Are you nuts?

Very likely. CDC says 25% of Americans have a "mental illness." They also say that half of us will have a "mental illness" at some time in our lives.

Bummer. (Uh oh, I shouldn't have said that. Maybe I'm depressed.)

The problem with this claim is that whether or not you have a "mental illness" is purely a matter of whether a committee of psychiatrists has decided that some state of affairs qualifies as a "mental illness" and some specific psychiatrist or otherwise authorized savant, such as a clinical psychologist or your family doc has decided that said state of affairs applies to you.

As you have likely heard, an effort is just winding up to create a new set of diagnostic criteria for mental illness. You can read all about it here. It's fascinating to explore. Keep in mind that as my old professor Sheldon Krimsky and his colleague Lisa Cosgrove have reported, 69% of the authors of the new DSM5 have ties to the pharmaceutical industry. And you know what happens to people who have "mental illnesses": they take pills.

Do you often argue with authority figures? Do you often actively defy or refuse to comply with requests from authority figures? Have you been spiteful or vindictive at least twice within the last six months? Are you often touchy or easily annoyed? Congratulations! You have oppositional defiant disorder. You are mentally ill.

Have you been sad for two weeks, even if you think you have a good reason? You're having a major depressive episode! Do you tend to misplace things? Do you talk too much? Are you easily distracted? Disorganized? You probably already know you have ADHD.

Even the definition of schizophrenia is based purely on whether somebody thinks you're just too weird, basically. Anders Breivik and Ted Kaczynski have both been diagnosed with schizophrenia but I read this and I have to say, "Huh?" A requirement to have schizophrenia is having at least one of delusions, hallucinations, or disorganized speech; and if you don't have two of those, you also need to have grossly abnormal psychomotor behavior (e.g., you are permanently in the fetal position); or diminished emotional expression or avolition.

Hating non-Europeans and non-Christians, or thinking that industrial civilization has been a disaster, are unpopular ideas in some circles, though not in others. Killing folks more or less at random in order to promote these ideas is teleologically inept, to be sure, also illegal. But I fail to see what is gained by applying a disease label to it.

Here's the basic problem. Psychiatrists like to say that these, and other traits they label as psychiatric diseases, have something to do with "chemical imbalances" and that they can be fixed by swallowing the right chemicals. However, they have no specific evidence for any particular chemical imbalance being related to any particular set of diagnostic characteristics. All they know is that if you drug people into a properly semi-stuperous condition,  they will be, for example, less oppositional and defiant, or less fidgety. As soon as a real chemical imbalance or functional neurological impairment is discovered and a reliable test for it is found, the problem ceases to be a mental illness and becomes a neurological condition, or perhaps even an infectious or endocrine disease.

Psychiatry, up to a point, may be necessary. But it is not properly considered scientific medicine. That's my opinion, anyway.

Town and Gown, cont.

One way universities can change is in how they do public health research, and other kinds of research with direct relevance to the communities in which they sit (and which they often dominate). As one review puts it:

Community-based participatory research in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved.

But . . .

Really doing CBPR is difficult. There are huge differences in resources, perspectives and interests between academic investigators and community representatives, whether they are professional staff of CBOs, patients or clients, community residents, people living with chronic diseases, or otherwise defined. Community based organizations are generally undercapitalized and have real difficulty investing the kinds of resources in speculative proposal development, with a potential payoff that we typically don’t see for two years or more, that we take for granted in the university. Unfortunately, despite the professed interest of NIH and the ICs in CBPR, NIH staff and proposal reviewers still have a long distance to travel  in adjusting their thinking to both the philosophical and practical demands of CBPR. The most straightforward practical mismatch between the NIH funding process and CBPR is that the specific aims and research strategy must be fully developed, with a high level of scientific rigor, before the proposal is submitted. But CBPR demands a planning and developmental process between the academy and the community during which the research problem and research strategy are shaped to meet the somewhat disparate needs of the two groups. Community representatives simply cannot engage in this process without financial support. The result is that putatively CBR projects are often actually completely developed and written before they are even presented to the community “partners.”

The philosophical difference between academic and community visions of research is complex.  Community representatives are typically interested in the specific problems and needs of their own community, obviously, but academic research, and certainly most NIH-funded research, cannot be satisfied with description of a particular instance but rather must create general knowledge which is broadly applicable. This is not usually an outright contradiction, but it can create tension. Most important, the ultimate goals of the two groups with respect to the uses of the research are different. Academic investigators have a personal interest in their careers – in publication, grants, tenure and promotion – and in the advance of science. Community representatives want their problems and needs to be understood, and addressed. Much research that is done in collaboration with community partners never results in any direct benefits to the community.

Rather than belabor these issues – and there are more -- I will just say that effective and, if I may presume, honorable, collaboration requires infrastructure. The community and the academy need ongoing institutional collaboration so they can grow to understand each other and benefit from mutual exchange of ideas, wisdom and resources to create the basis for truly equal partnership. This means an up-front investment. Which somebody with money has to make.

Town and Gown

As you may have heard, my employer has agreed to fork over $31.5 million to help keep Providence from going bankrupt.

This was a very contentious situation. A few weeks ago, I came to my office to find firefighters demonstrating outside. Their pensions are at risk in the city's financial crisis and they apparently didn't think the university  was paying enough for the protection they provide.

