Weird Science

It seems a doctor in has gotten into some trouble with the authorities for injecting cancer patients with insecticide, specifically dinitrophenol (it seems the AP story misspelled the name of the compound) which is toxic to the nervous system, liver and kidneys. (Not to mention, it's a high explosive!)

Unfortunately, the stuff the doctors legally inject cancer patients with isn't a whole lot better. You can check out the side effects of all the stuff here. Examples:

Cyclophosphamide (Cytoxan; CTX): may be administered orally or intravenously. Side effects include bone marrow suppression, hemorrhagic cystitis (severe inflammation of the bladder with blood in the urine), hair loss, electrolyte imbalances (especially sodium), gastrointestinal toxicity as manifested by nausea and vomiting and possible liver dysfunction. A rare lung toxicity manifested by lung inflammation and similar to "Busulfan lung" has been seen. Sexually, testicular atrophy, loss of periods (menses) and ovarian failure can occur.
Cis-platinum (Platinol): administered intravenously. The patient should be well hydrated prior to administration of the drug. It has been shown that administration in the face of poor hydration increases the likelihood of developing side effects. In patients with kidney dysfunction, impaired hearing, preexisting peripheral nerve damage (neuropathy) or past history of allergies to platinum this medication should be given (if at all) with extreme caution. Side effects include nausea and vomiting, anaphylactic reactions (consisting of fast heart rate, wheezing, lowered blood pressure and facial edema), kidney damage (nephrotoxicity), decreased hearing (ototoxicity), nerve damage (neurotoxicity; peripheral neuropathy) manifested by tingling and numbness of the hands and/or feet, bone marrow suppression with increased risk of bleeding and infection, electrolyte (sodium, potassium and magnesium) disturbances and possible heart toxicity (manifested by EKG changes) may be seen. It is important to discuss these issues with your physican so htat you may inform him/her of any symptoms, which may be attributable to the use of this drug.

And so on and so forth. They're all about equally appalling. Of course, the difference here is that all of these drugs have been FDA approved, meaning that in addition to being highly poisonous, they've been shown in some cases to result in shrinkage of tumors visible in X-rays, or to give people on average a few weeks or months of additional life, which as far as I know is not the case for dinitrophenol. On the other hand, an injection of dinitrophenol does not cost tens of thousands of dollars.

Cancer chemotherapeutic agents almost universally have very severe side effects, don't cure cancer, and buy at best only limited added survival. However, they are extremely expensive and they do buy yachts and cadillacs for drug company investors and oncologists. Not that some of these agents aren't worth trying in the right circumstances, but all the advances we have made in understanding the biological basis of cancer have yet to translate into major therapeutic benefits, contrary to anything you may have heard or read.

It's just the same old story -- we spend tens or hundreds of thousands of dollars to try to rescue seriously ill people, with limited benefit at best. We don't spend four bucks to save a poor kid from malaria, malnutrition, or fatal diarrhea.

Clueless

From ABC News:

Dec. 20, 2005 — - President Bush's National Security Adviser Stephen Hadley today labeled Iran "probably the No. 1 supporter of terror in the world today" and claimed a growing consensus between the Bush administration and its critics on the way forward in Iraq.

Speaking at the Center for Strategic and International Studies in Washington, Hadley said Iraq's recent parliamentary election is one way to offset Iran's influence in the region, claiming the high turnout on Sunday could help trigger democracy throughout the region.

"That is why it is so important that the terrorists be defeated in Iraq, and that Iraq be a showcase, in some sense, of a competition between the ideology of the terrorists and the ideology of freedom and democracy," Hadley said.

Hadley said he hopes that ideological struggle will spread to Iran. "One of the questions we keep asking is, when are the Iranian people going to begin to ask themselves, 'If Iraqis in Iran can participate in a free election in Iraq, why not us?'"

Hadley apparently doesn't know who won the election in Iraq -- Shiite religious parties, closely allied with Iran's ruling clerics. Many of their leaders, in fact, were living in Iran until the U.S. brought about regime change. The Iranian government praised the elections in Iraq and welcomed the results. Iraq's central government will be very weak, barely more than symbolic, but the majority of the country's population, oil resources, and military, will end up under the control of the Ayatollahs. (And by the way, Hadley is also apparently unaware that the Iranian government was elected.)

Democracy depends on a democratic political culture, not the ritual of voting. Iraqis have elected a fundamentalist, clergy-dominated government hostile to Israel, hostile to the United States, and closely tied to Iran. Now the plan is to keep U.S. troops in Iraq in order to protect and defend this government, build up its armed forces, and help it defeat the Sunni Arabs and secularists who do not wish to live in a Shiite theocracy. Mr. Hadley, and the Resident, define that proposed outcome as "victory."

Are they nuts?

(Note: Public health is about everything -- well, everything in the human realm, anyway -- so I get to talk about anything I want to. So there.)

Is there something wrong with me?

This fills me with sick glee. From the Associated Press:

Researchers Find Barbie Is Often Mutilated
LONDON, Dec. 19, 2005

---

(AP) Barbie, beware. The iconic plastic doll is often mutilated at the hands of young girls, according to research published Monday by British academics.

"The girls we spoke to see Barbie torture as a legitimate play activity, and see the torture as a 'cool' activity," said Agnes Nairn, one of the University of Bath researchers. "The types of mutilation are varied and creative, and range from removing the hair to decapitation, burning, breaking and even microwaving."

Researchers from the university's marketing and psychology departments questioned 100 children about their attitudes to a range of products as part of a study on branding. They found Barbie provoked the strongest reaction, with youngsters reporting "rejection, hatred and violence," Nairn said.

"The meaning of 'Barbie' went beyond an expressed antipathy; actual physical violence and torture towards the doll was repeatedly reported, quite gleefully, across age, school and gender," she said. . . ."The most readily expressed reason for rejecting Barbie was that she was babyish, and girls saw her as representing their younger childhood out of which they felt they had now grown."

Regarding more serious matters, no doubt people expect me to comment on the avalanche of recent news. I think others are saying all that can be said, but Rep. John Conyers and the House Judiciary minority staff, who report to him, are doing the work the congressional majority ought to be doing, that is defending the constitution of the United States against all enemies, foreign and, in this case, domestic.

Mr. Conyers asked staff, by year end 2005, to review the available information concerning possible misconduct by the Bush Administration in the run up to the Iraq War and post-invasion statements and actions, and to develop legal conclusions and make legislative and other recommendations to him.

In brief, we have found that there is substantial evidence the President, the Vice President and other high ranking members of the Bush Administration misled Congress and the American people regarding the decision to go to war with Iraq; misstated and manipulated intelligence information regarding the justification for such war; countenanced torture and cruel, inhuman and degrading treatment and other legal violations in Iraq; and permitted inappropriate retaliation against critics of their Administration.

There is a prima facie case that these actions by the President, Vice-President and other members of the Bush Administration violated a number of federal laws, including (1) Committing a Fraud against the United States; (2) Making False Statements to Congress; (3) The War Powers Resolution; (4) Misuse of Government Funds; (5) federal laws and international treaties prohibiting torture and cruel, inhuman, and degrading treatment; (6) federal laws concerning retaliating against witnesses and other individuals; and (7) federal laws and regulations concerning leaking and other misuse of intelligence.

The minority goes on to call for an impeachment investigation. Not going to happen, of course. Mr. Bush could do The Aristocrats act on national TV and Carl Cannon would extol his Lincolnesque vision.

Es muy difícil

I've been meaning to say something about Clostridium difficile for a while now, in part because I have personally had the extremely unpleasant experience of C. difficile disease, in connection with emergency abominable -- excuse me, abdominal -- surgery in 1991. Back then, C. difficile (hereinafter known as C) was known as a nosocomial infectious disease -- something hospitalized people get. The disease happened when otherwise debilitated people were given powerful antibiotics, which wiped out the normal symbiotic intestinal flora, allowing C to flourish. The symptoms, if you're lucky, are severe diarhhea. Worst case, it damages the colon permanently (or kills you).

Recently there has been a sudden, sharp rise in incidence in the U.S., from about 35 annual hospital discharges per 100,000 population in 2000, to more than 60 in 2003. Similar rises have been seen in Canada and the UK. For people 65 and older, the incidence is now more neaerly 350 per 100,000. (Per McDonald et al, 14th annual meeting of the Society for Healthcare Epidemiology of America, 2004.) Just as disturbing, the disease has shown up in the community, notably in Toronto earlier this year.

An analysis by Michael Warny of Acambis labs in Cambridge, Massachusetts finds that many cases are associated with a new strain that produces both kinds of toxin associated with C (most produce mostly one or the other). Now, Sandra Dial and colleagues from McGill University report in the new JAMA, based on data from the UK, that people taking proton pump inhibitors -- you know, that purple pill and its cousins which are constantly advertised on TV -- are at higher risk of getting C disease. Of course, widespread use of antibiotics may also be associated with the increasing incidence.

Here are some more dots to connect. Barry J. Marshall and J. Robin Warren won the Nobel Prize in medicine for discovering that the bacterium Helicobacter pylori causes stomach ulcers. Well, not exactly. H. pylori infection used to be nearly ubiquitous among humans, but only a minority got ulcers. So the cause of ulcers must be more complicated. However, it is true that if you eliminate H. pylori from the gut, ulcers heal.

