get fighter jets scrambled in order to possibly shoot down not one, but two, commercial airliners because people weren't feeling well and went to the restroom more than once.

So, if the bad scary Islamic man isn't going to kill us all, what story are they going to come up with to make us spend $600 billion a year on a useless military, give up our 1st, 4th and 5th amendment rights, and vote for Republicans? I'm not thinking of any just yet. Anybody got a nomination?

How we let the terrorists win

2011-09-11T08:34:00.000-04:00

The Freakonomics guys are sometimes so determined to be freaky that they are just plain wrong. However, they have this one pretty much right. The Sept. 11, 2001 terrorist attack cost almost 3,000 lives and cost quite a lot of money directly, but by far the greater damage was what we did to ourselves. They point out a lot of costs you probably have thought of and some you haven't thought so much about. But they pass very quickly over the wars in Iraq and Afghanistan, and they say nothing at all about the alienation of our liberties and the perversions of our republic to which most Americans willingly, nay eagerly, acceded.

Juan Cole has a good deal more to say about these deeper costs:

Dick Cheney, Donald Rumsfeld and George W. Bush, however, saw the attacks as “an opportunity.” They were an opportunity to assert American dominance of the oil fields of the Middle East, and therefore, they reasoned, of the energy future of the entire world, ensuring the predominance of the American superpower throughout the twenty-first century. They thus followed a successful overthrow of the Taliban in Afghanistan with a disastrous military occupation of that country. They coddled the military dictatorship of Pervez Musharraf in Pakistan. They threw international law into the trash compactor and invaded and occupied Iraq, kicking off a massive insurgency and then a civil war, and leaving the country a political basket case. They left hundreds of thousands dead and some 4 million displaced. In northern Pakistan and then in Yemen and elsewhere, a covert program of drone strikes was carried out lawlessly and with no oversight; because it is done by the CIA and is classified, our elected officials cannot even confirm that it exists, much less conduct a public debate as to its legality, constitutional validity, or wisdom. . . .

At home, our politicians, bureaucrats and even many judges actively pursued a profound betrayal of the US constitution and its bill of rights, virtually overturning the fourth amendment right to be free of unreasonable search and seizure of private correspondence and effects. Nearly a million Americans were put on a travel watch list and their travel often interfered with, most of them for no reason other than that they had attended peaceful demonstrations. The US government advocated for torture, assassination, and extra-judicial kidnapping. Via Abu Ghraib it became the world’s largest purveyor of prison pornography. A vast and labyrinthine national security state was constructed that appears to be under no one’s control, and the intelligence estimates of which are too numerous and too closely guarded for them ever to be given practical effect by our legislators.

We did this to ourselves. Sept. 11 revealed, not a powerful or even very consequential movement of radical Islamists. Al Qaeda was never anything more than a small, marginal, violent cult. What Sept. 11 revealed is the tragic immaturity of our political culture.

Wonder where the money went?

2011-09-08T13:42:00.000-04:00

The new issue of Health Affairs is titled "The New Urgency To Lower Costs." I'm not sure it's really all that new except that it has become a major political obsession -- not to lower costs, that is, but to dump them from the federal government onto consumers.

Health Affairs, like a lot of the cool stuff I get to read, is not available to people who don't have a faculty appointment, but all you need to get the idea is the Table of Contents and the abstracts.

September 2011; Volume 30, Issue 9
The New Urgency To Lower Costs

Desperately Seeking Savings: States Shift More Medicaid Enrollees To Managed Care
John K. Iglehart

A Decade Of Health Care Cost Growth Has Wiped Out Real Income Gains For An Average US Family
David I. Auerbach and Arthur L. Kellermann

Lower-Income Families Pay A Higher Share Of Income Toward National Health Care Spending Than Higher-Income Families Do
Patricia Ketsche, E. Kathleen Adams, Sally Wallace, Viji Diane Kannan, and Harini Kannan

Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries
Miriam J. Laugesen and Sherry A. Glied

The Growth In Cost Per Case Explains Far More Of US Health Spending Increases Than Rising Disease Prevalence
Charles S. Roehrig and David M. Rousseau