The issues seem fairly simple on the one hand. Even with the $31.5 mil, the university pays the city about 1/4 of what it would pay in property taxes, given the immense value of its real estate. The regular folks in Providence see privileged kids from all over the country and the world getting their ticket to a life in the upper reaches of business, finance and academia that their kids have no chance for. Why should the city subsidize this enterprise when all the people see when the students come in September is New Jersey license plates?

That seems fair enough but the matter is somewhat more complicated. In the first place, that real estate wouldn't be worth whatever gazillions of dollars if it didn't happen to be Brown University. Take away the university and Providence turns into a ghost town. All those stores and restaurants on College Hill would close, the apartments would all go vacant, the price of taxable real estate would collapse. The university puts the city on the map. I'm sure all this was argued over in endless circles during the negotiations.

Still, I believe that it is both an ethical imperative, and long-term very much in the university's interest, to move aggressively to tear down the ivy-covered walls between the institution and its communities. (Metaphorically ivy-covered that is. Brown has a strict policy against ivy. If you see a wall with ivy, it's RISD. Just an odd factoid.) We need to democratize the way we do science and education. Sure, the opportunity to get a degree from Brown is always going to be limited to winners of an intense competition. We can certainly do better about the criteria, but the prize is only valuable because it's rare and that is essential to the prestige of the institution and much of its raison d'etre, which no protest from YT is ever going to change.


However, there is a lot that we can do differently. I'll have more to say on this theme.

A tough problem . . .

. . . but there are solutions, or at least ways to improve the situation. A newly recognized consequence of the epidemic of prescription opioid abuse in the U.S. is a huge increase in the number of babies born addicted. Most, though not all (for reasons not well understood) of the babies born to women who are chronic opioid users will go through withdrawal (called Neonatal Abstinence Syndrome, NAS). Doctors give them opioid replacement, such as methadone, and wean them off gradually. They end up spending typically 16 days in the hospital at a cost of over $50,000, mostly paid for by Medicaid.

Stephen Patrick et al, in the linked report, find that the incidence of NAS increased from 1.2/1,000 births in 2000 to to 3.39/1,000, in other words almost triple. Investigators have yet to sort out the direct long-term consequences for these babies -- they often have problems later but their mothers, not surprisingly, are also disproportionately likely to smoke, drink alcohol, have poor nutrition and so on, and the babies go on to have a disadvantaged social environment. They have an increased risk of low weight birth, but whether that is a direct consequence of opioids is unknown. In any case, it's a humanitarian catastrophe and oh yeah, it costs a lot of money at a time when Medicaid programs everywhere are under strain.

I've discussed this opioid epidemic here before, but just a reminder, the driving force is misuse of prescription opioids. Some people who start with prescription drugs do end up using heroin because it's cheaper; but women tend not to like needles and so the epidemic prescription opioid abuse has meant a higher proportion of women get into trouble.

The difficulty is that there are completely legitimate uses for opioid analgesics, in fact they are a great boon to humanity and some people would suffer horribly, and unnecessarily, without them. But it's difficult for doctors to tell when somebody really needs them or just wants them because she or he is addicted, or intends to sell them. But here are some ways to improve the situation:

1. Shut down pill mills. Florida had a big problem with this, clinics that exist only to write scrips for dope. The governor refused to take action for a long time (maybe he had friends in the business), so Florida also has a disproportionate problem with NAS. These operations can be identified pretty readily, and there's no reason to tolerate them except that law enforcement doesn't make it a priority. We'd do a lot more good concentrating on them than on marijuana growing and trafficking.

2. Many states have registries for opioid prescriptions. They all should have them, and doctors should be trained (and perhaps required) to check them before writing a new scrip. That way they can find outif the person has recently filled opioid prescriptions elsewhere.

3. Offer treatment on demand. Stop locking up addicts in jail, which is very expensive and doesn't do any good. Have drug courts that divert them to treatment, and actually have the treatment available (which it often is not).

4. Create more comprehensive pain programs. There are alternatives to opioid treatment that will work well for many people, but there aren't enough physicians trained in comprehensive pain management.

5. Have universal health care, including dental care. Lots of people develop chronic pain because they have untreated conditions. They show up in Emergency Rooms and they need pain relief. ER docs can't tell the people with real dental pain (or whatever) from the fakers, so they write scrips indiscriminately. If they could just have the people seen right away by a dentist, that particular tactic would instantly become obsolete.

I can think of a few more but you get the idea. This is a problem that can be solved, or at least greatly ameliorated, if we take off the ideological blinders and approach it pragmatically. And that requires a government that responds compassionately to human needs.

Civilization and its Discontents

You have likely heard about a new study that finds that treatment of Type 2 diabetes in juveniles is very likely to fail. Here is the linked editorial in NEJM in which David B. Allen make a succinct statement of our doom:

[T]his is the essential, maddening conundrum of the epidemic of type 2 diabetes — collective failure to adhere to a lifestyle healthy enough to prevent the disease. A critical point is that the participants in the TODAY study were not adults, but youth immersed from a young age in a sedentary, calorie-laden environment that may well have induced and now aggravates their type 2 diabetes. Fifty years ago, children did not avoid obesity by making healthy choices; they simply lived in an environment that provided fewer calories and included more physical activity for all. Until a healthier “eat less, move more” environment is created for today's children, lifestyle interventions like that in the TODAY study will fail.

Please note that 20 years ago, nobody had ever heard of Type 2 diabetes in children. As a matter of fact, what we now call Type 2 diabetes used to be called Adult Onset diabetes. Nowadays, however, Type 2 diabetes is just as prevalent in children as Type 1 diabetes (an unrelated autoimmune disease with similar symptoms) which used to be called Juvenile Onset diabetes. This is a public health catastrophe that threatens all the gains we have made in life expectancy and health, and threatens every strategy to contain health care costs.