However, it's not only people with ulcers who have had their H. pylori eliminated, it's most of us, because most of us, at one time or another, have taken courses of antibiotics for various reasons, and they happened to kill the H. pylori in the process. That's good news as far as the prevalence of ulcers is concerned, but there are indications now that H. pylori, when it wasn't acting as a necessary condition for ulcers, was suppressing gastric acid production and protecting us against Gastroesophageal Reflux Disease, in which stomach acid damages the esophagus. So that may account for the rise in prevalence of GERD, which caused lots of people to be prescribed proton pump inhibitors, which is now making them susceptible to C. difficile . . .

The fact is that each individual human is a complex ecosystem unto itself, which also interacts complexly with the organisms around it. When we intervene in this system, we are begging for unintended consequences. We need to be as conservative in our interventions. Proton pump inhibitors are heavily marketed, and lots of people take them who don't need them, people who don't have GERD but just plain old indigestion, who can benefit just as well from much cheaper conventional antacids. And of course, those of us who don't have ulcers would probably do well to hang on to our H. pylori, meaning not take antibiotics if we don't really need them, which is a good idea for many other reasons as well.

Okay, that's it

I do not believe that the people are going to put up with this crap any longer. A college student got a visit at his parents' home in Massachusetts from two federal agents because he checked out a copy of Mao's "little red book" from the library. The book is on a "watch list." As it happens, he was researching a term paper on Communism.

I hereby declare that I own a copy of that particular book. I also own a book entitled Mao Tse Tung on guerilla war. Come and get me.

A right to health?

Mary Robinson, the former UN High Commissioner for Human Rights, and UN official Paul Hunt, with support from such worthies as Jimmy Carter, Bill Clinton, and the ubiquitous Bono, have launched a campaign to have the world acknowledge health as a human right, under the banner of their organization Realizing Rights, The Ethical Globalization Initiative. (There's a petition there that you can sign if you are so inclined.)

Of course, this could be viewed as redundant and repetitive. In fact the Universal Declaration of Human Rights already does this, as do various other treaties that most nations have signed. Indeed, the the international covenant on economic, social, and cultural rights famously declares, "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being . . ." As we have discussed here before, this statement is a nice sentiment, but it is largely meaningless. Without going into the practical and philosophical complexities of trying to make sense of the covenant, Realizing Rights cuts the Gordian Knot by asking governments around the world to acknowledge a standard of basic needs, calling on goverments

To promote access to clean water, health care, adequate nutrition and sanitation without discrimination;
To invest in strong health systems;
To make sure that health care decisions are made accountably and with public participation;
To support low-income countries in their efforts to bring decent health to their peoples

Unfortunately, the campaign is not redundant because these basic rights are not honored by the world's governments. The single biggest offender is the United States. The Bush administration has refused calls by the leaders of the other developed nations to contribute .7% of GDP to development aid; refuses to provide public health assistance without guarantees that recipients won't promote family planning and use of condoms; zealously defends patent rights that keep essential drugs expensive; refuses to eliminate agricultural subsidies that dump massive quantities of cheap grain on world markets and so destroy developing countries' agricultural sectors; and oh yes, does not provide health care to tens of millions of its own people, while yapping about something called a "culture of life." So I guess we need to sign the petition.

Truth

So it turns out that the claim by Korean scientist Hwang Woo-suk to have created human embryonic stem cells by cloning adult somatic cells may be fraudulent. Whenever such spectacular allegations of scientific fraud surface, some people will raise questions about the integrity of the scientific enterprise, or even the validity of the entire structure of scientific belief.

On the contrary, this incident cogently demonstrates the power of science. Either it is possible to create human embryonic stem cells by the methods Hwang claimed to have used, or it is not. If it is not, other scientists will discover that they cannot reproduce Hwang's results, and that will be the end of it, regardless of the denoument of this case. If it can be done, it will be done, even if Hwang in fact did not do it.

Some people think that we social scientists have a different view of truth than so-called "hard scientists" like biologists or physicists. We do not. (I acknowledge some embarassing departures from the epistemological consensus by some people who called themselves social scientists, particularly during the 1980s and 90s. Fortunately, the era of transgressive hermeneutics appears to be receding in the rear view window.) We are however perhaps somewhat more alert than other kinds of scientists to the existence of various kinds of truth.

The behavior of human cells when subjected to various manipulations, like the composition and motions of the heavenly bodies or the quantum states of the beryllium atom, is out there to be discovered. Although some people may have opinions about these matters that differ from scientific findings, it would be senseless to think of these truths as socially constructed or culturally dependent. (Of course, their importance or meaning to people might be.)

However, questions like the prevalence of depressive disorder or how best to treat it, or the nature and extent of racial disparities in health care, are quite different. Depressive disorder, like most of the psychiatric diagnoses, is defined as whether or not a person reports a certain percentage of a list of subjective feelings and sensations, at levels of intensity which are generally defined qualitatively. While people have various theories about specific, measurable biological states that might correlate with getting a diagnosis of depression (such as a "deficiency" of serotonin in certain parts of the brain) there is no convincing evidence for any of these. The disease of depression, like the personality disorders, is indeed socially constructed, by a consensus of psychiatrists assigned quite frankly to the task of constructing it. The definition of whether depressive disorder responds to various treatments is likewise socially constructed, as whether people's responses to a list of questions change by a certain arbitrary amount. One can easily and quite defensibly decide to use different criteria for diagnosing depression or the remittance of depression, whereupon the prevalence of the disorder and the effectiveness of treatments will also change. (Note that this is not true of all diseases.) Indeed, it is possible to make the disease of depression go away altogether simply by denying the ontological status of the bundle of observations that constitute it.

Then there is the realm of ethics -- what ought to be, including how people ought to behave, and what we ought to desire. Truths of the first kind -- such as our origin in biological evolution, or how people of various cultures and personal characteristics respond to ethical puzzles -- may inform ethical discussion but cannot finally settle ethical questions. Truths of the second kind -- what cases belong to certain categories -- also are obviously very important in ethical discussion but there is often no good way of settling them.

Scientists sometimes claim to have settled questions based on their findings of the first kind, when in fact those findings rest on truths of the second kind, and can be challenged on that basis; or else their prescriptions depend on ethical choices which may be made differently. Critical thinking depends on being able to keep these kinds of truths separate, and to process each of them in the appropriate way. So it is possible to criticize the scientific enterprise, to make claims about science having biases, or leading society astray in some way, without denying the epistemological claims of science.

When I talk about democratizing science, I don't mean deciding on scientific truth by taking a vote, or anything remotely like that. I hope we can have more discussion here about what I do mean, and what the idea of democratizing science means to some of you who read this.

Am I missing something here?

This is not exactly new news -- IIRC, the New England Journal of Medicine had an expose about it a while back -- but friend M.A.R. draws our attention to a Wall Stree Journal article by Anna Wilde Matthews that reminds us it still goes on.

We're talking about drug companies writing articles for medical journals, and paying academic specialists to pretend to be the authors. We aren't talking here about research reports -- the issues with drug companies running clinical trials and, in one way or another, managing the study design, analysis and reporting to appear favorable to their products have gotten plenty of attention here already. In those cases, the academic authors generally did really work on the studies, but the concern is that their conclusions may be influenced (or worse) by the funding source. The kinds of articles we're talking about here are clinical reviews, what you might call "how to" articles for physicians that give recommendations for use of particular drugs. (Matthews somewhat conflates these two situations, I am drawing the distinction.)

When they are caught out, the putative authors of these ghostwritten sales pitches generally claim that they reviewed the pieces and approved of their contents. The drug companies claim that these eminent professors are too busy to write a whole lot and maybe aren't the world's greatest writers anyway, so the practice helps humanity get the benefit of more of their mighty brainpower.

I say pish tosh and poppycock. If a student hands in a paper under his or her own name, that she or he did not write, we expel that student. It's called academic dishonesty. Most scientific papers are team written but the names of all the people who made substantive contributions are required by journal policy to be disclosed and appropriate authorship credit given. I'd feel a whole lot different about a clincal review knowing it was written by an employee of a drug company than I would if I thought it was just written by Dr. Bigname Knozall. And by the way, publication is the main currency of academia, determining promotions and tenure.

If students are expelled for doing what Dr. Knozall has done, Dr. Knozall should be fired. And oh yeah -- the journal should retract the article, and sue him for fraud.

Don't hold your breath.

PLoS

As long as we're doing initials . . . PLoS stands for Public Library of Science. At the blogger panel in Philadelphia, I mentioned that I'm often frustrated because I can't link to subscriber-only journals. Audience members had a good deal to say about this subject.

The way it works now, new scientific knowledge is generated (for the most part) in universities, which are then required to give it away free to scientific publishers, who sell it back to them at exorbitant prices that the general public, and even most public libraries, can't afford. (Subscriptions to scientific journals cost hundreds of dollars a year.) As a matter of fact, even university libraries in less wealthy countries can't afford to subscribe to many journals, although some publishers have started to offer discounts to subscribers in poor countries.

