Book Review

While we Were Sleeping: Success stories in injuries and violence prevention

David Hemenway. University of California Press. 2009

(The publisher was kind enough to send me Dr. Hemenway's book to review.)

David Hemenway, of the Harvard Injury Control Research Center, is a great champion of the public health ethos. The title of his new book, based on a Grimm fairy tale about a shoemaker who got unexpected help from elves in the middle of the night, reflects his observation that the huge reductions in our risk of injury over the past century have gone largely unrecognized. Indeed, he makes the broader point that our overall gains in life expectancy and health status are largely attributable to public health measures rather than medical intervention. I am particularly grateful to him for providing the original source of the well-known public health fable about the ambulance at the foot of the cliff, stationed at great expense to catch the people who fall while no-one can be bothered to put up a fence or a warning sign. (It's a poem by one Joseph Malins, dated 1895.)

Hemenway says that the target audience for his book is not his students, but their parents: he wants the world to know how much we have all benefited from the largely unheralded struggles of mostly little-known people. There are exceptions: Ralph Nader is among the heroes he profiles. But most of his subjects are indeed less than famous. The book is organized into chapters on various compartments of daily life -- riding in cars, work, play, hanging out around the house, natural disasters, etc. Each chapter consists of a set of brief histories of some policy, technical, or practice innovation that reduced injuries from one or another cause, followed by two-page professional biographies of three or four people who worked to bring about some of these changes.

Without a doubt, the method is effective at making the case that if we approach injuries as predictable events with ameliorable risk factors and consequences, rather than our folk perception of most injuries as random events, we can adjust the world so as to make them less probable or less harmful; and that doing so often looks, after the fact, like plain common sense. For example, we take guardrails along the highway for granted but somebody had to figure out that they were a good idea and do the engineering research to come up with the most effective models and configurations. In the old days, hockey goalies didn't wear masks. Duhh. And so on.

As you read through example after example, you will have a hard time clinging to a dogmatic belief that government regulation necessarily impairs our liberty or strangles economic productivity. Hemenway has deliberately chosen only examples for which clear evidence of cost-effectiveness is available. Few will retort that we should tolerate having little kids horribly burned for the sake of slightly cheaper pajamas, or blinded or brain damaged for the liberty interest of being allowed to throw lawn darts instead of horseshoes. Ideological libertarianism just ends up collapsing under the weight of a thousand bricks of truth.

I'm sorry to have to say, however, that I don't think Dr. Hemenway's students' parents are going to be able to finish the book, at least not without needing to deglaze their eyeballs afterwards. As a literary experience, it's like a 27 course meal consisting of boiled beets, boiled cabbage, boiled broccoli, boiled carrots, boiled squash, boiled spinach, boiled celery . . . Every course is good for you, not hard to eat, but relentlessly similar and insufficiently seasoned. Every scenario has to conclude with a little Aesop-like moral, e.g. "Roads can be made more or less safe," "Data are crucial both in highlighting the problem and in evaluating the effectiveness of interventions," "Sometimes the crucial step is to recognize that something can be done." These banal morals are chosen largely arbitrarily. Any one of them could apply to many, if not all, of the fables, while each fable could have been the basis for 15 different morals.

The mini-biographies are equally in need of salt. When I read in the preface that I could expect a biography of Ralph Nader, I got interested. I knew Ralph as a youth, and he is a very interesting character, not to mention extremely controversial. Before his flameout in the past decade, he was a major fighter in many a D.C. steel cage match. But Ralph's life story, like all the rest of them, is basically presented as the story of somebody noticing that it would be a good idea to do something (in Ralph's case, make cars more crashworthy), and then eventually talking people into doing it. The existence of politics, and controversy is grudgingly acnkowledged where it is absolutely inescapable, but you can read the entire book without even getting a vague impression that there is a conservative, corporatist politics in this country driven by greed and self-interest.

Hemenway never really grapples head on with the major ideological controversies and political conflicts at the center of public health: the putative tensions between liberty and equality, security and freedom, economic and social values; the struggles of class, diffuse vs. concentrated interests, the powerful and the weak, the idealist and the cynic. There is in fact great drama and real moral interest in these stories, not just the common sense lessons and simple inspiration he draws for us.

I suspect that Dr. Hemenway didn't give his students' parents enough credit for being able to grapple with big issues. He probably thinks that the most effective way to persuade is to avoid confrontation, and that might be true, but you need to get people to read the thing. A little more chili powder, please.

A quick -- but important -- note

Many people, it seems, having been pumped full of sturm und drang about the 1918 flu pandemic, are fearful that worst case scenario for the present novel virus strain is a similar death toll.

Not to worry. The 1918 event happened before the days of antibiotics and flu vaccines. The H1N1 swine flu has emerged at the very end of the northern hemisphere flu season. It will soon fade away. Bet on it. It is possible, but by no means certain, that it will reemerge next winter. That, BTW, is exactly the pattern followed by the 1918 flu. But, by the time that happens, if it happens, a targeted vaccine for this strain of flu will be fully ready to go into mass production. We can count ourselves lucky this time as far as the timing is concerned, but that's the fact.

Also, deaths from the 1918 flu were generally caused by pneumonia secondary to the flu itself. People who have access to medical care will be at much lower risk under those circumstances. No comfort for people in the poor countries, and still potentially a big disruption and problem even here, but a difference nonetheless.

Oh yes -- we're now subjected to screaming headlines that a toddler in Texas had died of influenza. Sadly, children do die of influenza. Every year. This is not unusual. Remember, while that child was dying, thousands more were dying of infectious diseases in Africa and Asia and South America. Without a headline or even an acknowledgment. Just keep that in mind.

Public Health in Perspective

One of the concerns of public health is indeed preparing for and responding to infectious disease outbreaks and epidemics. However, I fear that some of the leading voices for public health in the blogosphere have put far too much emphasis on this small slice of a big field and the result has been a huge missed opportunity to frame some strong progressive messages. Influenza control is a wonky issue that is pretty thin on political resonance compared to most of what public health is all about.

Public health is the endeavour -- more than a scientific discipline, or a profession, it's a unifying philosophy -- that treats human health at the level of populations rather than individuals. The latter is the province of medicine. Many people think that public health means "providing medical services to poor people." Not so. In fact, the intersection between medicine and public health is fairly narrow on both sides.

Until fairly recently, the most rigorous analysis showed that health care -- a mismomer, in my view -- made an almost undectable contribution to population health, particularly as measured by longevity but also in terms of disability and quality of life. More recent analyses give more credit to medical services, and it is also undoubtedly the case that immunization, which is a biomedical intervention, has made a huge contribution to human health and longevity, although it doesn't require a doctor or even a health care infrastructure per se to deliver. Nevertheless it remains true that the most important determinants of our health lie in the social order.

Those include the obvious. Rich people don't have to drink contaminated water, their kids don't go hungry, they don't have to live next to air polluting factories or highways, they don't do dangerous jobs, and so on. And they include the less obvious. There is an increment in health and longevity associated with social status that remains even after we control for every known factor we can think of. There's actually a cost of inequality within societies, independent of absolute deprivation. Even though poor people here in the U.S. have less material deprivation than poor people in poor countries, their relative health disadvantage is as great -- or even greater, compared to countries with less overall inequality.

Poor people also do worse on those determinants of health that my libertarian visitors are inclined to assign to personal responsibility -- tobacco, obesity. But they forget that corporations have engaged in decades long marketing and disinformation campaigns to promote tobacco addiction and consumption of calorie-dense, low nutrition foods, in order to enrich their executives. Our agriculture policy subsidizes corn syrup, but not vegetables or even healthful whole grains. That's why bad foods are the cheapest. Our schools feed junk food to our kids, in part because corporations actually bribe them to do so. Poor kids in the city don't have the chance to engage in physical play because it isn't safe for them to go out. These are all political issues.

Health equity is potentially the new civil rights movement. Everybody has the right to a chance at a healthy life and a natural life span. Try arguing with that, Cato Institute. But the only way to get there is through a just society. By the time people bring their problems to the doctor, it's already too late.

Unfortunately, the public health content on Daily Kos and elsewhere is all about influenza epidemics and universal health care. If the absolute worst case scenario happens with this swine flu flapdoodle -- and I mean the worst, the absolute most improbable catastrophe anybody is imagining -- it will be completely over in less than a year. It will have caused some tens of millions of people to spend a miserable week wrapped up in the snuggy slurping chicken soup, and it might cause the premature death of a few tens of thousands of people. Hundreds of thousands? Doesn't look that way from anything I've seen so far, but let's stipulate it just for the sake of argument.

Well then, that's on the order of 10% of the little kids who will die this year from malnutrition and not having clean water. Which of those should be on the front page of Daily Kos?

Flu Schmlu

Yes, it is prudent to assume that someday, somehow, an emerging infectious disease pandemic will cause major global problems. I've said it a million times. However, contrary to the famous motto of Faber College, it is not always the case that Knowledge is Good, if it leads people to do stupid stuff.

Influenza is a common disease and a continual pain in the parts. The virus reproduces very sloppily so new strains keep emerging, which means we don't get the lifelong immunity we do from bouts with most viral diseases, which means that we can keep getting the flu year after year. Fortunately, for the vast majority of us, the vast majority of years, that means nothing worse than a few days off from work or school feeling like crap. (I highly recommend ginger tea.) It's a bummer, but that's the human condition.