Yeah yeah, I keep saying it. We keep hearing from conservatives about personal responsibility and how people who develop health problems because of their own bad behavior don't deserve to have the rest of us pay for their health care. But the truth is that our behavior is a function of our social and physical environment.

We evolved to eat whatever food was available because there might not be any tomorrow; and to rest when we could because chances were rare and almost all the time, we had to keep moving if we wanted to keep eating. The human organism is adapted to an environment in which it no longer lives. The result is, many of us get fat. This isn't because we are irresponsible or gluttonous or slothful -- or rather, of course we are gluttonous and slothful, that's how we are made. It's not our fault that we have these faults, it's our nature.

So what is to be done? We can't just target and treat individuals who have this problem. We urgently need to change the cultural, physical and economic environment. There are a lot of ways to do that, first of all by defining junk food and sugary beverages as something other than food, and treating them accordingly. No matter how much the purveyors of this garbage pay corporate think tanks and phony scholars to yell about the Nanny State and personal freedom. What they mean is their freedom to rip us off and kill our children. 

Stayin' Alive

Yeah, it's not a very imaginative title. Anyway . . .

I live in a small New England town. The town center consists of a general store, a one-woman post office, a Congregational Church, a Catholic Church, the town hall, and an auto/tractor/whatever repair business. That's pretty much what it was 200 years ago, except that the auto/tractor/whatever business would have been the blacksmith. About a mile down the road is the old cemetery, which stopped taking new customers shortly after the Civil War.

Some history and genealogy buffs have made an inventory of the headstones, and the result is very relevant to the main concerns of Stayin' Alive. The list is in alphabetical order, which is almost as good as random, I guess. Here are some excerpts.

Adams, Mary, wife of Captain Thomas Adams, died Sept. 17, 1814, age 76
Allen, infant daughter of Asahel & Desire, died Apr. 23, 1772, age 4 days
Allen, infant son of Ezra & Lydia, died June 11, 1804, age 14 days
Allen, Anna, wife of Levi, died Mar. 5, 1834, age 23 yrs
Allen, Asahel, died Mar. 19, 1825, age 82 yrs
Allen, Charles H., son of Joseph R. & Susan M. Allen, died May 21, 1855, age 9 mos
Allen, Charlotte, wife of Erastus, died Jan. 2, 1875, age 86 yrs
Allen, Deziah, wife of Asahel, died Nov. 2, 1820, age 75, footstone
Allen, Erastus, died Aug. 28, 1856, age 74 yrs
Allen, Ezra, died Aug. 23, 1852, age 77 yrs
Allen, Joseph, died Aug. 28, 1815, age 76 yrs
Allen, Lydia, wife of Ezra Allen, died Mar. 10, 1855, age 70, footstone
Allen, Rebecca, relict of Joseph, died Nov. 17, 1819, age 87, footstone
Avery, infant daughter of Alfred & Fanny, died Oct. 24, 1853, age 2 mos
Avery, infant daughter of Alfred & Fanny S., died Oct. 24, 1853, age 2 mos 4 days

Bass, Betsey, wife of John Bass, died Jan. 9, 1837, age 42
Bass, Captain Ebenezer, Revolutionary War stone, died Mar. 6, 1814, age 67 yrs
Bass, Eunice, wife of John Bass, died Nov. 12, 1820, age 25 yrs
Bass, John, died Sept. 30, 1865, age 78 yrs 11 mos, footstone
Bass, John, son of John & Betsey, died Dec. 24, 1833, age 16 mos
Bass, Nancy, wife of Nathan Bass, died Nov. 23, 1834, age 44 yrs, footstone
Bass, Nathan, born Apr. 15, 1792, died Oct. 8, 1856, footstone
Bass, Ruth, relict of Captain Ebenezer, died Dec. 27, 1834, age 86
Bass, Ruth, daughter of Captain Ebenezer, died Nov. 21, 1794, age 1
Bingham, infant son of Gamaliel, died Nov. 30, 1804, age 3 wks

And it goes on like that. You will, I hope, notice something interesting. Lots of people lived to what we would today consider a respectable age, well into their 80s (there are a few in the 90s which I didn't happen to capture in the cut and paste), mid 70s is a typical age of death. But what is different from today is the many infants and children, and the women of child bearing age. These people were farmers and local artisans, for the most part, and the place was sparsely populated. In the cities, I expect there was more opportunity for infectious disease to carry off young adults and the middle aged. But out here, if you made it past age 4 or so, you could expect to get your three score and ten unless you died in childbirth. (There are a few men killed in the Civil War on the list, but that was a brief interlude in this story.)

This is a point I have made here before, but now we have a very clear and evocative illustration. The tremendous gains in life expectancy we experienced in the past century had little to do with extending old age and almost everything to do with actually getting there. Ruth Bass lived to be 86, but her daughter died at age 1, while her son lived to be nearly 79 and her grandson died at 16 months, while her daughter-in-law died at age 25, quite likely in childbirth. That was life in the good old days.

A world historical schtick dreck

I have sorta kinda been wanting to write something about John Edwards but what can I say that you haven't already thought yourself? Then I realized that he does sorta kinda make me rethink my political science.