To be sure, few non-specialists are interested in reading the sorts of highly technical reports on the latest, typically very narrow findings in physics, biology, or biomedicine that make up the bulk of scientific publication. However, journals of medicine and public health have a great deal of material on public health and health policy that would indeed be of interest, and accessible to, literate lay people, if they could get their hands on them. (One thing you can do is subscribe to Scientific American, which will keep you up to date on the broad range of scientific endeavor.)

A fairly new project, the Public Library of Science, makes academic science free to all by posting its journals on the world wide web. It's financed by the authors, but its still peer-reviewed -- you don't get published just because you pay. PLoS Medicine is the one that's relevant here. For example, Here is an interesting article by Lacasse and Leo about SSRIs. Contrary to the popular mythology, which is pushed heavily by the drug companies in their advertising as fact, there is no good evidence that depression, or any of the other newly invented diseases for which SSRIs are prescribed, is caused by a "deficiency" of serotonin, or any other specific "chemical imbalance" in the brain. Why anti-depressants work, to the extent they work at all (which is not much, at best) is completely unknown.

A librarian in the audience also suggested that many public libraries subscribe to services that make a range of journals available on-line, so you might want to try your public library if you're interested in that. But I want to make my sources readily available here, so I'll be turning to PLoS Medicine again in the future, I'm sure.

CBPR

That's not an acronym because you can't pronounce it (KaBopper?), it's the abbreviation for Community Based Participatory Research. This is an increasingly popular concept intended to address the power imbalances and exploitation that many people perceive in the way public health research is typically done.

Conventionally, a learned professor ensonced among ivy-covered walls deems some environmental hazard or social pathology worthy of study, and wangles a major chunk of change out of the taxpayers on that basis. The money pays a portion of the learned one's upper middle class salary, plus chump change for a bunch of graduate students who go out and collect a lot of information about the endangered or pathologized people, which they all then process into an article about odds ratios or beta coefficients which is published in a journal that costs $300 a year. The publication then becomes evidence in the learned professor's case for tenure or promotion, and for further grants.

CBPR principles include involving "the community" in defining the problem and the methods for studying it, benefiting in some way materially from the major chunk of change, and interpreting the results. "The community" also gets to actually learn what the results are, and if we're really cooking with gas, converting the new knowledge into some sort of action to solve problems. Of course there are multiple problems here, not the least of which is how to define, and then to represent, "the community," since the best you can actually hope for is some small group of actual real people who are intended to stand for the whole. And of course, it is extremely challenging to eliminate, or even substantially reduce, the power imbalances that will still exist within whatever participatory structure you create.

CBPR advocates generally recognize the problems and wrestle with them honorably. Nevertheless, in what I saw of the representation of CBPR at the APHA meeting, the medium is the message. We had learned professors standing on podiums addressing an audience three feet below, describing how they were empowering a lot of people who weren't there. Sometimes we had, speaking for the community side, a director of non-profit organization whose list of degrees might stop short of bestowing the magic word "doctor" -- somebody with an MSW or a Master of Public Administration, say. One presentation I heard, entitled "Being the community in community based research," described the speaker's travails confronting the power, insularity and self-absorption of academic scientists and their institutions. Fair enough, but the speaker is the director of an independent but university-based institute with millions of dollars in grant funding, who has been an executive for more than twenty years.

One place the community definitely wasn't was at the APHA meeting. Of course, the $300 registration fee and the $170/night downtown hotel rates might contribute to that.

Just so you know . . .

You may not hear from me again till Friday - I'll try to get something up Thursday but it will be tough.

The panel on bloggers was great, a lot of fun. We had a good audience -- quite a few of the people have their own blogs, in fact, but what is most amazing is that some of them actually read this one. As I said, I was among people with truly influential sites, but the session needed the perspective of a regular person, I think.

A lot of discussion was about where this technology is going. There are many ways to use it that we haven't tried yet, blogs as well as wikis, and a lot that could be done to bring order to the public health blogosphere, help people find their way around, develop cooperative projects, and use the technology to coordinate the development of ideas, organizing, activism, discourse -- I hope we'll have the chance here to try some new things, and I'm even negotiating that with a couple of people.

The conference has given me considerable material, so I'll be writing about it in the days ahead. Had a long day though, have to drive back to Boston tomorrow and teach a class tomorrow night. So, expect me when you see me.

Now, back to the convention

Yesterday I briefly mentioned a panel on food policy. The official title was "The Obesity Epidemic: Getting Beyond Individual Choices." The presenters discussed subjects we've paid a lot of attention to here. Americans aren't getting fat because we are lazy and gluttonous by nature. It's because greedy people are doing it to us.

Sarah Samuels talked about the "food environment" in the schools. The lunches prepared by those cafeteria ladies we all remember -- the sloppy joes and mystery meat -- are still happening, but schools today are full of vending machines and snack carts and even actual fast food outlets, all there because of contracts with the schools that they now depend on for financing that the citizens don't care to provide out of tax money. And what are these commercial enterprises selling? You know the answer. Sugar, fat, starch -- empty calories.

There is no hope for national school nutrition standards right now (viz. our earlier discussion about Congressman Boehnert's heroic crusade to save the junk food purveyors from Communistic tyrrany, violating their God-given right to poison our kids) but California recently passed standards, and local districts can as well. This is something citizens can take on at the local level. Get off your expanding behind, get down to the local school board, and make them get the junk food out of your schools.

Susan Roberts explained why we are eating so much sugar. It's because the U.S. government guarantees a high price to corn farmers, and the more they grow, the bigger the subsdies they collect. As a result, they keep growing more and more corn -- far more than we need. Some of it gets dumped on world markets at low prices, destroying the livelihoods of farmers in poor countries, and a lot of it gets turned into high fructose corn syrup, which becomes surgary soft drinks. The big food processors love to sell this stuff because it's very cheap to make, and they can sell it at a huge profit. So they market it aggressively, among other ways, by placing vending machines in schools. Today, according to Dr. Roberts, Americans consume the equivalent of 557 12-oz cans of soda per person, every year -- that's every man, woman and child, including babies. Teenage boys drink, on average, 913 cans a year. That's poison. It's killing us.

Why not subsidize spinach farmers, she asks? The subsidies obviously aren't going to preserve family farms, they're going to huge agribusinesses. We need an agricultural policy that rewards growing diverse, nutritious crops sold in short supply chains, mostly to local markets. That takes out the huge commercial interests that want to sell us processed foods made from the cheapest possible ingredients that can be mass marketed using cartoon characters. Then there are environmental issues, the consequences for social organization of the countryside, and the benefits for people in distant lands who are desperately poor. This just might be one of the most important issues we face.

Correction

According to the Philadelphia Inquirer, the guy who was arrested at the protest wasn't drinking iced tea, he was drinking lemonade. I'll go with the Inky's version since they had more time to interview witnesses than I did. And they say bloggers have no journalistic ethics.

The Inky also says that the guy who tried to intercede on the criminal lemonade drinker's behalf was his brother, so presumably it was his 3 year old nephew who the cops almost killed in their zeal to protect us from dangerous consumers of lemonade. The lemonade terrorist was charged with assaulting a police officer. However, the reality-based version of this incident is that the police assaulted him.

In a democracy, the police do not arbitrarily assault and arrest peaceful citizens who are expressing dissenting opinions. Is Philadelphia part of a democracy? Just asking.

Administrative Statements

First of all, for reasons that are too complicated to explain here, I've lost access to my e-mail until Wednesday at the earliest. If I don't have time to catch up when I get back to Boston, but before my Wednesday night class, I won't be able to use e-mail till Thursday. Sorry.

Numero dos. Get Firefox. Forget about Explorer.

3. If anybody who happens to be reading this is at APHA, the session on blogging is at 4:30 in the Convention Center, Room 103C. It turns out you can't stick up flyers everywhere at this one as is usually possible, so it's a little hard to publicize.

D. I'll be blogging about the meeting later tonight, I hope, and tomorrow morning, but might not be able to get much up about events tomorrow until Thursday. It's been great, interesting, worthwhile. But it's only a meeting of people who already mostly agree with each other about the stuff that matters the most. That's the frustrating part.

Takin' it to the streets

It's only 1:00 pm, and I've already had a long day. This morning I heard a panel convened by former APHA president Barry Levy on social justice and the Katrina disaster, then I went to a panel on U.S. food and nutrition policy. The room capacity was 79 and here we were, the American Public Health Association, violating fire safety policy by packing about 150 people in there. So now you know what's hot in public health these days. I'll have plenty to say about it, but first I have a more pressing issue.

A man who fraudulently pretends to be president of the United States just got done speaking at the World Affairs Council a few blocks away from the Convention Center. You already know where I was -- across the street with the protesters. The police tried to pen us in to a tiny free speech zone with barricades, but once the free speech zone was full, people kept showing up and since they were standing on a public sidewalk, they ended up staying there. Broad St. was closed to traffic, but the cops wouldn't let anybody stand in the street, so it was like the subway at rush hour. Police in plain clothes, with no badges showing but wearing police armbands, lined the sidewalk staring grimly at the protesters. This crowd was not professional protesters. There was not a Workers World or ISO flyer in sight. These were just plain folks, all ages, all colors. A lot of union members in fact -- communication workers, SEIU.