We hear that something called "influenza/pneumonia" is the cause of about 63,000 deaths in the U.S. each year -- 10% of the number attributed to heart disease -- but that's highly misleading. (The reason they lump them together is that most of the time, it isn't clear whether people had the flu or not. Some of the people who die of respiratory infections did, but we don't generally have laboratory confirmation. People who are said to die of "influenza" for the most part die of bacterial pneumonia secondary to influenza or a different viral infection that appears similar.) The vast majority of these people are already sick and debilitated; many have advanced dementia and death from pneumonia is a mercy. Tragically, a small number of children also die each year from ordinary seasonal influenza. It would be nice to be able to stop that from happening but it's nothing new or different or strange.

Every once in a while a strain of influenza emerges that for reasons which are not well understood causes more severe disease than usual and/or spreads more easily and so causes unusually widespread disease. In 1918, the virus was unusually dangerous to otherwise healthy young men, less so to older folks. The hypothesis is that an overaggressive immune response explains this.

Okay, so what's going on right now? Probably absolutely nothing out of the ordinary. We're at the tail end of the flu season right now, and it happens to be that at this time a new strain of flu has been detected. The Mexican authorities seem to think it can cause unusually severe disease, but that has not been observed elsewhere and it is not clear whether that is really true in Mexico City either. When a small number of young men in Mexico City suddenly die of pneumonia, my first thought is HIV, not pandemic flu. (And it is a small number. The Mexican authorities have attributed 100 deaths to this virus, of which only 18 have been confirmed as actual swine flu infections. 20 million people live in Mexico City.) Influenza normally cannot survive in warm temperatures, which is why flu season ends in the spring. Unless this virus has some as yet completely unknown properties for which there is no evidence whatsoever, this outbreak is almost certainly going to die out on its own in no more than a couple of weeks. Even if it does not, there is no particular reason to think it will ever be much more than an annoyance.

Unless, of course, we proactively make sure that it is more than that. Which is exactly what is happening. I am not going to accuse the Mexican authorities of overreacting because I don't have the information they do, they have difficult judgments to make, so they did what they did. Undoubtedly, however, they have imposed a huge economic cost on the country, with the political and economic capital completely shut down, tourism effectively suspended, and small businesses without customers.

Here in the U.S., the TV is wall-to-wall flu, with the hair hats screaming and yelling about 40 cases of swine flu in the U.S. -- every one of which has so far resulted in perfectly normal, mild, self-limiting illness. The Secretary of Homeland Security, no less, has held a press conference on national television to declare a Public Health Emergency. How do you expect people to interpret that? Of course it's upsetting and I'm sure people with the sniffles will be clogging emergency departments in the days to come. (I hope not, but I'll be surprised if it doesn't happen.)

Here's what they should have done. Have the Acting Director of CDC issue a statement to the effect that measures are being taken to permit the rapid transfer of supplies to places where they are needed, should that occur. Reassure everyone that local public health authorities are vigilant about surveillance and that we'll have information for the public as soon as there is any that they need to have. Right now, however, all you need to know is what you should always keep in mind: wash your hands regularly, cough into your sleeve, stay home if you're sick, and see a doctor right away if you have a high fever or trouble breathing. Meanwhile, as far as we know right now, there is nothing to be concerned about. Carry on.

And the newspapers should put it on page 15, and the TV news should do 1 minute in the middle of the broadcast. The Huffington Post should get a life. If things change, I won't regret what I just wrote, because it will still be correct.

country place

(Image Shack is foisting a lot of advertising on pic viewers, but at least they accept big files so I'm still using them. If anybody has a better idea, let me know.)

BTW if you keep clicking on the pictures -- first on the thumbnail, then on the image you get at ImageShack to view the image without advertising, and then on the image one more time to enlarge it, you'll get the full-size pic -- which you'll need to see the detail in most of these.

Here's a view of the barn. The farm field is off to the left. You can't see the house in this one, but it's through the woods behind the field.





Here are the peach blossoms just about to come out. Probably could have gotten you a beautiful peach tree to look at if I was still there today.




This is a view of the house from the perspective of the waterfall . . . (For some reason ImageShack hasn't been loading this image for me -- but it's not the greatest anyway.)





And this is the waterfall.




This is a view through the woods from the house toward the barn, which you can barely make out. The area between the house and barn is a protected wetland, with a bog and vernal pool. I've left a wooded buffer.




Here are a couple more views of the waterfall and the stream following a torrential rain, and the house for those of you who haven't seen it before.








So, that's where I've been spending my Saturdays for the past few years -- building that house and barn, mostly. Now I guess I'll have to write a book: How to Build a House.

A brief lacuna

I'm going out of town for a couple of days during which I expect to be disconnected from Your Intertubes. Meanwhile we've finally managed to get the cold and foggy miasma from the North Atlantic pushed away from our shores and something resembling spring is happening here. So, on Sunday, I hope to do a photo blog. People have expressed interest in what's going on in Windham County, so I will provide.

Eat your vegetables.

Goin' Home

As I was walking through the hospital yesterday, a woman's calm, soothing voice came over the PA: "5-6 CCU, adult code blue." PA announcements are now very rare, fortunately, and they've learned to keep them cheery sounding and enigmatic when they are necessary, both of which contribute greatly to a less horrific experience for the inmates. However, as you have no doubt guessed, this was a call for the crash cart.

So it got me to thinking. While I'm sitting here pondering and writing and what not (mostly what not), not too many yards away from me, people are dying. So I got curious: what percentage of people die in the hospital? Where do Americans die? It turned out that this question was suprisingly difficult to answer. There is quite a lot of research done in Canada, where apparently their data systems make it easier. But in the U.S., it's mostly state-specific or based on samples intended to address specific comparisons such as race or disease, so it is hard to put together the big picture.

I did find a study by Weitzen et al (Medical Care;41(2):323-335) which was published in 2003, but uses data from a national survey done in 1993. Back then, they found that 58% of deaths occurred in hospitals, 22% at home, and 20% in nursing homes. The older people were, the more likely they were to die in nursing homes. Black and Hispanic people were considerably more likely than gringos to die in hospitals. These authors note that in the early 20th Century, it was far more common to die at home; that by the 1980s three quarters of deaths occurred in insitutions; and that the introduction of the Medicare Prospective Payment System in 1983 was associated with a decrease in hospital deaths and an increase in nursing home deaths. The latter is not surprising: hospitals no longer got paid for every day they kept people, instead they got a lump sum based on diagnosis, so it became in their interest to move people out.

The most recent relatively comprehensive data I could find was by Mitchell, et al (Journal of the American Geriatrics Society 53:299-305), published in 2005 and using data from 2001. They were specifically concerned with the location of death for elderly people with dementia, so they don't aggregate their numbers completely, but they present data that enabled me to do it (after a correction published a few months later). Their sample is limited to people age 65 and older, but that's most of the people who die.

About 1 3/4 million Americans age 65 and older died in that year. About 47% of them died in hospitals, 28% in nursing homes, and 21% at home. A small number died in other places, I presume while away from home, at the scene of a traffic accident or cardiac arrest. People with dementia, however, were far more likely to die in nursing homes -- 66.9% met their end there. People with cancer, interestingly, were considerably more likely to die at home -- 37.85 -- than people who died of other causes.

These authors seem to think it unfortunate that so many people with dementia die in nursing homes, since most people say they would prefer to die at home, but I don't personally have a problem with that. My father died in a nursing home, and he had no idea where he was or what was happening. If he had been at home my mother would have been burdened with the death watch and with his care, which was best left to professionals. However, I don't see much sense in people with cancer dying in hospitals, as 35.4% did. The remainder -- the majority -- Mitchell et al just lump together as "other conditions," so it's hard to make much sense of the numbers. The slight majority of these people with "other conditions" die in hospitals.

So there you have it - the predicted trend toward more people dying in nursing homes and fewer in hospitals since 1993 did occur, but it has been slow. In 2001, fewer people died at home than in 1993, with nursing homes drawing from both other settings. I don't think that's necessarily bad. It all depends.

Anecdotal Evidence

Gulshan Sharma and colleagues, writing in the new JAMA, tell us that the likelihood that Medicare beneficiaries -- which means approximately all people over 65 -- will see their primary care physician while they are hospitalized declined from about 44% in 1996 to 32% in 2006. The likelihood is even lower in New England -- in 2006, only 16.2% of patients were seen by any physician they had seen on an outpatient basis in the past year. (Abstract here, but you don't belong to the private club that lets you read the article.)

Tell me about it. My mother recently fell and injured her back, and was hospitalized in an academic medical center in the nearest big city. Not only did her primary care physician not see her while she was hospitalized, he did not see her while she was subsequently in a rehabilitation facility -- even though I called his office and was personally assured that he was scheduled to visit her in two days. I guess he had better things to do after all.

There were consequences. The nursing home did not get complete information about her medications and she did not receive her glaucoma drops for three days. She had a nosocomial* bladder infection, which turned out to be antibiotic resistant, but she did not receive an effective regimen until after she had been discharged and finally saw her PCP in his office. (Try seeing a doctor, let alone one who gives a shit in one of those Intermediate Care Facilities. It's an M.D.-free zone, believe me. Actually, on evenings and weekends, it's often difficult to locate an employee anywhere on the premises.) Finally, of course, there is the sense of abandonment that people in that situation inevitably feel.

This trend is associated with the rise of the "hospitalist" model. It used to be that doctors had "admitting privileges" at a hospital, which meant they sent their patients there and then followed them while they were hospitalized. Now, a hospital employee who does nothing but see hospitalized patients is in charge of most people's care while they are hospitalized. This doctor has never seen you before and will probably never see you again. My mother liked the guy at Prestigious University Hospital, but he wasn't around once she left and we basically had nobody to talk to about her prognosis or aftercare. This model is supposedly more "efficient" but I am starting to question it. We had a similar problem when my father was hospitalized a few years back and the hospitalist inaccurately conveyed the family's wishes to his PCP, resulting in a great deal of confusion and anxiety. Had the PCP showed up while my father was in the hospital (which was in the same town as his office, by the way) all of this would have been avoided.