Had you asked me, pre-JE, I would have told you unhesitatingly that a politician's personal behavior and integrity in private affairs should be a minor issue in choosing among candidates. Ultimately, politics is about public policy. The reason it matters who gets elected to office is the extent to which candidates run on policy proposals and priorities; and to what interests they will likely be responsive when in office. Ergo, for example, the serial philandering of JFK and Bill Clinton, as far as I was concerned, was pretty much between them and their wives and children, plus whoever was affected on the side of the partners in philandery. (Am I the only person who has noticed that it is impossible for a man to womanize without a woman who is willing to manize?)

But the Edwards case is different, for a couple of reasons. In the first place, by the time he committed his sleazy affair, the context had changed thanks in large part to the Clenis affair. It didn't matter what Kennedy got up to because the media didn't consider it appropriate to report, even though they actually knew. Until Monica, Clinton's behavior mattered only to the extent that it might have cost him some votes among people who didn't think like me, but basically, he got away with Jennifer Flowers and whatever else he got up to so who cares? (There was an accusation of rape by one woman. If that was true, it would be another matter, but there's no way to know. Paula Jones's story suggests pretty strongly that she was miffed only because she expected him to continue to pay attention to her. But I digress, the point is about consensual behavior not whatever else might have happened.)

However, Edwards knew perfectly well that if he became the nominee, and the truth got out, the Democratic party would be crushed in the election, the party brand severely damaged for a long time, and the country and the struggling people he purported to care about horribly maimed for years to come. On that basis alone, his warped character destroyed any rationale for envisioning him as president based on public policy. His narcissism completely trumped whatever he claimed to stand for.

Beyond that, of course, using campaign funds to keep his paramour on retainer, and to finance an elaborate plot to deny his own child, is so sick you have to wonder what he'd do with an army and a nuclear weapon. All this while making what turns out to have been his fraudulent relationship with his very popular, seriously ill wife, a centerpiece of his self-presentation. This guy is as depraved as they come. So yeah, there is a point at which it does matter, where you don't want to vote for a bastard, even if he's our bastard.

A Hard Blow

I've been a football fan my whole life. I remember watching the Houston Oilers beat the Buffalo Bills with a last second field goal on a little black and white TV at my grandparents' house when I was maybe six years old. When I was growing up in Connecticut we were Giants fans - "we" meaning my uncle and grandparents and brother and I. (My father was still hooked on the Philadelphia Eagles.) I've been a passionate follower of the Patriots since I moved to Boston some 25 years ago.

But it looks like I may have to find another way to consume hours of unwanted consciousness. It may be all over for North American football. You have to read a British newspaper to really get this story told forthrightly, but it's now incontrovertible that football players, with a very high prevalence, develop chronic traumatic encephalopathy. That means they become demented, chronically depressed, and die early, often by their own hand. We've always known about the osteoarthritis and other joint and ligament problems, but you can see macho men making a choice to accept that risk in exchange for the money and glory. (Actually the glory for most NFL players is very fleeting, and the money not so much as you think.)

But to lose your mind? That's not so easy to reconcile. Now a lot of these players are suing, claiming that NFL executives knew about this but covered it up. And they have a case. The expert physician panel they employed for many years downplayed the risk based on clearly inadequate research, which they interpreted tendentiously. Now that the truth is out, how many mothers will allow their sons to play football? And no, you don't need an NFL career to suffer this catastrophe, it now appears that it can happen to players who never play past college, quite possibly to some who never play past high school.

Football as we know it can't exist without violent collisions. They are simply essential to the game. And helmet technology seems to be about as good as it's going to get. Hardly anyone seems to be facing up to it yet, but it's hard to see how the game has much of a future. Tell me why I'm wrong.

The Memory Hole

There are plenty of good reasons to despair at the state of our politics. One grows weary at the impunity of lies in public discourse; the continual elevation of trivia, name calling, and faux outrage to the headlines; the systematic exclusion of not only viewpoints, but facts, that do not conform with the elite consensus about what is "serious."

The great Paul Krugman, for one, labors tirelessly to muck out the sewers. (He himself is "unserious" because he thinks European leaders should be more worried about mass unemployment and general economic collapse than they are about this year's budget deficits or the fools who bought Greek bonds. But I digress.) Today he again points out the obvious: That for Romney to win the election people will have to forget that the recession began while George W. Bush was president and that job losses stopped nine months after Obama took office; that private sector employment has done better under Obama than it did under Bush throughout his term; that Obama has been unable to implement most of the economic policies he wanted to anyway because the Republicans in congress prevented it; and that Romney wants to return to the very policies that caused the financial crisis in the first place. But Krugman also figures he will likely get away with it: "Are the American people -- and perhaps more to the point, the news media -- forgetful enough for that attack to work?"

Why yes, they are. Thanks for asking. Larry Siems, writing in Slate, tells us that he has read thousands of classified documents obtained by the ACLU under a Freedom of Information Act Lawsuit. And, as we already basically knew, "Our highest government officials, up to and including President Bush, broke international and U.S. laws banning torture and cruel, inhuman, and degrading treatment. Worse, they made their subordinates in the military and civilian intelligence services break those laws for them." The U.S. tortured people all around the world. The U.S. tortured innocent people. The U.S. tortured people repeatedly even when their torturers had decided it was useless. Senior officials lied, suppressed dissent, and destroyed evidence in order to cover it up. Siems writes, "From emails among FBI agents sharing their shock over scenes they had witnessed in interrogation booths in Guantánamo, to letters and memoranda for the record, to major internal investigations, the documents show that those who ordered and carried out the torture did so despite constant warnings and objections that their actions were ineffective, short-sighted, and wrong. It is no wonder that so many of these documents were suppressed."