A man a few feet away from me was drinking iced tea from a bottle when a police man waded into the crowd and started to arrest him. Seriously. Evidently there was some sort of rule that protesters weren't allowed to have bottles, but I assume this guy didn't know about it. I certainly didn't. Another man, whose three year old son was riding on his shoulders, tried to intercede, when the cop pushed him roughly away and nearly knocked the child to the ground. People surged foward to save the child, whereupon police started wading into the crowd with their batons raised. The scene turned ugly, police shoving people aside and throwing punches. They finally dragged the guy with the iced tea away and into a van. His mother started pleading with them, but they wouldn't let her near him. The guy is African American, as was the guy with the little kid. (So were at least half the cops, by the way.) I introduced his mother to an eyewitness who is a Philly resident and will still be around, and he promised to help her. I'll read the Inquirer tomorrow and if they file any charges in this case, I'll let you know.

This is pretty typical of protests these days. The police show up looking for trouble, and they make sure they get what they want. There wouldn't have been any trouble at all if there hadn't been any police on the scene. As far as I'm concerned, they should have turned around and faced the Bellevue along with the crowd. They're honest American folks too (or at least we hope so), and that means we're on the same side. Or at least we ought to be.

(There you go Whisker, I was there.)

Okay. Lots more to come about the convention.

Seeing the sights

This computer I borrowed from my employer is so jammed up with spyware, adware, evilware, bacteriaware, and parasiteware that I expect everyone from the CIA to Merck is logging my keystrokes, but what the heck, I got nothin' to hide.

I went to college in the Philadelphia suburbs so back in the day I drove from Connecticut to Philadelphia a few times a year. Doing it again a bit later -- well, okay, it's been more than 20 years -- not much has changed. The Bronx from the Cross Bronx Expressway looks exactly the same - the el is exactly as rusty as it was in 1980, it seems as though the same tenement buildings are still abandoned and the ones that aren't are still the same boxes whose only architectural feature is graffiti.

North Jersey seen from the turnpike is the most aesthetically repulsive region in the United States, in sight, sound and smell. It's our national sacrifice area, I suppose -- if we simply must have petrochemicals and dispose of our garbage, we need it. Philly has tried hard since I took it to the streets here as an oranizer. There are quite a few new hypermodern office towers, they've spruced up the Reading Terminal and they've even tried to give the subways a facelift. During the Lebanese civil war, the warlord Walid Jumblatt visited Philadelphia (for some reason) and he refused to go down into the subway. "Oh no," said this man who have braved a dozen assassination attempts, "I would never go down there." Well, they have new cars now that don't catch fire all the time, so that's progress.

Still, Philly seems worn out, like it's been fighting the inevitability of decline with a facelift and a tummy tuck, but it's only a holding action against time and gravity. We'll see. Maybe the city will ultimately manage to adjust to a smaller population and a peripheral place among the nation's big cities, but right now there are still a lot of vacant lots and empty storefronts. The new convention center and all the other amenities they've installed to try to bring the city center back are islands among porn shops, blocks of decrepit lofts and low rent offices, and just plain nothing but a bunch of junk.

It's just about the exact opposite of Atlanta, where the countryside is being devoured by metastasizing malls, condo developments, office towers, restaurant chains -- absolutely nothing is old. I'm not sure why so much of the nation's life force seems to be heading south, but at least here in the east, that's what's happening.

I got here too late for Sen. Kerry's keynote address, just wandered around the exhibition hall. The biggest, most spectacular display, believe it or not, belongs ot Lockheed-Martin. After a long, honorable corporate history of blowing people up, they have gotten into the consulting business and they do a lot of public health related work for the feds. Really. Coming in second, not surprisingly, is Pfizer. Merck is laying low -- only their vaccine division has a booth. But mostly it's the schools of public health, federal agencies, some non-profits, and small businesses. This isn't your usual convention. It's extraordinarily ethnically diverse -- it really does look like America, only more so. The people do a lot of different kinds of jobs and make very different incomes. But we have a common purpose. That's good to know.

Road Trip!

As I may or may not have mentioned, I'm off to Philadelphia for the American Public Health Association meeting. This was going to be my first opportunity to visit New Orleans, where the APHA meeting was scheduled for November, but that sort of didn't work out. But who would pass up a chance to visit Philly in December?

I used to go to APHA every year, and I'd always submit two or three abstracts and give a couple of presentations. I stopped going for a while because, frankly, it's just too big and too much for its own good. There are hundreds of sessions, thousands of presenters, most of the panels are cobbled together out of three or four largely unrelated papers and it's impossible to figure out which ones you really want to go to. I always meet two dozen people who I exchange cards with and then never hear from again. There have been a couple of exceptions -- one year I had the opportunity to meet Mysterious Anonymous Reader, who sometimes contributes items to this blog, and I have run into one or more of the Reveres on occasion, as well as other friends.

One thing is for sure about APHA meetings though -- public health is a unique field of endeavor. It's an academic content area, not a specialty, so we have mathematicians, biologists, physicians, psychologists, sociologists, economists (yes, we let them in for some reason), lawyers, managers -- you name the discipline, we got it. We also have practitioners, the majority of them public employees, and also people who work for community based organizations. I have a foot in all three worlds -- academic, public, and community -- which makes me a bizarre trilaterally symetric extraterrestrial. One thing we all have in common is that we're talking about public health, which means we all believe fervently in the public sphere and the public good. That does mean that inevitably, certain currently popular political ideologies don't get a lot of support there.

This year, in addition to doing a poster session (yes, it's humiliating), I'm going to be on a panel of public health bloggers -- and I'll definitely be associating with my betters. The organizer of the panel is Jordan Barab of Confined Space, and a representative of Effect Measure will also be there. I think my role is to explain how any loser can start a blog.

So I'll be posting from the meeting and I'll let y'all know all the hot news from the realm. For a change, I'm looking forward to it this year, and I hope we'll have some interesting things to talk about.

Murder for Gain

Merck claimed that it did not know that Vioxx increased the risk of heart attack and stroke until a study last year, after which it withdrew the drug from the market. The company and its hired researchers, notably Dr. Alise Reicin, who has testified on behalf of the company at the Vioxx trials, claim that an earlier study published in The New England Journal of Medicine in 2000 showing an increased risk of heart attack in subjects taking Vioxx, as opposed to Aleve (naproxen), demonstrated a protective effect of Aleve, not a harmful effect of Vioxx.

It turns out, according to the editors of NEJM, that the 2000 study could only be interpreted in that way because it was fraudulent. They have posted an editorial on-line, available to non-subscribers (PDF). Specifically, the authors of this study knew of three additional heart attacks in the Vioxx groups which they did not report. This raised the relative risk for Vioxx users from 4 to 5. They also deleted information from the manuscript about strokes and other vascular problems.

The company then went on to continue to market the drug aggressively for four years.

There is a term for that. Read the headline, Dr. Reicin.

A Primary Problem

As our readers are probably tired of hearing, our enormous investment in so-called "health care" in the U.S. -- now 16% of the economy and growing -- isn't paying off. One reason is that our non-system, a patchwork of perverse market incentives and regulated sectors designed more to satisfy political constraints than to keep the population healthy, ends up allocating disproportionate resources to specialty care and high technology interventions for already sick people, than to primary care intended to catch problems early and keep people healthy.

Robert L. Phillips discusses the present and future of primary care in the U.S. in, where else, the British Medical Journal. (Sometimes you need your friends to tell you what you can't see about yourself, it seems.) Primary care docs in the U.S. -- internists, pediatricians, and family medicine practitioners (familiatricians?) -- are paid less than half as much as radiologists. They have far too little time to spend with patients -- from their own point of view, as well as from the patients' point of view. Relatively lucrative diagnostic and surgical procedures, as well as care for their patients when they are hospitalized, are increasingly being taken away from them and given to various categories of specialists. Patients' lack of continuity of insurance coverage means that primary care physicians often have only short-term or episodic relationships with patients.

Given the patchwork of financing for health care in the U.S., the scope for government policy to fix this problem is somewhat limited, but certainly Medicare can do a lot. Medicare can increase reimbursement rates for primary care, and assure that more primary care preventive services are reimbursable. State Medicaid programs can do the same. In addition, although Phillips does not say it, we need to find ways to redirect the investments being made in medical services and research in the U.S. Capital is flowing to lucrative, high technology equipment, tertiary care hospitals, and research into expensive treatments for preventable diseases, such as heart disease and Type 2 diabetes. Public policy can direct more research dollars toward such subjects as effective physician-patient communication in primary care (if I do say so myself), practice improvement techniques to enhance coordination of care (which primary care physicians were once expected to do), and enable more procedures to be performed in primary care settings, presumably at lower cost and with better integration into patients' overall treatment.

Compensation for the primary care specialties has to be made more comparable to that of other specialties, so that more young physicians will go into the field. Right now, starting primary care physicians will struggle to pay their educational debts, which are typically more than $100,000. And, if doctors are better reimbursed for each episode of patient contact, they can spend more time with patients. A basic problem is that talking and listening are the least well compensated procedures. But they are the most important ones.

Backing into the future

CDC has released preliminary data on births for 2004. If the conservative ascendancy means we're supposed to be returning to conditions of the past, they're winning.