So, no specific recommendation here except that this ought to be revisited.

*Nosocomial means "of the house." Hospitals are very dangerous places because they are full of very nasty, antibiotic resistant drugs and you probably have tubes going into your body through which they can enter, which is exactly what happened to my mother. Urinary catheter infections are as common as doughnuts at the nursing station. Stay out of hospitals if at all possible.

One way to derail a promising medical career . . .

is to serially rob prostitutes at gunpoint and occasionally murder them. While BU Medical School has not hesitated to suspend Mr. Markoff, and will no doubt expel him should he be convicted of felony murder, short of such extreme circumstances, medical schools and residency programs are often disconcertingly reluctant or ineffective when it comes to purging incompetent, bizarre and even dangerously psychopathic individuals from the profession. Don't get me wrong -- these cases are uncommon, and aren't reflective of the medical profession per se. But the fecklessness of institutions in dealing with these rare serious wackos does point to more widespread, though less profound problems with the assurance of medical professionalism.

One of the most notorious cases is that of Michael Swango, a serial murderer of patients who also enjoyed poisoning his colleagues with arsenic-laced doughnuts. In spite of these bad habits, he managed to maintain a career in medicine for 13 years, bumping off an estimated 60 people. As Bill Vourvoulias writes in reviewing James B. Stewart's book on the case, Blind Eye:

Swango's poisonous ways began at the Ohio State University Hospitals in Columbus. Three witnesses saw the young intern inject a substance into a patient's IV moments before she suffered a life-threatening seizure. Swango gave conflicting accounts of the incident, but the senior doctor assigned to investigate took his word over that of the witnesses (none of whom were doctors), and the hospital dropped the matter.After completing his internship, Swango spent the summer of 1984 in Quincy working at an EMF unit, where he often bought doughnuts and drinks for his co-workers. When a number of paramedics came down with violent flu-like symptoms, they had a glass of iced tea tested; it contained arsenic. The evidence was strong enough to convict Swango of battery.


After his release from jail in August 1987, his life became curiously repetitive: He'd secure a residency by falsifying records; mysterious deaths that were circumstantially traceable to him would follow; hospital officials would become concerned but do little; they'd learn about his past, usually through the media, and revoke his privileges; and Swango would find another hospital willing to hire him.

Actually, one might ask why Swango was admitted to the OSU residency program in the first place. As a medical student at Southern Illinois University, Swango was fired from his moonlighting job as an ambulance driver for forcing a heart attack victim to drive himself to the hospital. His fellow students were so disturbed by his bizarre behavior and evident incompetence that they wrote to officials about him. A vote to expel him fell just short.

In 1991, Berkshire Medical Center employed a second year resident whose first year had been oddly divided between two institutions, but he came with references. According to an account of the case in Academic Medicine (Tulgan, et al, Nov. 2001):

From the very onset of employment, unusual behavior was observed. Textbook publishers were approached for complimentary books on the basis of a nonexistent medical school faculty rank. Offers to teach nurses, for a fee, were made. Behavior in the hospital food line was inappropriate. The resident had difficulty in organizing ward rounds and in interacting with fellow residents and medical students. When approached with suggestions, there was inability to admit to faults or to take corrective action. Attending physicians were dissatisfied about patient care and professional deportment.

The resident claimed that both peers and attending physicians were subversive. Allusions were made to a conspiracy. A physician from the second prior institution was accused of having passed $3,000 to two members of this staff to make the BMC experience unworkable for the resident. Age discrimination was also raised, although a number of peers were older. After five months of continued inability to resolve these numerous problems, corrective action as defined in the Residency Program Personnel Policies of BMC was implemented.

snip

It has been a matter of concern throughout the process at BMC that neither program director at the other institutions conveyed any warning about potential problems. Indeed, one hospital actually misled us. Honest communication between programs should be encouraged and could ward off situations such as ours and the others we have cited.

As it turns out, this dismissed resident then embarked on a 9 year course of litigation which was very costly to BMC. No doubt the other institutions feared such consequences, as did the institutions through which Michael Swango passed. More generally, physicians who are only marginally competent or who behave inappropriately with patients are commonly sent off with positive recommendations. Rather than leaving the profession or ending up in roles without patient contact, they may simply fall down the ladder and end up as prison doctors or in other settings where employers are not very concerned about patient welfare. (Yes, that's a sweeping assertion -- I believe I can back it up but I don't have time today.)

Again, all the physicians I know are exemplary professionals who are dedicated to their patients. This is an institutional problem which many are concerned to solve, not an indictment of medicine. Still, no good can come of ignoring it.

Rescue me?

My employer has recently been certified as a Level 1 trauma center. While our bosoms swell with pride, the principle consequence for me has been an increase in the frequency of helicopters landing on the roof just down the block from my 10th floor window. It is mighty impressive, I must say. If you haven't been close to these things, they are very powerful machines and they make one hell of a racket.

Unfortunately, in the process of saving lives, they sometimes crash killing not only the original trauma victim but the helicopter crew and the EMTs. Quite a few of these incidents have been in the news of late. I also presumed these flights cost a lot of money so I naturally started to wonder, is it really worth it?

It turns out a lot of people have been wondering the same thing. Alas, the only serious discussion I could find of this is in subscription-only medical journals, so I can't give you a link. JAMA reporter Mike Mitka discusses the issue in the March 25 issue, as does Jan Greene in the March Annals of Emergency Medicine. I have to conclude that this is yet another example of how we Americans spend big bucks and do aggressive, high tech stuff in medicine without the slightest idea of whether it's actually worth it or does more good than harm.

In 2008, 9 medevac crashes killed 35 people. Now, that doesn't mean your odds are necessarily terrible. According to one expert, Ira Blumen M.D., there were fewer than 25,000 patients transported by helicopter in 1980, but more than 275,000 in 2007, which means that the rate of fatalities actually declined to 2/100,000 flight hours. On the other hand, a helicopter ride costs about $8,000, compared to $800 for an ambulance ride, and nobody has actually figured out when the cost and risk might actually be worth it. Basically, we just do it.

As the Natasha Richardson tragedy reminds us, it's often difficult or really impossible to assess the urgency of trauma cases, so it would be challenging to write guidelines. A further complication is that diverting an ambulance from a rural area for a long ride to a distant trauma center would deprive the region of adequate ambulance coverage for the duration.

Still, we have guidelines in place for all sorts of difficult medical situations and the bottom line is, just doing more and spending more does not necessarily translate into a benefit, not only for society, but also for the individual who gets the service. It turns out the federal law assigns regulation of medical air transport to the Federal Aviation Administration, which pre-empts any efforts at regulation by state or local authorities. The FAA completely lacks relevant expertise and pretty much does whatever the industry wants it to, which is nothing.

So, as much as I would miss all those helicopters, it might must be that we could save some money and some lives if we you know, violated the sanctity of the free market with some sensible cost-benefit analysis and rationing. As in rational. As in smart.

Hard Times

The fiscal disaster facing the states means more than potholing roads and laid off teachers and cops, and other unpleasant consequences that get public attention. The states are responsible for most of the public health effort in this country, and public health is getting slammed. Brian Rosman of Health Care for All -- Massachusetts runs it down for the People's Republic. Not pretty:

Public health programs took wrenching cuts. The House Ways and Means proposal calls for cutting nearly a quarter of the DPH budget compared to the FY09 budget, and some areas were cut deeper. Compared to FY 09, these are the budget cuts proposed in the following areas:

Health Promotion/Disease Prevention – 50%
Oral Health – 41%
Domestic Violence Prevention and Services – 37%
Smoking Prevention and Cessation Services – 37%
Infection Prevention and Control Program – 32%
Early Intervention, a cost-effective program serving children birth to three with developmental delays – 27%
School Health Services – 23%
Teen Pregnancy Prevention – 22%
Substance Abuse Services – 21%
Communicable Disease Control Program and State Laboratory – 15%

Now, think about it. What happens when you have more infectious disease, more domestic violence, more people smoking, more pregnant teenagers, more substance abuse, more kids who hit school age with developmental delays . . .

You spend more money on health care, you have a less productive workforce, you have more kids who fail in school, you have more social pathology, more crime and more people in jail, and you are a poorer and meaner and sadder society.

In the meantime, the people who work in those programs are out of work, which means they can't spend at local restaurants and stores and the state collects less in taxes as a result and so on and so forth. So, Cato Institute psychos and self-destructive teabaggers:

We need to spend in deficit now in order to make the investments that are necessary to pull the country out of recession in the short term, and prevent long term damage to our society that will make us worse off in the future and make it that much more difficult to pay off the debts we have already incurred. Teabag that.

Decisions, decisions . . .

Hmm, had a spam comment from from some schtickdreck hawking vicodin. Yuck.

Anyway, a question that very much interests me is the relationship between people's rationale for undertaking a treatment, and the likelihood that they will stay with it and/or be adherent. If anyone's personal experience seems relevant to this issue, I'd love to hear from you.

In interviewing people with HIV, and older people about whatever pills they might be taking or have had prescribed, I basically find people in the following categories -- people who put people into categories, and those who don't. Oh no, that wasn't it. It's these:

1) I just do whatever my doctor tells me. Nowadays this seems to be a distinct minority, but it used to be considered more or less the norm. Why are you walking backwards on the golf course, Norm? Doctor's orders. People in this category generally express a low demand for technical information about their condition and treatment, and may even actively reject it. They've got other problems to think about.