Health Care Costs Are A Key Driver Of Growth In Federal And State Assistance To Working-Age People With Disabilities
Gina Livermore, David C. Stapleton, and Meghan O'Toole

Enrolling People With Prediabetes Ages 60–64 In A Proven Weight Loss Program Could Save Medicare $7 Billion Or More
Kenneth E. Thorpe and Zhou Yang

Not that real income gains for the average U.S. family were all that much over the past 10 years -- they would have been a little over 600 bucks, but it turns out that all but 95 bucks went to health care. That's including premiums, out of pocket, and taxes. Part of the reason it costs so much here is that physicians in the U.S. -- especially outside of primary care -- get paid a lot more than physicians in other countries. You may think that's as it should be, but we're just pointing it out. And we aren't spending more and more all the time because we're getting older, or sicker: it's because we're paying more all the time to deal with similar problems. And it's busting state budgets. And we could save a lot of money just by not being so fat. That's the story you can read off of the table of contents.

News to no-one, I hope. It's fine to spend more on health care if we get more for our money and we want to pay for those better outcomes, but we're only getting a little bit more for a lot more money. Instead of kicking old folks off of Medicare and giving them vouchers that won't pay the cost of what they need, and just kicking poor folks off of Medicaid and telling them to drop dead, we can get better results and spend less money at the same time.

We need universal, comprehensive, single payer national health care.

Not that it really matters . . .

2011-09-07T10:54:00.000-04:00

I can't get all that hot and bothered about anything to do with the ridiculous congressional super committee that's supposed to decide how to gut the United States like a bluefish in order to eliminate taxes on plutocrats. It obviously isn't going to come to any conclusion, and if it does, congress will just pass it and then start selectively reversing pieces of it, undoubtedly turning disaster into catastrophe.

Nevertheless, it is instructive to look at this list of contributions to committee members ranked by industry. (I hope this link takes you straight there, it's one of those interactive pages.) You'll note that lawyers and law firms are at the top of the list, with about $13.8 million, followed by "retired," which I assume mostly means AARP with $9.2 billion. I expect that "lawyers and law firms" mostly actually means lobbyists for whoever, but generically they probably don't care that much about deficit reduction. Retirees presumably want to protect Medicare and Social Security, although the AARP has weirdly wavered on this question.

However, if you add up Health Professionals (probably mostly specialist medical societies) -- $7.9 million -- plus Pharmaceuticals/Health Products -- $4.3 billion -- plus Hospitals/Nursing homes -- $2.9 million -- plus Health Services/HMOs -- $2 million -- you already have $17.1 million, which would make the medical industry the biggest contributor by far. "Insurance" contributed $6.7 billion. It doesn't break out how much of that represents health insurance but I can guess it's the biggest chunk, since other insurers have less at stake with congress.

This is why you know that nothing good can possibly come of this. Collectively, medical/industrial complex contributions are at least double those of retired people, and otherwise, I don't see any patient interests represented here at all. Oh yeah, "Republican/Conservative" weighs in at $2 million, but "Democrat/Liberal" isn't on the list.

You know the Golden Rule of politics: He who has the gold, rules.

Once more, more is less

2011-09-06T15:51:00.000-04:00

It shouldn't be a surprise that oral surgeons think that 80% of people who don't have their wisdom teeth prophylactically removed will eventually end up with big trouble, but it turns out not to be true. Unless you have recurrent infections or other serious problems, you're better off just leaving them there and waiting until and unless something goes wrong to have them extracted, according to the Cochrane review, the American Public Health Association, and other disinterested parties.

Once again, if we had an equivalent of the UK's National Institute for Health and Clinical Excellence, we could spend considerably less money on medical goods and services and actually be happier and healthier. Unfortunately, the resistance to this comes not only from the lunatic "Death Panel" fringe but also from medical specialty societies and drug companies (who are probably behind the death panel lunacy in the first place). Achieving real, fundamental health care reform in this country will be extremely difficult because of the enormously powerful vested interests that stand in the way. But we really must try.

So let's collectively move the Overton Window:

We need universal, comprehensive, single payer national health care. Like those commies in Canada and Britain.