The percentage of mothers who did not begin to receive prenatal care until the third trimester, or who received no prenatal care at all, rose from 2003 to 2004, from 3.56% to 3.59%. While this is a small increase, it is based on data from 99.1% of live births, not a sample. In other words, the phenomenon is real, there is no confidence interval for it. This number had been falling steadily since 1990.

Of more import, the pre-term birth rate rose by 2%, continuing an upward trend. Even worse, the low birthweight rate rose from 7.9% to 8.1%, also continuing a trend. Low birthweight is the principal factor associated with infant mortality and morbidity. A larger number of multiple births -- probably due largely to fertility treatments -- accounts for only part of these trends.

These are among the most important standard measures of population health, widely used for international comparisons. So there you have it -- we're still spending more and more on health care than any other country, and we're still getting less and less for it in the overall health of our population. Why? That's easy. We have the most inequality of any of the wealthy countries. The rich get richer, and the poor get sick and dead babies. The mistake these babies are making, from the standpoint of getting any political support, is that they are being born. Once they are born, they no longer have a right to life.

The Unscientific Method

David C. Reardon is an anti-abortion activist who has adopted a unique strategy -- to try to convince the world that abortions are harmful to the women who have them. His organization, the Elliot Institute, has a web site called AfterAbortion, which archives numerous "scientific studies" purportedly showing that abortions are traumatic and psychologically damaging, etc.

Reardon managed to get a study published in the British Medical Journal in 2002, finding that women who terminate an unwanted first pregnancy are at higher risk for subsequent clinical depression than women who carry the pregnancy to term. Now Sarah Schmiege and Nancy Felipe Russo have taken another look at the same data and found that no such thing is true after all. On the contrary, women who chose to end unwanted first pregnancies end up with higher levels of education and smaller family size (obviously) and are probably at lower long-term risk for depression as a result.

Why the difference? Reardon and his collaborator manipulated the data in various ways in order to produce their result. For example, they excluded women in the group who delivered who then had abortions later on. Since people with multiple unwanted pregnancies are probably more likely to experience depression, this had the effect of reducing the apparent incidence of depression in the women who delivered. (Got that? It's a little tricky. Depression in women who have an unwanted baby when they are young is likely a risk factor for having subsequent unwanted pregnancies. By eliminating these women from his sample, Reardon rigged the outcome.)

Scientific research, unlike theology, is not a method for demonstrating a preconceived conclusion. It is based on the principle that the truth exists independent of our preferences about what it ought to be, and awaits discovery, not invention. For the modern conservative movement in this country, that definition of science does not apply. Activities intended to promote some convenient belief -- that environmental tobacco smoke is harmless, that burning fossil fuels does not contribute to global warming, that abortion causes abortion or breast cancer -- are disguised as scientific research. This pseudo-science is typically sponsored by entities that will benefit from a particular outcome -- the oil or tobacco industries, or religiously motivated anti-abortion activists. Earlier we discussed the bogus anti-gay research of Dr. Paul Cameron. Then of course there is the Discovery Institute, which promotes so-called "Intelligent Design."

Unfortunately, very few science journalists have either the skill or the motivation to sort this out for us. Real science and tendentious pseudo-science are presented side-by-side, with equal credibility, on the TV and in the newspapers. They call it journalistic "balance." With the federal government now engaged in promoting pseudo-science, real scientists need to be much more engaged with the public.

Not that we didn't basically already know this . . .

but it's not official till it's published in a peer reviewed journal.

Robert Hurley, Hoangmai Pham, and Gary Claxton, in Health Affairs (and this one is free to all, no subscription required), report on new information from the Community Tracking Study, which is a largely qualitative ongoing study of health care markets in metropolitan areas selected to be representative of the U.S.

There is too much detail here to really do justice to it in a summary, but the main idea is that there has been a strong trend toward growing inequality in access to high quality health care. Investments continue to be made in new facilities which are not only state-of-the-art, and have the latest and greatest equipment, but also offer lavish amenities to consumers. There has been growth in the development of free standing specialty care centers, where highly paid medical specialists can ply their trades without the burdens of working in a general hospital where they have to do things like cover the emergency department and take care of people without the best insurance. Meanwhile, primary care providers continue to lose ground in compensation. People with private, employer-provided insurance, and Medicare beneficiaries, have access to this high quality, high priced care, and they continue to benefit from the latest in medical technology.

At the same time, states have cut back severely on Medicaid benefits, both reducing payment to providers and eliminating coverage for some services. As a result, specialists don't want to take care of Medicaid patients. They are consigned to community health centers and other providers, which don't have the amenities, or the great equipment, and are overburdened. Medicaid beneficiaries often have difficulty getting specialty care at all. And then, of course, there is the sharp rise in the number of adults with no health care insurance at all, who get only urgent care when they are seriously sick or injured.

The disparities in access to high quality care are exacerbated by the tendency for investment to flow to affluent areas. Hospitals serving poorer communities can't raise the capital to upgrade their facilities and equipment, so poor people are harmed by geographic disparities as well as the kind of insurance they have.

Because emergency departments are required by law to take all comers, they are a potential portal to care for people without insurance, or to higher quality or specialty care for Medicaid beneficiaries. Consequently, other providers try to dump patients on emergency departments. However, the EDs are having increasing difficulty in finding specialists who will be on call for them, and follow-up care for people who come in through EDs is even harder to find.

The people who fare the worst, as our readers know well, are the chronically mentally ill.

In my view, we are moving beyond a class structure in the United States to a caste system, in which the boundaries between social strata are almost impossible to cross. Once you lose insurance, and become sick (in whichever order), you will never be able to recover, because you will not get health care or rehabilitative services, therefore you will not be able to work, and you will never again have insurance, unless you are lucky enough to make it to age 65. That's what the culture of life will do for you.

People Unclear on the Concept

The Institute of Medicine today released it's breathlessly anticipated report on marketing of food to children. The eminent scientists have discovered (get ready for it) that, according to Senior Scholar J. Michael McGinnis, "The foods advertised are predominantly high in calories and low in nutrition -- the sort of diet that puts children's long-term health at risk."

Now that they have made this major scientific discovery, what does the august Institute recommend? That the food and beverage industries should promote healthier foods, and that the media and entertainment industries should campaign for healthier diets.

Now see folks, I know you are really brilliant doctors and everything, but it's like this. The food and beverage, media and entertainment industries, do what they do for the following reason:

To make money.

Sugary junk food is cheap, very cheap to make -- and it's cheapness, by the way, is enhanced by agricultural subsidies that pay farmers to overproduce sugar and corn. It's very easy to get kids to eat it, and to eat a lot of it. Sponge Bob and his friends advertise it because they are paid to do so. TV networks run the ads because the food companies pay them. The food companies pay these companies to advertise their junk food because that's how they figure they can make the most money.

About the moral exhortations of the Institute of Medicine they give not a jot nor a tittle.

More on HIV Exceptionalism

Thomas Frieden and colleagues from the New York City Dept. of Health and Hygeine, in the Dec. 1 NEJM, discuss ways in which our approaches to the HIV epidemic differ from our responses to other transmissible diseases. To some extent, I think, they exaggerate these differences, but it is worth having this discussion.

In the case of most reportable diseases -- and there are a lot of them, from Amoebiasis to Yersiniosis (plague), including embarassing ones like syphilis and gonorrhea -- laboratory directors and health care providers are required to report to the public health authorities information including the name, address and telephone number of the infected person. (And note -- this is an exception to the HIPAA privacy regulations. These reports are handled confidentially, but they do go to state and local authorities.) In the case of HIV, most jurisdictions do not have name-based reporting, although some states have introduced it. Here is one state's set of reportable diseases and reporting forms.

Also, for many common conditions for which inexpensive screening tests are available, people are routinely screened in doctor's offices. Not so HIV, for which in most cases an elaborate counseling regimen is required to go with testing. Then there is partner notification -- if you are diagnosed with an STD, the local public health authorities will ask you for information about your sexual partners. A person called a disease intervention specialist will then contact them, and inform them that they may have been exposed to what we used to call a "social disease," and offer them testing and treatment. In the case of HIV, that happens inconsistently, depending on the jurisdiction.

There is also less systematic monitoring of whether people with HIV receive treatment than in the case of some other diseases of special concern; a more patchwork and inconsistent system of case management; and less systematic monitoring of the development of treatment resistant strains of the virus.

These differences principally arise from the highly stigmatized nature of HIV infection, particularly early in the epidemic, when there was also no effective treatment available. There were entirely legitimate concerns that anything less than absolute confidentiality would discourage people from getting tested; while at the same time, the direct benefit to the individual of knowing his or her HIV status was questionable. Today, although there is no cure for HIV, there are treatments that can be quite effective in most cases at slowing progression of the disease and giving people many years of productive life. At the same time, the stigma associated with HIV is much less, at least in large parts of the country. These developments suggest that the public health benefits of name based reporting, partner notification, and monitoring of treatment in individual cases as well as at a population level may now outweigh some of the earlier privacy concerns.

I have reservations about this argument. However much we may like to believe that we are now more enlightened, as a society, about HIV, for many people at risk for the disease, stigma is still a huge worry. I know many people who have not been able to disclose their HIV status to close family members. People are shunned and abused in prison because they are HIV positive, and may lose employment or suffer other harms. Many addicts and prostitutes do not visit doctors offices; some people who do see a doctor regularly might not want their doctor to know about their HIV risk behaviors. That's not desirable, but it's reality. Community based testing programs are still necessary, and being able to at least offer confidential testing is still desirable in many cases. With confidential testing, must come counseling, for various reasons which don't fit in a blog posting.