2) What I will call non-biomedical heuristics. People I know did it and it worked/didn't work, went fine/gave them agita; Magic Johnson is doing it; my spouse would give me a dope slap if I didn't. That sort of thing. Could actually be more important than people are likely to tell me, but those who say this sort of thing explicitly in interviews are only a few percent.

3) People who believe in non-allopathic healing modalities (as we say in the medical sociology biz); people who reject biomedicine as a conspiracy against the public, a money making plot, an offense to nature. I try to stay free of all drugs. The important thing is to have order and harmony in my life so I'm pursuing Reiki therapy. They Ayurvedic doctor pours ghee up my nose and has me eat lots of cucumbers and that's what really works for me. Again, it's a small percentage who do this in place of officially sanctioned scienterrific medicine, although a lot of people do it in addition to . . .

4) People say they made the decision or shared it with their doctor on the basis of a biomedical rationale. Nowadays, this is by far the most common kind of response. However, when I actually ask people to articulate that rationale, the degree to which it matches what I happen to know their doctor actually thinks is extremely variable. Some people give scientific explanations that are basically accurate, others give what they no doubt believe are scientific explanations, but really do not match up at all.

Some of your post-modernists and critical theory types believe that, as a social scientist, I'm just supposed to ignore this mismatch since all knowledge is socially constructed anyway but, err, no. Especially since what the people are actually doing as a result of this non-scientific belief is what scientists tell them to. The only reason anybody believes that she or he is, for example, HIV infected, has dangerously high levels of low density lipoprotein in the blood, has glucose resistance, or has high blood pressure, is because a medical professional wearing a white coat performed a test on them using a fancy machine or a lot of laboratory equipment with centrifuges and enzymes and electrophoresis and what not and then told them so. That they go on to think of their HIV as a mother virus continually having babies is a contradiction. Sorry.

But how does accurate understanding and decision autonomy and so on relate to whether or not people take the pills? I think that's a complicated story.

Q&A

I was planning to go no with the medication adherence thing and now you've got me all distracted. Anyway . . .

Yes, there is still lead in the soil near heavily trafficked roads because there used to be lead in gasoline prior to 1970. I did a little bit of a lit search and I was somewhat surprised to find that most of the recent research on this has been done outside of the U.S. where there is still lead in gasoline or has been until much more recently. This study done in Florida in 1996 shows that yup, it's still there, and at levels considered hazardous by the EPA. I do know anecdotally that in many densely populated areas, there have been efforts at mitigation. BTW another source is the paint on highway overpasses, which used to contain lead and which they would just sandblast off when they went to repaint. These areas undoubtedly constitute hot spots.

Second, I hadn't heard about differential risk for women from near highway pollution but then again, when you catch me at the right moment I'll admit that I don't know everything. Just offhand -- and I'm talking out of the wrong orifice here -- it would be a bit hard to sort out because women have differential rates of smoking, hypercholestrolemia, baseline heart disease etc. and that all gets mixed together in epidemiological models with highway exposure. It may well be that women have a higher raw relative risk, simply as a function of lower baseline risk therefore pollution can make a bigger contribution to overall risk. But I'm just blowing smoke to give you an indication of how tricky these analyses can be. If you have a reference, let me know.

And Stephanie, all I can say is, there are a lot of factors that go into where we choose to live and you certainly shouldn't panic, but 150 yards is awfully close. Those gross particles that you clean off your windowsill -- black carbon -- aren't in themselves as dangerous as fine and ultrafine particles, but they are an indication that the bad stuff is there.

As for cancer, as far as I know the epidemiology isn't as well established as the cardiovascular risk, but it's certainly biologically plausible. The UFP contain nasty chemical components including polycyclic aromatic hydrocarbons (PAH) and oxidative free radicals, and variations on PAHs which are halogenated or contain dioxin bonds, etc. All this stuff is known to be carcinogenic and probably causes other forms of DNA and cellular damage as well. Personally, I would prefer to live somewhere else. (I'll have to get used to your new last name . . .)

Check the sidebar

For a new link, to the Community Assessment of Freeway Exposure and Health. Doug Brugge, of Tufts University School of Medicine, is the PI for this 5-year community based participatory research study of the health effects of air pollution from major highways. (YT has a little piece of it, having to do with how culture and ethnicity are related to people's perceptions of environmental risks.)

It's a scandal that you probably don't know this, but the ultrafine hydrocarbon particles that condense out of motor vehicle exhaust are very damaging to your health -- and not just your lungs, but your cardiovascular system as well. These are particles less than 2.5 microns in diameter, that can pass through the lungs into the bloodstream. They disappear with a few hundred yards of the road, but near major highways, there can be very high concentrations -- and people live there, work there, sometimes there are parks there. Next to the highway is a very popular place to put public housing developments. There are other pollutants from motor vehicle exhaust as well, of course, that you don't want to be breathing either, but this appears to be about the worst.

We'll be monitoring the air at very specific locations -- which most studies of this problem don't do, they generally look at broad areas such as census tracts -- and sampling people who live near the highway, and elsewhere in the city, asking them about their health, where they spend their time so we can get a good estimate of their exposure, and even taking blood samples and other physical measurements from people so we can understand more about how this kind of pollution causes disease. It will be a while before we have any results, but this is one of the ways in which your tax dollars get invested in public health research. It would never happen if the federal government didn't pay for it, so keep that in mind when you go to the teabag party.

Props to the Prez

For nominating Thomas McLellan as Deputy Director of the Office of National Drug Control Policy. This is a good indication that we'll finally start to move away from the insane, counterproductive, ideologically driven policies of treating addiction punitively, locking up more of our population than any other putative democracy on the earth. I've gone into why and how this is a horrendous disaster plenty of times before. Anyway, the times they are a changin'.

and the flip side of that is . . .

So yes, physicians would like for their patients with HIV to come as close as possible to taking their pills on time, every time. But in reality, there is a bit of wiggle room -- the probability of viral drug resistance developing because of a single missed dose, or a whole day, here and there, is quite low. And the situation is generally similar in other chronic diseases. Recent studies have found that when people with diabetes knock themselves out to achieve even stricter than standard glycemic control, there really isn't any benefit. If you miss your blood pressure meds one day you really aren't going to drop dead. You should just take them the next day and move on.

So what do you tell somebody who's doing the best they can and managing to take, say, 80% of their doses? Well, one thing you don't tell them is that they're failng, it just isn't good enough, they have to do better or the guy in the black cloak wit the big sickle is gonna come calling. It's human nature. If I'm trying, but all the feedback I get is that I'm not cutting the mustard, what am I going to do? Give up, most likely. That's why people drop out of school. Quite often, that's why they become drug addicts in the first place: because they are repeatedly told that they're failures, they just aren't good enough, YOU SUCK.

Unfortunately, I'm hear to tell you that when it comes to adherence to medical advice, quite a few doctors haven't gotten that memo. So here's my theory: if somebody is managing to take 80% of their meds, or if they have ever managed to stick with the program for even one week, or if they even say they want to make it happen, that's what you work with. Go with the positive. Go with the affirmation.

"That's great that you're taking the meds, and you're taking 80% of them on time, it's a major commitment and you're hanging in there. So let's make a plan so that you can keep doing it, and get even better. Let's have you think about the times when you miss, or you're late, and figure out why that happens, and see if we can't fix the problems, one at a time. It doesn't have to be more than you can do, let's just make it easy and keep building on success."

So you don't tell the person what to do, you don't scold, you don't lecture, you don't threaten. That's exactly what doesn't work. You encourage, you support, you affirm, you facilitate. That's what does work.

We make aspiring doctors spend 7 years (or more) of sleepless nights getting all the knowledge of the Library of Congress stuffed into their heads (most of which they soon forget), but we don't teach them that. Go figure.

And there's more

First of all, don't be shy about commenting on this subject -- I just study HIV because it's a good example, but this is about all patients and all doctors and all treatments, okay? Your experiences and your thoughts are 100% relevant whether you're dealing with male pattern baldness or metastatic cancer.

Even when people are committed to taking their pills -- when those basic psychological reasons I talked about yesterday aren't staying their intentions -- it can be difficult to do it precisely, every day. I mean sure, you have lots of regular habits -- you get up every morning, perform your ablutions, eat something, etc. But think about it -- do you even do those things at the same time every day? Maybe you sleep late on the weekends, or travel, or go camping or skiing or you're sick for 3 days and the routine gets disrupted. And these are basic habits that you've learned since you were a toddler. It doesn't matter if you sleep in for a couple of hours on a Saturday, but it does matter if you were supposed to take your antiretrovirals and you're three hours late. It might matter a lot, because that gives the virus a chance to replicate, and then you've got a whole lot of virus particles floating around, then you take your next dose and if there happens to be a drug resistant mutant among those millions of virions, you are screwed, because all the others will be wiped out and that mutant will take over and the drug will do you no good any more.

I've heard people tell their doctors a million stories: I missed a day because my daughter gave birth and I was at the hospital; I was on a vacation and we took a side trip and I forgot to bring the meds; I broke my leg; my boyfriend beat me up and stole the pills (really); the cops picked me up and I was in jail for 4 days and they didn't give me my meds (really -- and it was some other people in the house who had the drugs, nothing to do with me . . . Might even be true, who knows?); I couldn't get to the pharmacy for a couple of days; etc.