Have you heard anything about this on the nightly news, public affairs yack shows, Sunday morning gabfests? Heard anything about it from anybody holding public office, including by the way B. Hussein Obama? Didn't think so. Nor will you, I predict. It would be too unserious to decide that the former president is a criminal.

The unbearable heaviness of fandom

With specific reference in this case to the Boston Red Sox. Baseball has an aesthetic quality. Just as chess masters can see elegance in a position that tells them it is strong even without close analysis, connoisseurs of baseball can perceive elegance in a team's play that speaks to its prospects. The analogy isn't perfect because there is a random element in baseball, so you need to look at several games before that spiritual sensibility can emerge. We can now proclaim that the Red Sox are a putrid, stinking, excrescence. Yesterday, while Phil Humber was completing the 21st perfect game in major league history on the west coast, the Sox were blowing a 9-0 lead, in Fenway Park, to the New York Yankees, in the nationally televised game of the week. This was just the latest in an unrelieved series of atrocious debacles dating back to the last month of last season. The players have no respect for new manager Bobby Valentine, whose mind is on vacation while his mouth is working overtime at his regular radio show, in New York City, with the New York Yankees play-by-play man. Really. Oh yeah, Valentine, in addition to being manager of the Boston Red Sox and a radio commentator for Yankees fans, is Director of Public Safety for the City of Stamford, Connecticut. Truly. But here's the thing about fandom. The fans have nothing to do with anything that happens. They wear lucky shirts or turn their hats around or leave the room when there's a critical moment on TV because they think they're bad luck or whatever, but really folks, it's not about you. At all. The emotional investment of sports fans in the fate of their team is difficult to explain. Red Sox fans, who are nearly suicidal right now, were euphoric a few years back, but their lives have actually been unaffected by the team's fate. I'm old enough now to have figured this out. (I didn't drop that pass, Wes Welker did. Not my problem.) But many people never do. It's a mystery.

Bad News

Coca Cola's earnings jump due to big growth in sales. "Revenue grew 6 percent to $11.14 billion, compared with $10.5 billion in the first quarter last year, propelled by a 5 percent increase in sales volume driven by even larger increases in emerging markets. After India [20% growth!], China experienced the greatest growth, 9 percent, followed by a more modest 4 percent in Brazil."

Good news if you own stock in the company, I suppose, but bad news if you are a human being. The Coca Cola corporation sells poison. That's the business they are in. They make their money by killing people. Kelly Brownell and colleagues explain the benefits of a tax on sugary beverages that would be steep enough to push down sales. But the merchants of obesity and diabetes have more than enough political clout to prevent this from happening. Coca Cola funded the American Legislative Exchange Council to do some of their dirty work, and of course we got Stand Your Ground and other noxious legislation as a side effect.

We have got to stop these evil scum. That is all.

Unintelligently designed

That would be us. Frank Bruni is a restaurant critic who for some inexplicable reason was awarded an endowed chair in punditry at the NYT, but today he's writing about food so I guess that's okay. He isn't saying anything we don't already know, or that hasn't already been said right here, but it's good to repeat it and with luck, focus our attention on the real problem and possible right solutions.

The reason we (collectively speaking, not necessarily you or I specifically) keep getting fatter is simply that we're swimming in an ocean of calorie dense food. Bruni could add that we also sit on our butts all day, but that's part of the same picture. For pretty much all of the history of life on earth, but certainly including 2 million years of genus Homo, having too much to eat was pretty much never a problem. If there was abundance, it only lasted a few days, then the elephant started to rot. And the amount of work our ancestors had to do in order to get what food there was burned as many calories as they were able to eat - and that's if they were lucky. So whenever there was extra food around, people would snarf up all they could, trying to put on a couple of extra pounds to get them past the next missed meal.

That wasn't a matter of choice -- it was hard wired into their brains. And it still is. The problem is, obviously, that the situation has completely changed. We weren't designed for the current environment, we evolved in a different one.

The solution to this problem does not lie in gastric bypass surgery, or inventing a miracle diet pill, or switching to a diet of nothing but grapefruit. It lies in changing the food and calorie expenditure environment. There are ways to do this through public policy, but the industries that create the current food environment won't let it happen. Also industries that create the built environment and associated transportation system. This is fundamentally a problem of the political power of vested interests. And it's making us sick and killing us.

I'll have more to say anon.

Revenge turns sour

Quite to my surprise, my home state of Connecticut is in the process of eliminating its death penalty. (At this writing I believe the governor has yet to sign the legislation but he has said he will.)

It may not seem all that surprising that our relatively liberal state would join its neighbors in Massachusetts and Rhode Island in taking this step, but the timing is notable. We have recently endured the second of two death penalty trials in a notorious case that made national headlines. It was even the occasion for one of those New York Times in-depth, four full broadsheet page reports, specifically on the life and family of one of the murderers. (Joshua Komisarjevsky was adopted into a somewhat withered branch of a distinguished clan.)

The surviving victim, Dr. William Petit, whose wife and two daughters hideously tortured and murdered, along with extended family members, demanded the death penalty. Accordingly, prosecutors rejected offers from both perpetrators to plead guilty in exchange for life without parole. Connecticut law requires a trial of guilt, as well as punishment, in capital cases, so the defense could not simply stipulate to the facts. Two juries had to endure the trauma of viewing evidence too horrific to publish, while our community endured the dutiful recitation of its description every evening on the television news, in repeated episodes nearly a year apart. My mother would hit the mute button on he remote whenever the story appeared, as I suspect a lot of people did. Dr. Petit had to testify to his unimaginable experience, twice. No one felt any right to publicly question the ultimate penalty in this case while his ordeal continued.