I do support universal availability of voluntary partner notification; case managment, without the overlap, duplication and gaps that currently exist (maybe more on this later); and follow-up monitoring of entry into treatment. The latter can be accomplished within a confidential reporting system by making the testing agency responsible for it, although it would eliminate the option of anonymous testing, which still exists in some jurisdictions. (Confidential testing means no reporting of identifying information to the authorities; anonymous testing means the testers don't even have identifying information.) But these issues require discussion by all the people affected -- people with HIV, people at risk for HIV, counseling and testing providers, HIV service organizations, public health authorities, citizens -- not just an essay by authorities in a medical journal.

Then there are the questions of condom promotion and needle exchange, where the fracture is along entirely different lines. More on that later also.

Mutiny in the Chamber of People's Deputies?

Remember when there used to be people called "moderate Republicans"? You know, those scions of prominent families who learned all about fair play in prep school and whose mothers taught them to be charitable toward the servants? They were certainly friendly to big business -- after all they had to be able to show their faces at the country club -- but they liked national parks and clean rivers; didn't mind taking a little bit off the top of the dividend stream for taxes; liked spending aircraft carriers full of thousand dollar bills on ships, planes and tanks but were fairly averse to actually using them; hated budget deficits, because they wanted their bonds to hold their value; and were willing to throw a few dimes out the window of the limo to the wretched refuse on the sidewalk.

It seems they may be back. From The Oregonian (brief, painless registration required):

Sen. Gordon Smith, R-Ore., said Wednesday that he will vote against a massive budget bill being considered in Congress if it includes cuts in the Medicaid and food stamp programs that he and a handful of other Republican senators strongly oppose.

Smith's unequivocal statement could be critical in shaping the final version of the 2006 Budget Reconciliation Act. The continued opposition by him and the other GOP senators would all but doom any bill containing the Medicaid and food stamp cuts in the Senate.
snip
Smith added that he thinks the six Republican senators who have joined him in opposing the cuts "will hold with me."

Under growing pressure to reduce the federal budget deficit, House Republican leaders passed a version of the budget legislation that would slash about $50 billion over five years. The House bill included steep cuts in Medicaid -- the joint federal-state health insurance program for the poor -- and the food stamp program.

In the Senate, Smith was instrumental in crafting a measure that would cut the budget by about $36 billion over five years. It makes relatively mild cuts in Medicaid that would not directly affect beneficiaries and does not reduce food stamp spending.

That version of the budget bill passed the Senate by only five votes, meaning Smith and his six GOP allies could hold the balance of power in deciding the outcome of the budget battle.

snip

"The central strand in America's safety net is Medicaid, and it must not be weakened," he said. "Food stamps, like health care, ought to be a part of what America holds out to the disadvantaged in our society."

About 220,000 Oregon households receive food stamps. Under the House bill, an estimated 15,000 Oregon households would be cut off.

Several Medicaid and food stamp beneficiaries attended Wednesday's news conference and thanked Smith for his stand.

Ron Pollack, executive director of Families USA, a health care consumers' advocacy group based in Washington, D.C., said Smith played a "heroic role" in the Medicaid fight.

"Senator Smith," Pollack said, "has been the --and I underscore the word the -- most important leader in protecting Medicaid in the United States Congress."

Now, he still represents a vote for Republican control of the Senate, and I don't see him out there wanting to investigate the phony case for war, torture, war crimes, administration incompetence and corruption, or any of that other really nasty stuff that a Democratically controlled chamber would blow the lid off. He's all for the Bush tax cuts for the wealthy, of course, but he's also for stem cell research and he emphasizes nicer stuff like USAID over kicking butt with the army in his foreign policy rhetoric. And BTW, in good old Republican conservationist tradition, Smith opposes oil drilling in ANWR. So now you know we're non-partisan here, without fear or favor.

More on AIDS exceptionalism

I've now had a chance to carefully read the original NEJM article by Patrice Severe et al on antiretroviral therapy in Haiti. As I said before, it isn't news that ARVs can be successfully administered in poor countries, but some people had remained skeptical about Haiti, which may present one of the most difficult environments.

But there is a bit of a -- puzzle? dilemma? oddity? Most Haitians live on less than a dollar a day. (That, believe it or not, is the World Bank's official international poverty line.) The program to treat HIV with ARVs, described in the article, costs about $1,600 per person per year. That includes providing food -- rice, beans and oil -- the most undernourished patients, and nutritional supplements to all of them. The participants also were treated for TB and other co-morbid conditions.

Now, think about this. Most Haitians are probably borderline malnourished, and a high percentage of them suffer from clinical malnutrition. But now they can get an adequate food supply -- if and only if they are HIV infected. Most Haitians seldom or never get to see a doctor, even though many of them carry tuberculosis and have other chronic diseases. But they can get comprehensive medical care -- if and only if they are HIV infected.

It is rather odd, and not entirely clear, why there is public demand, and government and philanthropic support, for taking care of people in impoverished countries who are infected with HIV, but no comparable demand for doing anything much about all of the other severe health problems faced by people in these countries. Under the present regime, it might actually make sense for some people to go out and deliberately acquire HIV infection in order to get access to medical care and nutritional benefits.

By the way, there are comparable situations right here in the U.S. -- housing, vocational, mental health and substance abuse treatment programs that are available only to people living with HIV. Some people actually claim falsely to be HIV infected in order to get access to these programs, and the programs have to require proof of HIV infection. But people without HIV are out of luck -- no mental health care for you, pal, you failed to practice unsafe sex or share needles.

Just something to think about.

The Fat Years and the Lean

When I was 15 years old, a boarding school student, the United States, accompanied by troops of the puppet South Vietnamese government, invaded Cambodia. The result was a firestorm of protest. On May 4, 1970, national guard troops fired on unarmed demonstrators at Kent State University in Ohio, killing four. In response, striking students and faculty shut down hundreds of colleges and universities. My boarding school -- which happens to be the same school from which George W. Bush had received his high school diploma a few years earlier -- was also shut down. Shortly after that, I was kicked out of the band for wearing a black arm band in the Memorial Day Parade. Yup -- wearing a black armband at a ceremony to honor the dead was an unacceptable political statement. As I was collecting signatures on a petition to end the war in downtown Andover, a man said to me, "Do you want to be a Communist slave? Get wise to yourself!"

The war continued for three more years, but in the face of massive protests, Richard Nixon was forced to systematically withdraw U.S. troops, and in 1973, to sign a peace agreement which amounted to capitulation. Two years later, the U.S. withdrew completely from Vietnam and the country was reunified under the Communist Party. Of course, no harm to the U.S. or the world came from that. No dominoes fell, and neither that man in Andover nor I became Communist slaves. Today, the U.S. has normal relations with Vietnam, which supplies us with coffee and shrimp.

The movement against the Vietnam War began in the context of the Civil Rights movement, which became the Poor People's Movement; and the women's movement. All of these social movements engaged millions of Americans in activism. And that energy continued. I participated in marches on Washington against U.S. military involvement in Central America (citizen protest almost certainly prevented the Reagan Administration from invading), and nuclear power; I spent a year of 80 hours weeks working as a community organizer in Philadelphia, and we filled the streets and the City Council chambers with protests against the racist Rizzo administration. Once we shut down a City Council meeting with our chants while our friend and ally John Street, who is now the Mayor, filibustered on the council floor.

Even into the 80s, with Mobilization for Survival in Boston, I was part of an active, visible movement of citizens for all that good stuff -- peace and justice.

So what the hell has happened? Today, we have the worse presidential administration in the country's history, and a Congress completed controlled by an alliance of atavistic religious fanatics and rapacious capitalists. We are engaged in a war even more dangerous to the world and, if such a thing is possible, more pointless than the Vietnam War. The global environmental crisis, the hollowing out of the U.S. economy, growing inequality, national decline and planetary peril -- it really ought to be enough to have an uprising.

Sure, there are a few signs of life in the populace, some relatively modest antiwar demonstrations, lots of people like me bitching and moaning on blogs, some of which are widely read. But there is no mass movement, no political opposition. The pathological liar, war criminal president is now unpopular, but it doesn't matter very much. I'd be out there protesting, if there was anything to join. But there isn't. Why is that?

Stayin' Alive claims another victim . . .

Andrew Natsios has resigned. Obviously, he couldn't stand the heat from this site.

Hot enough for you?

Yes, I know, it's fairly chilly in the most of the U.S. today, as it ought to be in December, but the world is still getting warmer.

How many of you newshounds already know that right now, today, the UN Climate Change Conference is happening in Montreal? Probably quite a few people don't because the corporate media in the U.S. has largely ignored it. This meeting is a conference of the parties to the UN Climate Change Convention. The U.S. is a signatory, but as everyone knows, the U.S. pulled out of an annex to the treaty, the so-called Kyoto Protocol, which is the only part that actually requires countries to do anything, and continues to unequivocally oppose the substantially greater reductions in greenhouse gases that many countries are calling for.