So this is actually very hard to do for 40 or 50 years. In order to truly succeed, you actually may have to reorganize your life around this central discipline. But unless you truly believe that very strange story I just told you about mutant viruses, why would you do that? Sounds like a crock, doesn't it?

So what the heck's the matter with those people with HIV . . .

who don't take their pills? Would it seem less strange if I told you that fully half of people with high blood pressure don't take their pills at all, as opposed to 20 or 30% of people with HIV who don't manage to take them on schedule? You probably aren't deathly afraid of hypertension, but in fact, although it may lack the precise inevitability of HIV disease, it will kill you, and quite likely in a highly unpleasant way such as kidney failure or strokes.

Furthermore, the high blood pressure pills generally have only mild side effects, or none worth mentioning, for most people. You only have to take them once a day, they're small, and you don't have to be ashamed of people seeing you take them, or picking them up at the drug store. For people who are lucky enough to need only a thiazide, they are even ridiculously cheap -- less than the typical insurance co-pay. Some people need a couple of more expensive pills, such as an ACE inhibitor and a calcium channel blocker, so cost does become a little bit of an issue. If you have insurance, you might be spending $20 or $30 a month out of pocket. But doesn't that beat winding up on dialysis, or being paralyzed, or dropping dead? It does for me.

It's the same for every kind of medication. People don't use their eye drops for glaucoma, even though they are likely to go blind. They don't take beta blockers and statins after they've had heart attacks. Don't take their diabetes meds, and what's more, they keep on eating doughnuts. And so on. Maybe you're one of them. What the hell is the matter with you people? Are you irresponsible? Suicidal? Crazy? Just plain stupid?

No, unfortunately you are human. There are some standard psychological wiring issues involved here, and it's self-contradictory to call them "irrational" because rational means thinking and this is how we think. One is discounting of the future. In general, rewards or punishments that may occur in the future mean a whole lot less to us than what's happening now or is likely to happen soon. The discount is so great that the mere annoyance of having to go to the drug store and stand in line is worth more than the prospect of losing the ability to urinate in 10 or 15 years. Throw in 20 bucks and it's no contest.

Another standard psychological mechanism is denial. If you're in an unpleasant situation that you can't get out of, it's best not to think about it and worry about something else. Taking these pills every day means there's something wrong with you. Forget about it, and it goes away.

Finally, why should I necessarily believe this whole story in the first place? I feel fine. There's nothing evidently wrong with me and you're telling me to ingest powerful, unnatural chemicals that are going to mess with my natural bodily functions. That might be a good idea, and on the other hand, it might not be. I do know that taking the pills makes me feel worse. (Hypertension meds can make you pee a lot, feel dizzy when you stand up suddenly, develop a dry cough, and other annoying stuff like that.)

So maybe it's not so strange after all. Maybe people are making a "rational" decision, weighing up costs and benefits in a way that makes sense to them right now. Of course they'll probably feel differently about the whole thing when they're lying on a cot three times a week with their blood being pumped through a filter. So what can or should we do about this? We can simply say that we respect people's autonomy and they should make their own choices, or we can define this as a problem that we need to do something about. I know how most doctors feel about that question. How about you?

pill taking in context

As my faithful readers are well aware, no doubt to the point of anaesthesia, I am firmly of the opinion that, while individual behaviors are a huge component of what makes us healthy and not healthy, it is inane to ascribe responsibility for such behaviors exclusively to the behaving individual. I'm not going to get all profound about this -- we can save the illlusion of free will for another time -- but we all obviously exist in context, social and physical, and our free will, real or illusory, floats on the currents of the subconscious, driven by the winds of the world. (Analogy borrowed from Archibald MacLeish.) Were it not so, tobacco and junk food manufacturers would not bother to advertise, as one simple example.

Anyway, it all gets very complicated and maybe not that easy for some people to understand when we come to the question of what the docs call Anti-Retroviral Therapy (ART). The facts known to science are that, untreated, HIV infection, in the vast majority of cases, invariably leads after some years to a truly unpleasant state of illness and a death you don't want to die. But, if you take some pills on time, every day -- typically, say, at 8:00 am and 8:00 pm -- for as long as you do so you are very likely not to experience any HIV disease symptoms at all and you will probably be able to live a perfectly good long life. There are side effects, which are worse for some people than for others, but with rare exceptions, they beat the alternative hands down.

Given those facts, most people who haven't tried it would say fine, I'd do it, what's the big deal? If I were to tell you that at any given time, something like 20% or 30% of the people who have prescriptions for these drugs aren't doing it sufficiently well, and that as time passes, more and more start to fail in the discipline, you might say WTF, it's their own damn fault, just give them a dope slap.

Well, a) that doesn't work and b) it's based on a faulty premise. I shall elaborate going forward.

Retro Note: Finally caught up with some comments on previous posts. Regarding flame resistant sleepware, it is true that fire retardant chemicals can be hazardous, including, indeed, containing bromine which you definitely want to avoid. However, not to worry: children's sleepwear in general is not treated with flame retardant chemicals. It's flame resistant simply because it is made out of cotton and/or polyester, which do not burn easily. The garments that left kids horribly scarred were made of nylon. Cotton, untreated -- which has swaddled kids for untold centuries -- is safe. (Yes, you can get it to burn if you hold a hot flame to it long enough, but by that time whether the pajamas are burning or not is the least of the kid's worries.)

This Week's Puzzler

This is a fancy hotel, but they don't have unwired Intertubes and I have to check out by noon, so I won't be able to say more about the conference until later. Meanwhile, I've had some more random neural firings.

The earthquake in Italy was not particularly powerful but the destruction was nevertheless horrific. I presume this is because most of the structures that collapased were very old and not up to modern standards. We've all seen those ancient Italian town centers and villas in the movies and maybe the Food Channel if you go for that sort of thing: medieval buildings that antiquity has rewarded with a charm that can't be faked. Unfortunately they are largely unframed masonry, so give them a shake, and down they come.

This got me to thinking. What is the oldest human edifice that is still in regular use, whether as a dwelling, a workshop, a place of worship? It must be enclosed from the elements and still authentically in use, so the Parthenon and the Coliseum and all those famous monuments of classical antiquity don't count. Nobody is worshipping Athena or Apollo any more and even if they did, the rain would fall on their heads. Tombs don't count either. The pyramids are still useable to store human remains, but not living people.

One might start thinking in terms of Southern Europe, what is now Turkey, and Jerusalem, but maybe that's too eurocentric. Maybe it's in China, India, Nepal or Tibet. Tropical climates and relentlessly encroaching jungle aren't conducive, certainly. I'm inclined to think that places of great religious significance might have a survival advantage as well as a good chance of being well built in the first place. But maybe the answer is surprising, say a stone hut in Norway where a blacksmith still plies his trade.

Anyway, it's not an easy question to google, and thinking about it may yield some insights.

Back on topic tomorrow, most likely.

Travelogue

For those planning to visit Miami, I can already tell you that this city is a lot more historical and folkorical than you may think. Just outside my hotel is a small plaque marking the site where, in 1933, an assassin's bullet intended for Franklin D. Roosevelt missed its target and struck Chicago mayor Anton J. Cermak. Falling to the ground mortally wounded, Cermak uttered the immortal words, "I'm glad it was me instead of you." Really. Think how different U.S. history might have been.

Just a few yards away is a statue of the late Claude D. Pepper, looking heroically nerdy, just as he did in real life and just as he was. The simple inscription reads, "Champion of the poor and disadvantaged." It's not to be missed.

Across the water is the Royal Caribbean cruise line dock, flanked by ENORMOUS floating hotels. They're actually grotesque. Further across the bay is Miami Beach. Been there, done that. Fuggedaboutit.

Health vs. Medicine

IAPAC doesn't lend itself to live blogging, in part because this fuchachta hotel doesn't have wireless, and in part because it just ain't that kind of thing. It's partly the same cast of characters as the International AIDS Society meeting in Mexico City, which anybody who was watching this space last summer heard more than enough about, and it's just as international. But no demonstrations, no rabble rousing speeches, and no Bill Clinton.

We did, however, get Paul Farmer this morning. I asssume y'all know who he is, but here's the Partners in Health web site in case you want to learn more about the organization he founded and maybe even throw them some of your loose change. Dr. Dr. Farmer (two Drs. because he's an M.D. and a Ph.D., which is just sick) showed a few of his famous Lazarus slides -- people he found in Haiti who were dying of AIDS, who they started treating, and who now look healthier than he does. I hope some of the AIDS denialists out there will look at these pictures.

Anyway, his talk was wide ranging but the core of it was, for many years we heard all sorts of sober, scientific and practical reasons why we couldn't treat people with HIV in poor countries: they won't take the pills (remember Andrew Natsios?), it's not cost effective and we should put all our money into prevention, it will take resources away from other health care needs and undermine existing programs, yadda yadda yadda.

We don't hear that so much anymore because now we know it just isn't so. Believe it or not, people in poor countries are more adherent to their meds than people in the U.S., although what Farmer did not emphasize is that in Africa and Haiti, ARVs come with support programs, community health workers who make sure the people take their meds, and they often come up with other stuff people need such as food. (Farmer says he's completing a study, for which he hopes to win the Nobel Prize, showing that food is the only effective treatment for hunger.) And HIV-related programs don't undermine other programs (even if they exist), they develop health infrastructure which makes everything work better.