Neither of these defendants is a poster boy for the injustice of the death penalty. They are both white, both career criminals, well into adulthood, sane and of normal or above average intelligence. And yet, after all this, the legislature chose this moment, to little or no observable public outcry.

Sam Harris discusses the currently most compelling intellectual argument against revenge here. A warning: he very matter-of-factly recites the events of this case. I doubt many legislators or voters are thinking about the illusion of free will as they consider this issue. However, both defendants seemed not so much evil as helpless and almost pathetic, even if it's hard to feel sorry for them. They seemed perplexed by their own actions, lost in their situation. Sure, they're psychopaths and they aren't apparently remorseful, except for the consequences to themselves. But killing them just seems pointless.

The law is not retroactive and they, and the other nine men on Connecticut's death row could, in principle, face execution some day. ("Death row" is metaphorical -- Connecticut doesn't have a dedicated housing unit for the condemned, they are scattered about.) But it takes decades for these cases to wend their way through the courts, and costs the taxpayers millions. By the time anyone is executed, the reasons for it have faded in memory.

Michael Ross, the only person put to death by the state of Connecticut since the Supreme Court allowed executions to go forward, ordered his lawyers to stop defending his life. The judge had to struggle with whether Ross could take it upon himself to embrace his own execution, but finally allowed it. Ross had specifically and horribly traumatized the rural area where I live. People talked about his death with sadness, but no real satisfaction.

So, in the end, I think our people just recognized that capital punishment isn't worth it, doesn't accomplish anything good, and only adds to the trauma and cost of already evil events. Why the folks in Texas and Alabama don't feel the same why, I'm not really sure.

You know what? Medicine really has come a long way.

I was just hanging out with a couple of physicians around my own age, and they go to reminiscing about the old days when they were interns and such. Their earliest memories of doctoring were of young men showing up with wasting and generalized lymphadenopathy and disseminated cytomegalovirus and dying -- one after another after another, and there was absolutely nothing they could do about it. That was AIDS.

One of them is now a cardiologist. The age adjusted death rate from heart disease in this country has fallen by about 50% since then. (I don't feel like looking up the exact number, but it's in that ballpark.) It's not because we're eating better, or exercising more -- on the contrary. It's because of pills, mostly, and clot busting for people who have just had heart attacks. Childhood leukemia and other cancers of childhood are now largely curable. The death rate from many adult cancers has also fallen sharply. We're living longer and longer.

When I was in graduate school, the general picture was that the huge gains in life expectancy during the 20th Century didn't have a whole lot to do with medicine. They had a lot more to do with public health (e.g. clean water) and higher standards of living, mostly better nutrition. It was even possible for Ivan Illich to write a highly respected book, that everyone had to take seriously, that made the claim that medicine, on balance, did more harm than good. (It's called Medical Nemesis, if you're interested.)

Well, you just can't say that any more. Yes, we'd much prefer for people to exercise and eat right and not smoke and drink only in moderation and practice safe sex and all that good stuff. But the incontrovertible truth is, when we do get sick, we've got a much better chance, and that's now the biggest part of the story of increasing life expectancy.

It's important to remember that this is why universal access to health care, and medical costs and affordability, have become such a crisis. 60 years ago, medical intervention just wasn't as important. Doctors couldn't do nearly as much, there was much less on which to spend money even if you had it, it really was possible to take care of the basic needs of poor people through charity and for country docs to accept chickens from struggling farmers. If you had cancer or heart disease, you were just going to die anyway so que será será.

It isn't like that today. It's important to keep all that in perspective.

Conservadoofism

There seems to be a cornucopia of studies lately finding that conservative political beliefs and attitudes are associated with a paucity of brainpower. The latest of this bounteous harvest is from some folks in the universities of Arkansas, Kansas and Wisconsin, whose home states will not feel flattered. Scott Eidelman and colleagues find that it's not necessarily low IQ, but also essentially cognitive laziness, that generate conservative ideological orientation. They define "conservative" as including presumptive attribution of personal responsibility for individual outcomes; endorsement of hierarchy and status differences; and default preference for the status quo. (Note that logically, the first two tend to conflict with each other. Just a passing observation.)

They find that controlling for education, self-identification as liberal or conservative, and gender, people hanging out in a bar tended to endorse more conservative statements as their blood alcohol level increased. In other words, even if you start out considering yourself a liberal, beer goggles actually make you more conservative.

In other experiments, they got similar results when people were multi-tasking; and when they were given only a short time to formulate their responses. The basic idea is, it's a lot easier to come up with answers and explanations that are consistent with conservative ideology. If you do a little work and think about issues harder, you start to grasp more liberal ideas.

So yeah, it seems more liberal ideas are generally a little more complicated. That person isn't poor because he's a lazy slob, or belongs to an inferior race, it's because the economic order both perpetuates initial disadvantages and fails to provide adequate opportunity for everybody. Slightly more complicated, and also more likely to be a) true and b) potentially ameliorable, which would also of course mean that things would have to change. And this explains the appeal of the moronic ranting of the vulgar pigboy. He speaks to the intellectually lazy, not just the stupid.

Can consequences trump ideology?

I recently had the opportunity to talk with an actual professor of constitutional law at an Ivy League university (not my own, we don't have a law school). He thinks that the Affordable Care Act is constitutionally valid, but that the conservative majority on the SC would just love to find some reason why it isn't because conservative jurisprudence means coming to conclusions that are politically congenial to conservatives.