The most excellent web site of the UN Framework Convention on Climate Change is truth central on this issue -- and you won't get the truth from the U.S. government, and very little truth from its servant news media. Click on the link on the left side called Essential Background and you'll find excellent, user-friendly summaries of the major issues.

Here's the bottom line: global warming from pre-industrial levels is now about .6 degrees centigrade in average surface temperatures. Predicted additional warming for the rest of this century is from 1.4 to 5.8°c, which means that the absolute minimum possibility is 2°c above pre-industrial temperatures, which just so happens to be what many climate scientists consider to be the tipping point -- the amount of warming which will induce positive feedback effects, such as release of methane from permafrost, that will cause continued warming regardless of the amount of greenhouse gases humans continue to pump into the atmosphere.

So, it will happen. Here's what it will mean. This happens to be related to most of what else ails us -- dependence on petroleum and natural gas from foreign suppliers, the disastrous war we're involved in right now (see previous point), the distortions caused by agricultural subsidies in the rich countries (it's kind of a long story how that ties in, but it does -- that's for an upcoming post), loss of biodiversity, even obesity and diabetes and heart disease (because of the way we live, that makes us drive instead of walk). The Terrorists™ are close to being the least of our worries.

And while we're on the subject of AID . . .

Oy

(If it's good enough for Atrios . . .)

Answering one question . . .

asking a thousand.

Today is World AIDS Day, of course, and as it happens, there is relevant news. An effort to treat people living with HIV in Port-au-Prince, Haiti, has shown great success in its first year. Haiti is the poorest country in the Americas. Its approximately 8 million people (an accurate census does not exist) have a life expectancy at birth of 53 years. The infant mortality rate in Haiti is about 73/1,000 births, and the adult literacy rate is just over 50%. Haiti also has the highest prevalence of HIV in the Americas, at about 5.6% of adults, which means there are 280,000 Haitians living with HIV. (These are estimates from 2003. There is some evidence that prevention campaigns have reduced HIV transmission, which mean the prevalence will be declining as people with HIV die.) Haiti, in other words, resembles poor African countries.

Back in June 2001, the Director of the U.S. Agency for International Development, Andrew Natsios, told a Boston Globe reporter that there was no sense providing anti-retroviral treatment to Africans because they would be unable to adhere to the drug regimens, which require taking doses consistently and on time. Natsios said, specifically, "Africans don't know what Western time is. Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o'clock in the afternoon, they do not know what you are talking about." Earlier in the year, one of those "anonymous senior administration officials" had told the New York Times essentially the same thing.

Natsios was justifiably excoriated for his ignorant, racist comments, but even after losing that particular excuse, the Bush administration continued to fight efforts to allow poor countries to manufacture or purchase generic versions of HIV medications (all of which are under patent and very expensive), and has provided far less in assistance to poor countries for HIV treatment than it has (repeatedly) promised. Haiti and African countries cannot afford to provide even generic drugs to their large populations living with HIV -- only the rich countries can make that possible.

Well, we already know that anti-retroviral drugs can be used effectively in poor countries. Brazil has led the way with an aggressive, successful program, but in most of Africa and in Haiti, few people with HIV have access to drugs. Today we learn, from a report in the New England Journal of Medicine (subscription only, news story is here), that a team of Haitian health care providers that has been providing antiretroviral treatment to 1,000 people, still has 87% of its patients alive after one year, including almost all of the children. It appears they didn't have a control group per se, but based on the natural history of the disease in Haiti, they estimate that expected survival without medications would be about one-third of the cohort.

Okay then, let's give antiretrovirals to all 280,000 Haitians living with HIV! Well, not so fast. As the investigators say, these folks were living without running water or sewers. Like most Haitians, they didn't have enough to eat. Some of them were TB positive or had active tuberculosis or other diseases. The doctors gave them food, and took care of their other medical needs, which undoubtedly contributed to their survival at least as much as the ARVs. Providing antiretroviral medications to 280,000 people would cost a lot of money. If somebody is willing to step up and spend that money, will somebody provide 8 million Haitians with clean water, sanitary sewers, an adequate diet, decent housing, education, economic development and jobs, and basic medical care? If not, why should somebody provide 280,000 of them with expensive medications that will probably keep them alive for one year, but as far as we know so far, may not keep them alive for two? I'm just asking the question, I'm not anwering it.

Volunteer for this . . .

As you may know if you obssessively read the back pages of the newspapers, or if you happen to live in Tennessee, the Volunteer State is making drastic cuts to its Medicaid program -- they've already thrown 200,000 of the state's sickest people off the roles, and instituted the most restrictive prescription drug benefit in the country. More cuts are set for January. According to the Tennessee Health Care Campaign:

Governor Phil Bredesen’s new plans for TennCare will have a detrimental impact on the health care and health outcomes for all of the 1.3 million people currently enrolled in TennCare. Under the Governor’s proposal approximately:

226,000 enrollees will likely be cut from the TennCare program altogether and most of these will join the ranks of the uninsured;

97,000 enrollees will be subject to draconian benefit limits and their coverage will terminate over the next year;

396,000 enrollees, no matter how sick, will have drastically limited health care services and treatments; and

Every single person who remains on the program will face a new definition of “medical necessity” that will limit their ability to obtain needed care.

Much of this has now happened. The specific details, which you can read all about, are too disgusting for words. This is going to happen in other states, if we don't fight back. I'll say it again -- the solution is universal, comprehensive, single payer national health care. But meanwhile, we must defend Medicaid, and build it up, not let it be trashed. The Tennessee Health Care Campaign has organized meetings, vigils and demonstrations across the state, including a sit-in in the Governor's office. They are trying to raise funds now to hire community organizers to work throughout the state to reverse the cuts.

Oh yeah, there's Senator Bill Frist (R-Tenn.). Remember Terri Schiavo and the Culture of Life, Senator? Unfortunately, almost all of these 700,000+ people have functioning cerebral cortexes. Therefore Frist doesn't care whether they live or die.

Better than Publisher's Clearinghouse

Wanna win 100 large? SEIU is sponsoring a contest called Since Sliced Bread. All you have to do is go to their website, and, in 175 words or less, tell them your idea to "strengthen our economy and improve the day-to-day lives of working men and women and their families."

That's it. The deadline is Monday. A panel of judges will pick 21 finalists, then there will be 2 rounds of on-line public voting. Two runners up also get 50K! Most important, SEIU will work hard to make the winning ideas a reality. Hmm, I might try to think of something . . .

(Thanks to the mysterious anonymous reader for the tip, known hereinafter as MAR.)

A test you can't fail . . .

Marc Hauser and Peter Singer, in the new Free Inquiry (sorry, article not available to non-subscribers but there's their home page anyway) describe a survey they have been doing to determine whether people's ethical intuitions differ according to religion or culture. You can take the test here.

In the article, they offer three scenarios. You are to decide whether the protagonist's proposed action is "obligatory," "forbidden," or "permissible."

1. A runaway trolley is about to run over five people walking on the tracks. A railroad worker is standing next to a switch that can turn the trolley onto a side track, killing one person, but allowing the five to survive. Flipping the switch is ______.

2. You pass by a small child drowning in a shallow pond, and you are the only one around. If you pick up the child, she will survive and your pants will be ruined. Picking up the child is _______.

3. Five people have just been rushed into a hospital in critical care, each requiring an organ to survive. There is not enough time to request organs from outside the hospital. There is, however, a healthy person in the hospital's waiting room. If the surgeon takes this person's organs, he will die, but the five people in critical condition will survive. Taking the healthy person's organs is _______.

Hauser and Singer tell us that more than 90% of respondents agree on the answers to each of these questions -- actually 97% agree on the answers to 2 and 3 -- regardless of whether they are religious, or what religion they adhere to if any. (By the way my own answers were with the consensus in all cases.) They give this as a refutation of the assertion that many people make, that morality flows from religion and that people without religion must somehow be amoral. Instead, they argue, ethical intuition is a product of evolution.

I'll buy that, but what interests me about this test is that the preferred answers to 1 and 3 are different -- but if you look at them a little harder, it's very difficult to say what is different about the two scenarios. Neither protagonist has created the situation in which five people are imperiled. Both protagonists have the opportunity to perform an affirmative act which will save five and kill one. Both are acting in their professional capacities. Both potential martyrs are innocent bystanders. The difference seems to lie, somehow, in the degree of agency involved -- or perhaps some of you have a different explanation.

In ethical dilemmas, it's surprising how often very small differences in circumstances tip big differences in our judgments. Doctor Kevorkian helped dozens of people to take their own lives, and juries repeatedly refused to convict him -- until, in the final case, he actually physically opened the IV himself, because his client (or patient or customer or whatever he was) was paralyzed and could not do it. The client clearly stated on videotape that he wished to die, that he would open the IV himself if he could, and that he wished for Dr. Kevorkian to do it for him. Even so, that tiny distinction -- providing additional, wished for assistance -- was too much for the jury, which convicted him of murder.

The distinctions among allowing someone to die by turning off life support; providing analgesia with the stated intention of relieving pain, but knowing the dose may hasten death; and giving an injection for the purpose of hastening death seem very small and in a credible analysis, meaningless. But they are pretty much universally accepted. Action one is generally considered permissible under certain circumstances; people are somewhat divided about whether action two is permissible but it is de facto legal in the U.S.; and action 3 is illegal almost everywhere although some people feel it should be permissible under some circumstances. Note that unlike the scenarios given by Hauser and Singer, these situations do not produce an ethical consensus.