The problem is, here in the U.S., health insurance doesn't pay for community health workers. Of course they would also be a lot more expensive than they are in Africa but they're still cheaper than Emergency Department visits, hospitalizations, and second line ART regimens. Not to mention, the people don't get sick and die. But they're considered a luxury. Just one more example of how screwed up our reimbursement policies are.

dodging the shark attacks and the hurricanes

I'm off to Miami this afternoon for a conference sponsored by the International Association of Physicians in AIDS Care, focusing on antiretroviral adherence. I'll be giving a presentation about how physicians talk to their patients about this subject. (Hint: Think Daddy. Maybe Homer Simpson.) I'm not a real doctor, I'm a doctor of philosophy, so we'll have to see if they listen to me.

I'll try to post about anything interesting I hear while I'm there -- last year there was quite a bit. Just as funding for health research and public health comes down disease specific stovepipes, our conferences and our journals tend to reflect the same reductionist approach to people, as piles of separate organs and systems. HIV exceptionalism extends to sociology -- there's a lot more about the sociology of HIV than there is about, say, kidney failure or heart disease. But in fact, while there are some differences having to do with issues like stigma and the demographics of the population of sufferers, there is also a lot in common, and we should really be learning from each other and trying to understand the health care experience of whole people. I'm trying to stretch in that direction if I possibly can.

With luck, my new laptop will work and you'll be hearing more from me soon.

Rummaging through the cortex

I covered this essay by John Ioannidis when it first came out, but I've been thinking about it recently. He claims that most published research findings are false, which may be an exaggeration, but the argument is nevertheless important. You will probably find it much easier to understand if I tell you -- as he does not, unfortunately -- that it is largely based on Bayes' theorem. If you read my little introduction to Bayes first, and then read the article again, it will suddenly be intelligible. Promise.

Anyway, the basic point is that most of the hypotheses we can make up are false, because the universe of our imagining is close to infinite. Put it another way, most syntactically well-formed assertions are false -- indeed, the percentage that are true is minute. The conventional p value to accept a finding as valid is .05, in other words the specificity of our tests need be no better than .95. Bayes tells us that a test with specificity of .95 and a prior probability of 1 in a million is is going to give a wrong result about 50,000 times for every time it is correct.

Fortunately, a lot of scientific research is not like that -- we do invest in testing hypotheses that we already have good reason to believe are true. Warning to post-modernists, creationists, and anti-vaccine wackos: There is a helluva lot that we really, truly, do know.

But there's a lot of exploratory research that gets published, and even publicized, as if its findings are definitive. Unfortunately, when it comes to health advice, that isn't good enough. It's a combination of scientists rushing to claim credit and reporters rushing to hype exciting news that gets us into trouble.

In other news, I'm really, really starting to worry. Not that I wasn't already. But the economic news is terrible -- much more terribler than the corporate media is letting on. How the public is going to react when, after all the stimulus spending and bailout and re-regulation and Easter Bunny and Santa Claus, they're still out of work and the tent cities are growing, I don't know but the speculation is killing me.

That's the Republican game plan -- they know their psychotic spending freeze and tax cuts for the rich aren't going to happen, but when Obama's policies fall short, they'll claim their ideas would have worked, even though in fact they would have made things even worse than they are going to be. And Chris Matthews will go along with it.

Another buried lede

I don't know why the ink-stained wretches spell it "lede" instead of "lead," but anyway, here it is once again in the last paragraph of the story. (And once again, the day's health care news is in the NYT business section. Res ipsa loquitur.) The original study is not available to you common rabble but you can read the abstract if you like.

In a nutshell, 20% of Medicare patients who are discharged from the hospital are back in the hospital within 30 days, and a third are back within 90 days. Of those who are only out for a month, more than half had apparently not seen a doctor during that time. Now you might ask, "How much of this is actually avoidable?" And that would be a good question -- it's not necessarily a no-brainer that you could knock these numbers down by a whole lot. The answer is that in many cases, the hospitals don't do take some simple steps that would help, such as making sure the patients have adequate instruction and counseling about medication adherence and other self-care issues, that their primary care physicians are informed about what's going on and a visit is scheduled, etc.

Now here's the lede in the last paragraph: the hospitals have a strong financial incentive to make sure the people do come back, because that's how they make their money. Or, via NYT reporter Reed Abelson, "'Reducing admissions in a hospital is quite punitive in today’s environment,' said Dr. Amy E. Boutwell, a policy specialist at the Institute for Healthcare Improvement." Well, we certainly wouldn't want to punish hospitals for taking proper care of their patients. So here's the answer:

Do what the rest of the civilized world does -- you know, communist totalitarian dungeons like Canada and the United Kingdom. Put hospitals on a budget that reflects the cost needed to take care of the population in their catchment area, by keeping them as healthy as possible and sufficiently well-supported in the community that they don't need to be admitted more often than necessary. Then their incentive will be to do exactly that -- to keep people out, rather than bring them in. And believe me, the last place you ever want to be is a hospital. Hospitals are very dangerous places, filled with sick people with holes in them and tubes going into the holes followed by very nasty microorganisms that eat antibiotics for breakfast and get fat on them, and then come around and eat you.

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

Moral Stupidity

Richard Dawkins, who has a nasty habit of saying what he thinks, says "The Pope is either stupid, ignorant or dim" for claiming that promoting condom use will make the problem of AIDS in Africa worse.

Mr. Ratzinger -- I mean, he can call himself whatever the hell he wants I suppose but I'm just reminding everybody that he's actually a plain old human being who used to have a rather un-euphonious name -- is certainly wrong, and if anybody believes him his words will be deadly. It's awfully hard to see how causing people to die of a truly awful disease is consistent with anybody's idea of a "culture of life." But I wouldn't attribute ole Ratzy's murderous words to intellectual deficiency or even ignorance of the facts. He's well-read and no doubt has an above average IQ.

He is, however, a moral idiot. The Catholic hierarchy is so obssessed with their own fear and loathing of human sexuality that the prospect that people might have non-procreative sex is more appalling to them than the prospect that people might die a horrible death and go on to cause others to die horribly. As I have argued here before -- convincingly I hope -- that is also why they condemn abortion, not because of any concern about "human life," which in fact they despise. They don't even know what it is.

For those of you who follow Jesus, I must point out that there is precisely nothing in the Gospels which can be remotely construed to support the moral priorities of the Catholic hierarchy. I would suggest that y'all tell the Pope and the Bishops to get honest jobs and leave the rest of us alone. To put it more politely than I probably ought to.

The scum of the earth

That would be your friendly neighborhood health insurance company. It's an interesting observation in itself that most of the important news about health care is to be found in the business section, which is why I always turn to Business Day first.

It turns out that Senator Rockefeller, although he doesn't seem to have a big problem with cooking up phony intelligence to start an illegal war of aggression (but I digress), is bent out of shape by health insurers cheating physicians and consumers. The latest scam has to do with payments for out-of-network providers. Insurers typically reimburse 80% of "reasonable and customary" charges, but it turns out they have been using phony intelligence to determine what these are.

This is just one more rotten turnip in the health insurance stew, of course. The only function of these companies is to squeeze profit out of the transaction between the ultimate payer and the provider making sure that people who really need health care can't get it, that people who do have insurance don't get the services they need, and that employers and taxpayers overpay them while they underpay providers. In other words, they are parasites who perform no socially beneficial function whatsoever.

If we had a single payer system, of course, there would be no such thing as an out of network provider. There would be one network, and all the providers would be in it. Contrary to the BS touted by the insurance industry and its ventriloquist dummies in the corporate media, you, the consumer, would have more choice, not less: you would be able to go to any doctor, any hospital, anywhere in the country, and you would be fully covered.

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

Filial Piety

Sorry for the absence, still dealing with family responsibilities. Anyhow . . .

Few of us ever think about the huge reduction in traumatic injuries that Americans enjoyed during the 20th Century. I'm reading a book about this subject, of which more anon once I am ready to write the authoritative Cervantes review, but for now I'll just note that changes in building codes, consumer product regulations, highway design and features, automobile design requirements, workplace safety regulations etc. had an enormous impact of which the public is little cognizant.

The picture is complicated because there are separate statistical systems for workplace injuries, motor vehicle injuries, violent, injuries, etc., but just as one example the death rate from motor vehicle crashes in the U.S. was about 22/100,000 per year in 1980 and has fallen to about 15. Unfortunately, while deaths from other causes of injury have fallen steadily, deaths from accidental poisoning -- meaning mostly drug overdoses -- have been rising lately. Note that the progress results from a combination of technological advances, and government regulation to force builders and manufacturers to use the technology. This is just one more area in which simple-minded libertarian ideology fails utterly.

When I was a child, my cousins had a friend whose nightgown caught fire from brief exposure to a gas burner and who suffered agonizing and disfiguring burns over much of her body. Nowadays, that can't happen, because children's sleepwear is, by law, flame retardant. Think about that, Cato institute.

Unfortunately, one problem for which there is no simple technological or regulatory fix is falls by elderly people. This information service of a consortium of Ohio universities is one of those reliable Web resources I commend to your attention. They tell us that nearly 1/3 of women over 65 will fall every year, and the rate goes up with age. The risk for men is somewhat less but still substantial. Although hip fractures are the classic disastrous consequence of falls, head injuries and back injuries can also occur. These incidents can set people on the path to long-term decline and disability. The National Institute on Aging also gives out a lot of helpful information.

Thoughtfulness about people's physical environment is helpful -- night lights, keeping cords off the floor, making sure there aren't any loose throw rugs, grab bars and railings in all the right places, that sort of thing, can help. It's also important for people to do their best to stay active and to keep up their muscle tone and balance; to be alert to possible drug side effects that might cause dizziness of fainting, and not take any bullshit from their doctors about it; to look after bone strength and all that good stuff. Help out your friends and relatives and neighbors if they need to change ceiling light bulbs or do other chores that require climbing ladders or standing on chairs -- not a good idea if you're getting on, I'm afraid.