However, they do confront a difficulty. There is no limit to the sophistry they are willing to employ, viz. Bush v Gore. But in the latter case, the consequence of their action was that GW Bush occupied the office of president, which was fine with them however disastrous it was for the rest of us. However, in this case, here are their alternatives:

They go along with the Scalia plan, i.e., the individual mandate is unconstitutional and it's obviously just too much to ask for them to actually read the bill and decide which parts are inextricably linked to it and which parts aren't, so rather than forcing Justice Scalia to work after 5:00 pm they will just throw the whole thing out.

Since Scalia hasn't read the bill and apparently never will, he doesn't know this, but I'll let y'all in on the secret. There's a whole lot of stuff in there that has already happened. This includes the creation of the Patient Centered Outcomes Research Institute, which already has a funding stream which does not come from the federal budget or from congressional appropriations and which is a private non-profit corporation. It has paid staff and reviewed proposals, for which it will make funding awards in May, presumably before the justices rule. (Disclosure alert: I might even get one.) Similarly, the Center for Medicare and Medicaid Innovation has already spent money and will make substantial awards (maybe a billion clams) before the court rules. (Disclosure alert: They have paid me and several hundred other people $500 as an honorarium for reviewing proposals.) So what happens if the act is struck down? Are these entities dissolved? Do we all have to give the money back? What about people who have been paid salaries by PCORI and CMMI?

Then there are the high risk pools, from which people already have purchased insurance. The people under 26 who are staying on their parents' plans. The grants to states to set up insurance exchanges. What happens to all that? The result would be total chaos.

So let's say Scalia decides he can at least assign his clerk to read the bill and decide what is and is not severable. Is there some consistent, defensible constitutional basis for doing this? What about the medical loss ratio requirement? The insurance exchanges? Guaranteed issue? (Could that survive without the community rating requirement? I don't see why not.) Ban on recissions? If they do sort all this out then, a fortiori (yeah, fancy pointy headed Latin term) they will have to analyze and accurately describe how insurance markets work, which means the whole broccoli analogy and the rest of the right wing blog jive Scalia and the others quoted in oral arguments will blow up like a Pakistani wedding hit by a predator missile. They will have to conclude that the individual mandate is essential to congress's legitimate purpose in regulating interstate commerce in order to fix real problems in the market for health insurance.

As a matter of fact, my friend said that arguments on the third day, regarding severability, suggested to him that Roberts and Kennedy may have had the light bulb go off. They may have seen that the argument for severability essentially unmakes itself; whereas if they don't find severability and strike the whole thing down history will remember them as irresponsible lunatics. The question is whether they care about option B. (Scalia, Thomas and Alito clearly do not.)

A brief moment in history?

Margaret Hostetter, as part of NEJM's 200th anniversary celebration, reviews the history of pediatrics. She tells us that the very concept of pediatrics - of children as a group with particular medical needs - did not exist until the end of the 19th Century.

One reason for this, it seems, is that children in general were not expected to live. The wise approach to the death of children was acceptance. Hostetter writes, "By the middle of the 19th Century, a child's death, far from intolerable, was frequently viewed as blessed, a release from the torment of hectic infection or the lingering complications of diseases . . . " The old graveyard in my home town in Connecticut is full of children's tombstones. Yet the death of a child, once a routine occurrence, is today an unbearable, and rare, tragedy -- in North America and Europe, anyway.

What has changed is not so much living standards -- the children of the wealthy had little more chance in the 19th Century than the children of the poor. It is the conquest, by science, of infectious disease. There are three branches of the militant force which has won this world historic victory: environmental public health, antibiotics, and immunization. By environmental public health I mean such measures as the provision of clean water and safe handling of sewage, pasteurization and other food safety measures, isolation and quarantine (seldom needed today), sterilization of medical instruments, environments, and providers -- that sort of thing. Killing the germs before they get to the people, or keeping them away. The understanding of the nature of infectious disease, and measures such as these based upon it, made a tremendous difference even before there was much in the way of medical intervention against infectious disease.

Antibiotics, in fact, did not become important until after World War II. My mother lost an eye to infection as a child, something that would not happen today. Smallpox immunization was available in the 19th Century, or course, but the ability to immunize against a broad range of infectious diseases also came in the second half of the 20th Century.

So nowadays, for the first time in 2 million years of genus Homo, and 250,000 years or more of Homo sapiens, we expect our children to live. We take it for granted, in fact. But will this be true 30 or 50 years from now? Quite possibly not, if we continue with our present folly. This includes indiscriminate use of antibiotics -- including using them to fatten cattle even while maintaining them in unsanitary conditions. It includes the idiocy of people who refuse, and even campaign against, immunization. And it includes increasingly dangerous underinvestment in public health infrastructure. Maybe people who talk about a right to life should think about this.

Some folks may be interested in . . .

Rational Wiki. Quite a lot of useful and generally cool stuff here, although it's all preaching to the choir.

Our purpose here at RationalWiki includes:

Analyzing and refuting pseudoscience and the anti-science movement.
Documenting the full range of crank ideas.
Explorations of authoritarianism and fundamentalism.
Analysis and criticism of how these subjects are handled in the media.

Good for refuting whatever nonsense your Uncle Max comes up with, as well as amusing and enlightening yourself.