Rationing life

One of the objections we often hear to a national health care program is that it will cause health care to be "rationed." Well, yes. Spending on health care under a national health insurance or health care program will not be infinite. Right now, in the U.S., we ration health care -- specifically, on the basis of ability to pay. Some people decide every month whether to buy drugs, eat three meals a day, or heat their homes. Some people are bankrupted by medical bills and lose their homes entirely. And lots of people don't get basic medical care and end up with serious, expensive and completely preventable illnesses that the rest of us end up paying for. Meanwhile, we spend more and more money, and a higher percentage of GNP on health care every year -- without knowing how much good most of it is doing. New technologies and new drugs are introduced constantly, most of them very expensive, and as soon as they are approved -- which only requires that they be shown to have some marginal benefit, such as a few weeks added survival for cancer patients -- they quickly become necessities. We're all paying for them, but are they all worth the cost?

In Britain, where they have fully socialized medicine -- not just national health insurance, but a government-run health service that is available to all citizens -- they set up an organization called NICE -- the National Institute for Health and Clinical Excellence. (I think the H is missing from the acronym not only to make it spell something cute, but also because public health was added to its mandate later, after it had already just been NICE.) NICE evaluates new medical technologies, including drugs, not only for effectiveness, but also for cost-effectiveness. It uses a very open, transparent, and rigorous process in which there is representation of all affected sectors. Check out their web-site, and just click on the link to "Final Appraisal Determination: Cardiovascular Disease: Statins," to find out how it works. If NICE recommends a new treatment, National Health Service bodies have to provide funding for them.

"Ah but," I intuit that you are thinking, "how is this 'cost effectiveness' measured?" Here's where it gets into territory that many people find disturbing. Cost-effectiveness, in a nutshell, means that you know what you are buying with each dollar, and in this case, it's something called a Quality Adjusted Life Year, or QUALY. To measure QUALYs, researchers first surveyed large numbers of people and asked them how much of their life span they would give up in order not to have, say, disabling heart failure or intractable pain. (This procedure may be criticized on various grounds, but if you want to criticize it, you are required to come up with a better idea.) Then they use this information to weight years of life in calcualtions, e.g., two years with a disability might be worth one year in perfect health.

So, NICE generally decides that an intervention is cost-effective if it buys one QUALY for something less than $45,600. (Of course they use British Pounds.) Above that, they are likely to say that it isn't.

But wait! How can you put a price on life? Isn't life infinitely precious? Is NICE saying I should let Grandma die rather than spend $45,601?

Well, kind of -- although that's only if the money will keep her alive for less than one additional year in good health. There are two problems we need to consider:

a) Grandma will die, just like everybody else, no matter how much we spend. It's only a question of when and in what condition.

b) Life might be infinitely precious, but we don't have infinite resources. Every dime we spend on Grandma is coming from somewhere else, which might for example be food for a hungry child or the money for noble missions such as occupying Iraq. These choices have to be made somehow.

At least the kind of work that NICE does makes these choices explicit. Whether Americans, with their Culture of Life and their equally powerful Culture of Entitlement will ever be able to look truth in the face remains to be seen, however.

More on ICCC

Michael White, the webmaster at Iraq Coalition Casualty Count, writes with a bit more info about the site. It actually started when Patricia Kneisler posted a table showing Coalition military casualties in Iraq on Daily Kos. Michael saw the post and contacted Patricia, the rest is history. Michael says (a bit less colorfully) that he knew an insurgency would emerge even as the Mighty Conqueror was landing on that aircraft carrier wearing his Mighty Codpiece. This is a real success story for Daily Kos as a networking site -- I am registered there and I used to visit quite a bit and contribute to the discussions, but who has time to keep that up?* Apparently a lot of people -- and more and more all the time, as you will know if you've been following Kos. As Michael writes about ICCC:

How do we find the time? Pat and I both have full time jobs that have nothing to do with Iraq, the military, journalism, etc. We just make the time and don't get enough sleep. We are fortunate that we are assisted by a volunteer (Evan) who post news to the site while we are working. Each day at lunch I go to the nearest wifi coffee shop and check emails and post updates.

Many people have what I once thought were wild visions of the Internet as a democratizing technology. But maybe those visions weren't so wild after all. Now anyone can publish, with minimal capital investment. Bloggers and site-builders like Kos have created a new mechanism for holding the corporate media accountable and channels for engaged citizens to discuss issues, build alliances, and even broadcast information and ideas to thousands or hundreds of thousands of readers, if their work is sufficiently compelling.

But, while a blog only has to cost the proprietor as much time as she or he chooses to invest, a more complex site like ICCC takes a lot of time and some actual money. So Michael does have a request:

Anything I'd like revealed? I long to have more time to add features to the site (a listing of post Iraq suicides, mapping daily attacks - Iraqi and coalition, etc). The only way these features are going to get included is if I can gather enough donations to pay for me to take time off from my paying job to work on the site.

So here's another good cause -- I know, there are far too many -- with potentially good bang for the buck.


*(Alas, one of the reasons I spend less time at Kos is that I just couldn't get people there interested in public health and health care reform. These, it seems to me, are rich sources of winning issues for Democrats and progressive candidates. Nevertheless, I have the opportunity to keep yelling and screaming here and at Kos, and who knows, maybe some day national health care will be back on the progressive agenda.)

Liberal bias

My dictionary's definition of "conservatism" is "disposed to preserve existing conditions, institutions, etc., or to restore traditional ones, and to resist change." To the extent that the modern Conservative movement in the U.S. (which I capitalize to refer to it specifically) really does fit that description, it is easy to see why it is likely to be in tension with science. Science is dynamic. Science exists to explore the unknown, to generate new explanations, to overturn established ideas. Scientific discovery drives technological development, which fuels social change, and forces reevaluation of philosophical and religious ideas.

Specifically, the contradictions between modern Conservativism and science are of two main kinds that grow from the two quite independent constituencies which have been stitched together in the Republican Party -- religious primitives and powerful corporate interests.

Atavistic religion is in conflict with science, not only because scientific explanations of the world contradict scriptural and traditional stories, but also because religious conservatives put deontological (rule based) ethics ahead of rationality and inquiry. So, not only do religious conservatives deny scientific findings about evolution and the age of the universe because they contradict scripture. They also insist that condoms are ineffective against the transmission of HIV, not because the Bible or traditional doctrine has anything to say about the efficacy of latex barriers, but because they don't want people to have sex, except with the intention to procreate within monogamous marriage. They promulgate scientific falsehoods in order to further this moral objective. The Bush administration has promoted this particular falsehood, and many others, such as lies about supposed adverse effects of abortion, in order to further the religious right's moral crusades.

Conservatism's business constituency deliberately undermines science in order to avoid regulation which might constrain profits. They fund ideologically driven think tanks that employ failed academics to create the appearance of scientific controversy where there is little or none in reality. They also finance considerable university-based research in ways designed to buy the opinions of less than ethical scientists and control the interpretation and dissemination of findings. Again, the present administration has firmly allied itself with the corporate anti-science campaign, on issues from global warming to mercury pollution to drug regulation.

We often hear complaints from Conservatives about the preponderance of self-described liberals among higher education faculty. They see this as proof of bias in academic hiring and promotions. But the true explanation is quite different. One can imagine that there might be one form or another of political bias in humanities or social science departments. But why would departments of physics, or geology, or mathematics, or biology, favor one or another political viewpoint? The answer is that scientists are committed to reason, and to the fair evaluation of evidence. (That includes social scientists, by the way -- at least most of them, although I am sorry to say that we went through a period a few years back where things got a little wacked.) Therefore, they are liberals, because reality has a liberal bias.

Unfortunately, unlike academia, the journalistic profession has yet to grasp the idea that balance means dispassionate evaluation of the evidence. Journalists still think that balance means giving exactly the same respect and prominence to the pronouncements of self-interested liars and raving lunatics as to people with facts and reason on their side. That interpretation of journalistic ethics is one of the most important factors behind the decline of the United States, to which Revere draws our attention below.

Superpowers: and then there were none

Jane Smiley at Huffington Post had a telling elegy for American superpowerhood the other day. Here is some of Smiley's post:

We are a country that can no longer pay our bills, no longer wage an effective military action, and no longer protect our citizens from disaster. And it doesn't matter what fiscal responsibility individuals show, what bravery individual soldiers show, or what generosity individual Americans show. As a nation-as a geopolitical entity-we have been stripped of all of our superpowers and many of our powers, and it has been done quickly and efficiently, in the name of blind patriotism, by Bush, Cheney, Rumsfeld, Rice, and their neocon advisors. The very powers that these people thought they were going to enjoy exercising have slipped out of their grasp. It's laughable now to remember the name of the campaign against Baghdad, "Shock and Awe". No one in Iraq feels any "shock and awe" toward the US presence there any longer. "Fear and Loathing" is more like it.

Oh, and one more thing to add to Smiley's list. We are no longer a country able to protect our citizens from the threat of epidemic infectious disease.