Be mindful.

Exterior Motives

Diane Rowland in NEJM (and yes, ya'll get to read it, bless 'em) describes the impact of the recession on the percentage of people without health insurance. You don't need to be a Doctor of Science to figure out that it's probably not good. However, I want to focus on the other side of the dynamic, which is the multiplicative effect on the economy as people lose health care and the states lose revenue to cover the increasing demand for Medicaid.

Contrary to John Boehner and that grumpy old guy -- what was his name again? -- who ran for president, recessions and depressions are not caused by excessive marginal tax rates. They are caused by what is happening to us right now, which is one trigger or another -- such as a burst asset bubble -- withdrawing aggregate demand from the economy and starting a chain reaction. As some people buy less stuff, other people lose their jobs or have reduced incomes, so they buy less, and so on and so forth. And of course businesses cut back on investment as well when they don't figure they can sell more stuff. So that giant sucking sound is economic activity swirling down the bowl.

Health care is the largest single industry, so it has a big potential role in stopping this negative momentum. Even better, it can have strong positive externalities, it provides jobs at every level of skill, and it's comparatively non-energy intensive and has readily policeable environmental costs (though we don't always do as well as we should -- viz all those pharmaceuticals in the water. Uggh.)

As Rowland points out, Medicaid and its extensions to more moderate income people, such as the Children's Health Insurance Program, can be an important automatic stabilizer -- a circuit breaker for depression -- if it can be fully funded by the states. Because these are entitlements, when people lose employer-provided insurance they may be eligible to be picked up by government-sponsored programs, which keeps the health care industry from contracting and so slows the downward spiral. The American Recovery and Reinvestment Act -- known more colloquially as the Stimulus Package -- was hurried through Congress so quickly that most people don't know what's in it other than that ridiculous, wasteful volcano monitoring and beaver management, but in fact, as Rowland says, it "provides $87 billion for a temporary increase in the federal share of Medicaid costs through 2010 and $25 billion in temporary subsidies to assist unemployed families with the cost of their COBRA premiums." Now, that's going to keep people from dying in the streets, which is nice, but it's also going to save a whole lot of jobs. Even better, 0% of it goes to pay for insurance company marketing, although some of it will go to profit and administrative waste.

With a national single payer plan, all that good stuff would happen automatically, every time there's an economic downturn, and it will happen even bigger and better because it will keep 100% of the people 100% insured instead of just helping a little bit the way the ARRA does. That will make economic downturns shorter and shallower and much less damaging. Does that help sell the idea? I sure hope so.

Bizarro World

Reed Abelson in the NYT is aghast at the prospect of a government sponsored health plan open to all:

It is one of the most contentious health care proposals President Obama has floated: offer a federal, Medicare-like insurance plan to anyone, at any age. And let commercial insurers offer their private health plans alongside it. . . . But the insurance industry and others wary of too much government intervention vehemently oppose the idea. They say the heavy hand of the government will eventually push out the private insurers, leaving the government option as the only option. . .

The main selling point for a government-run program would be its low cost. It would have a much lower overhead than private plans, with no need to make a profit or spend money on marketing or brokers’ commissions. And, if allowed to flex its muscle, the government would buy medical care at much lower prices.

The horrifying prospect that the government sponsored plan might actually deliver health care for all, at lower cost, has Chuck Grassley's knickers in a twist: “There’s a lot of us that feel that the public option, that the government is an unfair competitor.” Abelson goes on to explain that "Even Mr. Obama has acknowledged that those concerns are valid, and it is unclear how the government plan could be set up to give insurers a fair chance to compete."

How about this? If the government plan is cheaper, and better, then we don't need the private insurance companies at all. They can go away. Good riddance. No problem.

Brave New World?

Probably appropriately, having been burned by Pons and Fleischmann and the cold fusion debacle of the 1980s, the mass media have been largely avoiding this, but it appears that cold fusion is back, or rather, given the prior embarassment, what is now called "Low Energy Nuclear Reactions," LENR.

There is no telling whether anything will come of this, and it has physicists sufficiently baffled that I would still bet "no" if I had to. But . . .

If it ultimately is found to work, it will change our world so profoundly that the consequences are largely unimaginable. All the predictions about the potentially dire consequences of the decline of petroleum extraction, and the utopian visions of reordered values and a reorganized society that will carry us happily past the age of oil, will blow away like dust.

It is quite premature to invest much energy in contemplating the possibilities, but I mention this because it reminds us of how cloudy all of our crystal balls really are. Just as adults realize that their childhood obsessions with cliques and who the popular kids are and the unbearable crush on Mary Lou and all of that were just a lot of pish tosh, so might be everything we believe is important now in public policy, from the future of Social Security to geostrategy to economic development of the poor nations. A lot can change in a hurry, for better or for worse. Don't forget that. (I'll skip the negative catastrophe scenarios for now, but they're out there too.)

The disconsolation of philosophy

I don't have a big problem with mortality. Death is essential to life -- if organisms didn't get out of the way, they couldn't have progeny, there would be no evolution, and we wouldn't be here. Not to mention no nitrogen cycle or carbon cycle and hence most probably no biosphere of any kind. It's also not necessarily a bad thing that we know our time is limited so we'd better get off our lardbutts and accomplish something. Right now I need quite a few more years but definitely not eternity.

However, what I do have a big problem with is decrepitude. Our real worry should not be dying, but living too long in a helpless state. (While this may seem obvious to my typical reader, I hardly need remind you that it is the opposite of the view of the Christian champions of moral virtue, and the Republican Party.) The goal of medicine and public health should not be the arbitrary extension of life, but rather making sure we can cross the finish line under power. Unfortunately the Rule of Rescue (also see here) forces our research and treatment agenda off of that point. As we (I hope) embark on a new path of comparative effectiveness research and more rational allocation of medical resources, I hope we can find a way to make life, rather than the mere delay of death, the ultimate goal.

Depravity

I'm going out of town for a few days due to a family emergency, and I expect to be disconnected from Your Intertubes until at least Sunday. (My relatives are rather primitive in some respects.) Before I go, I want to make sure everybody has read Mark Danner's summary of the ICRC Report on the Treatment of Fourteen "High Value Detainees" in CIA Custody. It has gotten a bit of attention throughout the blogosphere, but of course the corporate media has tried very hard to ignore it.

You will learn how George W. Bush, dripping with Christian piety, ordered such actions as the following:

Two black wooden boxes were brought into the room outside my cell. One was tall, slightly higher than me and narrow. Measuring perhaps in area [3 1/2 by 2 1/2 feet by 6 1/2 feet high]. The other was shorter, perhaps only [3 1/2 feet] in height. I was taken out of my cell and one of the interrogators wrapped a towel around my neck, they then used it to swing me around and smash me repeatedly against the hard walls of the room. I was also repeatedly slapped in the face....

I was then put into the tall black box for what I think was about one and a half to two hours. The box was totally black on the inside as well as the outside.... They put a cloth or cover over the outside of the box to cut out the light and restrict my air supply. It was difficult to breathe. When I was let out of the box I saw that one of the walls of the room had been covered with plywood sheeting. From now on it was against this wall that I was then smashed with the towel around my neck. I think that the plywood was put there to provide some absorption of the impact of my body. The interrogators realized that smashing me against the hard wall would probably quickly result in physical injury.

That is just a very small taste of an elaborate, bizarre, unending program of torture. Now, the only thing I have to add to this is that for the individuals interviewed by the ICRC there is good evidence, at least according to their torturers, that they were involved in crimes, although they can never be prosecuted because they were tortured. However, as we also know, most of the people who disappeared into the network of CIA and military dungeons, and who were subjected to at least some portion of George W. Bush's psychopathic sadism, were completely innocent. Just think about that as Mr. Bush markets his memoirs and raises funds for his presidential library.

As Dr. Ruth is always careful to say . . .

I am not a physician, I cannot advise. However, my loyal 4 1/2 readers know that I have been something of a skeptic of some of the most widely promoted routine cancer screening procedures, notably PSA and even DRE screening for prostate cancer and mammographic screening for breast cancer. The basics are well-trodden ground here: the cost and hassle of the screening itself, followed by the angst and cost and pain of biopsies when they are positive, often falsely, followed by surgery and chemotherapy and all the associated horrors when the biopsies are positive even though many prostate cancers and breast "cancers" called ductal carcinoma in situ might just have sat there and done nothing if you'd just left them alone -- is it worth it?

This randomized controlled trial of prostate cancer screening, with 10 years of follow up, finds that men in the screening group were diagnosed with more cancers, but had no mortality benefit. In fact, the men who were not screened were actually less likely to die of prostate cancer than those who were screened, although the difference is considered not statistically significant. Who knows, with longer term follow-up, whether this trend would reverse? But it seems unlikely. If it's real, then it follows that you are more likely to die from the treatment than you are from the cancer.

The information women are given about mammography is often presented in misleading form. Here's the bottom line: If 2,000 women are regularly screened for breast cancer for 10 years, precisely 1 will benefit by avoiding dying of breast cancer. On the other hand, 10 women who would not have died from breast cancer will undergo breast cancer surgery, and possibly radiotherapy or chemotherapy.*

You will have to decide for yourself what to do with this information.

* Gotzsche, et al. BMJ, February 21, 2009.

So why did I just go off on a big tangent?

Well, of course it's partly just topical rage at the idiocy of the political discourse coming from the right and channeled by the corporate media with full aiding and abetting by the clown college called academic economics. But, when it comes to our main obsessions here -- public health, that is health promotion and disease prevention at the level of populations -- and reform of the medical institution -- economic orthodoxy is even more pernicious than it is when discussing the best way to meet society's need for plastic furniture covers.

Public health is, essentially, a public good and one big externality, more or less by definition. It is true that the market does provide most Americans with adequate protein and calories -- to say the least -- and other stuff without which we would be people of deadness; but when it comes to public health, what we mostly find ourselves doing is figuring out how to fix the market, or act entirely outside of it, to achieve social welfare that it cannot possibly provide. Public health, indeed, is very nearly co-extensive with all that which lies outside of the market, which I have described over the past few days: limiting harmful externalities, reducing inequality, giving people information, producing underproduced social goods, maximizing social capital, and all that good stuff. Some of the most powerful and cost-effective public health interventions consist of directly attacking the pernicious effects of the market, as by, for example, taxing tobacco and limiting food advertising to children. Occupational health and safety regulations, universal public education, consumer product safety regulation, food labeling laws, nutritional support for poor children and families -- all that stuff that conservatives call communism -- is what public health is all about.

Of course, it isn't communism. I asked my sociology class a few years back to define "communism," since people bandy the term about quite a lot, and one student told me that according to this father, the Boston Globe is a communist newspaper. Sometimes, I wish. I don't mean to embarass anyone, but we had a commenter here a few days ago who maintained that the collapse of the Soviet Union discredited Keynes. I can assure you -- and I know the good people at the Cato Institute will back me up -- that John Maynard Keynes was not a communist. (He was, however, a homosexual, which I understand is nearly as bad. He nevertheless had a happy marriage of convenience to a beautiful ballerina. History is so fascinating.) Nor did the Soviet Union practice Keynsianism. It's rather like claiming that the precession of the equinoxes proves that Jupiter is made of Jello. All you can is "Huh?" Still, this is the rhetorical world we inhabit.

Communism is a rather quaint idea these days and not something you need to worry about unless you are planning a trip to North Korea. Nonetheless we do still have to worry about the "S" word. I'll say a bit about that soon.

Depressed . . .

Repressed, oppressed, suppressed and compressed. After contemplating why many people, particularly of the starboardside variety, cannot seem to grok the basic concept of what a recession or a depression is, and how to get out of it, I have come to the following conclusion.

If you just assume that the market is "self-correcting" and that it "efficiently allocates resources," and then you look around and you see that there are factories sitting idle, fields unplanted, and workers unemployed, it seems obvious to you that the market could not be responsible for this, and something or somebody must be getting in the way and stopping it from doing what it does naturally. I mean, why don't those factory owners just start up the factories and hire the workers and start making stuff and selling it like they were before? What's stopping them? It's gotta be those onerous taxes and government borrowing crowding out private investment and burdensome regulation blah blah blah. Cut spending, cut taxes, get the government off the backs of the people, and we'll all be back in business and getting rich again.

Why is this wrong?

It's wrong because it is circular. The market does not do what you think it does. The market is not a natural phenomenon, it is a human social construction, cobbled together painfully and largely accidentally over many centuries. When it has been obvious that in one way or another it wasn't doing what people in power wanted it to do, they took steps to modify it -- whether to your benefit or mine, or not, all depends. It does not, as many economists assume just because, well, because they assume it, have an "equilibrium" state either. It is a chaotic system that goes through periods of pseudo-equilibrium in which change is generally slow, other periods of more rapid change, and occasional catastrophic changes which leave it in a new pseudo-stable state called a depression.

Here is what happened, in a nutshell. Due to an asset bubble (one of the rapid change states alluded to above) people spent a whole lot of money and businesses invested a whole lot to sell stuff to them. Commodities with fairly inelastic supply -- like petroleum and food -- became disproportionately expensive. Then the bubble popped and people everywhere felt a whole lot poorer and/or they couldn't borrow any more money, so they stopped spending. Factories closed, workers were laid off, the price of commodities collapsed curtailing investments in their production or extraction, meaning more workers were laid off. As people lost their jobs, they spent even less and more factories closed, along with the restaurants that fed the workers and so on, and now those people were out of work and they spent less and so on and so forth.

People who still had money weren't inclined to invest it because there was nobody to sell stuff to. Factories sit idle, not because they would have to pay workers comp and social security and unemployment taxes if they hired people, but because they wouldn't be able to sell the products those people made. They wouldn't even accept the workers as volunteers, because they would still have to pay for raw materials and electricity and what not, and they'd end up with a lot of stuff sitting in a warehouse that they couldn't sell.

So there is only one way out of this, unless we're willing to wait a long, long time. We're in a liquidity trap. Money is there, but it just sits there. Factories and workers are all there, but they just sit there too. Think of an internal combustion engine. You've got gasoline, you've got pistons and cylinders and ignition, but it doesn't spontaneously start running. You need a starter motor, which can draw current from a battery and get the whole thing moving.

There is only one such starter motor available in all the world. The government. The government has to spend money. It could cut taxes to zero and it wouldn't do any good. It could cut interest rates to zero and it wouldn't help. Instead, we have to turn the crank. Buy stuff, hire people, get the machine going again. That's called Keynesianism. And it isn't just true. It's completely fucking obvious.

My way 5 -- taxes

In the context of externalities and the place of the market in society, I have alluded to public goods. Loosely speaking this refers to goods that for one reason or another, in principle, cannot or perhaps should not be owned by individuals. But the theory of the market requires that everything be owned or it is helpless.

I would argue that public goods are far more important than private goods, and that therefore we ought to assume that public goods are the default and therefore it is private goods that are problematic and need to be accounted for as an anomaly. Certainly that is obvious for most of human history, during which people have very little in the way of individual possessions, and quite probably nothing that they kept for very long; most of what people did "own" in any sense was shared among the band; and the ecosystem yielded sustenance to the people with no-one even thinking of claiming ownership of any part of it. The idea would have made no sense, could not even have been stated.

Alas, we are so accustomed nowadays to think of everything as being owned that I have to make an argument about what economists largely ignore and only grudgingly acknowledge as exceptions. There are three main reasons why goods are public. Some are a little bit of two or more. First, it is impossible to limit the use of some goods to people who have established ownership. This includes not only bounty of nature, such as the atmosphere, but also certain manufactured items such as lighthouses. A shipper cannot build a lighthouse and exclude competitors from seeing it. But this is only subtly different, when you really think about it, from the second reason why goods are public, which is that they have such huge positive externalities that there obviously would not be enough of them produced if we left it to the market. It might or might not be worth it to an individual shipping magnate to build a lighthouse for the benefit of his own company, but if this did happen, it would not happen in all of the places for which a net social benefit to society would accrue by the creation of a lighthouse.

This latter argument requires a bit of elaboration. If all of the shipping companies and fishers and recreational boaters in the world could get together and parse out exactly what their benefit would be from the building and maintenance of lighthouses in all the places where they might be useful, and they voluntarily agreed to kick in the amount of their benefit to a common pool, there would no doubt be far more than enough money to build and maintain all the lighthouses they could possibly want. However, it would not happen, because most of them would wait in hopes that the next guy would do it and they wouldn't have to. And if some of them did step forward and do the right thing, they'd end up paying the cost while a bunch of freeloaders shared in the benefits, which doesn't seem fair.

Solution? Taxes. We form a government that enjoys enough popular legitimacy to solve problems of this kind, by compelling people to contribute to the common good, since, lamentably, most people just won't do it if we merely ask politely.

So government must a) protect commons such as the atmosphere from overexploitation and b) create new commons such as lighthouses which nature has not provided.

There is a third kind of quasi-public good, which is a so-called "natural monopoly." It would be ridiculously wasteful to build two or more separate networks to distribute electricity to people's homes. It's bad enough that our streets are cluttered and defaced by long lines of poles with wires, but what if there were three or four of them marching side-by-side down the sidewalk? Not only would we be unable to walk to the bus stop without stepping into the street, but electricity would cost much more because the investment and maintenance in each of the separate networks would be shared among a fraction as many consumers.

BUT

A monopoly utility would have us by the sensitive parts. It could charge whatever it wanted because it would have no competition. For some reason, in this country we have mostly allowed private companies to operate these networks but we regulate them closely to limit their prices and profits to a reasonable amount. Remember what happened in California when they tried not doing that and Enron stole billions?

Now, this ought to be perfectly obvious to everyone. We need to pay taxes, and we need to have government spending and regulation, because if we did not, capitalism could not exist. It is 100% false, and is not even supported by the most radical version of any intellectually respectable theory of the market, that taxation and government spending are necessarily harmful to economic growth or make people poorer. On the contrary, they are an irreducibly necessary condition for markets to exist and to flourish. When government collects taxes, the wealth doesn't disappear: the government spends and invests it. Whether this contributes to economic growth and overall welfare depends not on how much the government collects and spends, it depends on what kinds of activities the tax code differentially encourages and how the government spends the money. When government invests in public goods, that makes us all wealthier.

There is no consistent historic or cross-sectional relationship between the level of taxation in a country and its long-term rate of economic growth. European countries with far higher marginal tax rates than the U.S. have done just as well if not better economically (depending on what you measure) and with far less poverty, far less social problems, and happier people. Their corporate CEOs make a fraction of what ours do, and keep even less of it, but they still get up in the morning and go to work and run strong, profitable companies. Historically, in the United States in the past century, our strongest periods of growth have coincided with the highest marginal tax rates.

Duh. I can't believe we have to argue with these idiots.

Next: Recession.