The scum of the earth

For some mysterious reason I've been getting e-mails from a PR flack for a company called -- no, come to think of it, I won't even name them. A company that sells homeopathic "remedies," i.e. a scheme to defraud the public. The first thing they wanted me to know is that an unnamed "major pharmaceutical company" is in negotiations to buy them, so it can sell their product line in pharmacies. I have no idea whether this is true, but if it is, there will be hell to pay, let me tell you.

Next, they are bragging that the company "has generously offered their product to India's Minister of Health and Family Welfare to help in their H1N1 Flu outbreak. India has stated it is suffering from an outbreak of H1N1, specifically known as the "Swine Flu". To date, the strand of flu has claimed 12 lives. . . .In a gesture of compassion, [company], Inc.'s CEO Kelly Hickel has informed the Indian Minister of Health that he has a modest supply on hand which he will gladly send over immediately, and should more product be necessary they will gladly donate their net profit as a humanitarian effort to aid in their fight against the H1N1 Flu strain."

Kelly Hickel is depraved. He/she/it is a pure, unalloyed evil. That is all.

Guess what? Climate change is bad for business.

And maybe some persons of richness are starting to figure this out. Via Climate Progress, the resort operators in Aspen are wondering why in tarnation they are paying dues to the U.S. Chamber of Commerce, since climate change is, you know, destroying their business and the Chamber denies that it's happening. Which obviously it is. The answer from the Aspen Chamber Resort Association is weirdly lame: "Officials say that while they fundamentally disagree with the U.S. Chamber's stance on climate legislation, they still value the group's administrative services."

Still, I would expect them, and other local chambers suffering from adverse weather, to defect pretty soon. I'm also wondering why we haven't heard from agribusiness and coastal communities. The warming and acidifying ocean is catastrophic for fisheries, and rising sea levels and more severe storms are really bad news for coastal resorts. There are rich people affected by all of this, who could be giving their money to the Sierra Club and Center for American Progress instead of the Chamber of Commerce and the Heartland Institute -- if they had any sense at all. Evidently they do not.

ABC News, at least, has gotten over the false balance fetish, even though the New York Times has not. This story tells it like it is. We'll see if more of the corporate media join them, but I'm not holding my breath.

There are, of course, more important things . . .

. . . than pink bowling balls. Here is a perhaps insufficiently alarmist review of the emerging global food supply crisis. It leaves out some huge problems, including the steady degradation of farm land, the likely catastrophic impacts of climate change, peak phosphate, and the growing competition between food and fuel for agricultural output.

The fact is, the only way we're ever going to feed the population two decades from now is if we do absolutely everything right. That means greatly improving the sustainability of farming techniques the world 'round; recycling phosphorous instead of letting it flow into rivers (and generally keeping agricultural runoff out of the water and recycling it back into the soil); and oh yeah, much less consumption of meat. Base your diet on vegetables, fruits, whole grains and legumes. The planet is depending on you. And I mean it -- things could get mighty ugly.

Not that this has anything to do with politics or policy as it is actually practiced in the United States.

Bob Abeshouse for Al Jazeera runs down the quite likely successful project of the Koch brothers to buy the government of the United States. Which largely explains our predicament.

Update: For some reason, I am unable to post a comment to my own blog -- I get an error message. So, I'm not trying to big foot Mr. Anonymous, but in response to the comment:

Turning grain into meat uses 8 times as much land and other agricultural inputs as eating grain directly. And whatever nutrients animals add to the soil came out of the soil in the first place. True, cattle can graze marginal land unfit for planting, and chickens and pigs can clean up some waste, but that's not how we're using those animals today. A sustainable agricultural system requires far less meat consumption than at present.

Eating whole wheat causes health problems only for people who are allergic to gluten, which is actually uncommon, although there's a quack fad against wheat. Soy is good for you, excellent food.

Is Rick Santorum actually satirical performance art?

Maybe I've failed to understand him all this time:

Washington – At a campaign event at a bowling alley in Wisconsin today, GOP presidential hopeful Rick Santorum told a boy who reached for a pink bowling ball: “You’re not gonna use the pink ball. We're not gonna let you do that. Not on camera.” Santorum went on to say “Friends don’t let friends use pink balls.” The comments were tweeted by Reuters reporter Sam Youngman.

Dream on . . .

The shiny silver lining meme that's going around progressive circles these days is that if the Supreme "Court" tosses the Affordable Care Act, congress will have no choice but to go to single payer national health care. This was actually first proposed by Robert Reich in the Puffington Host, but I don't link to purveyors of quackery and pseudo-scientific gibberish.

In fact the "justices" are going to have a hard time twisting themselves into the contortions necessary to hand the far right a victory in this case. Note that I say "far right" advisedly because the basics of the Affordable Care Act were first proposed by the Heritage Foundation. If they toss the whole thing, it's unclear what happens to the money that's already been spent and the structural reforms that have already happened. For example, the Patient Centered Outcomes Research Institute already has its income stream and has started to spend the money. The Center for Medicare and Medicaid Innovation, the Independent Medicare Payment Advisory Board, high risk pools, limits on medical loss ratios, extending eligibility for inclusion in family policies to age 26 -- all of these would seem to have nothing to do with the individual mandate, and the closely linked provisions of guaranteed issue and community rating. (All of which are contrary to the Bible, of course, as well as the Constitution.)

So they could leave all that alone, and just toss the individual mandate along with guaranteed issue and community rating. But if they do that, they will have to admit that health insurance isn't anything like broccoli after all, and that congress did indeed have a perfectly good reason for including the individual mandate in order to accomplish its clearly legitimate and constitutional goals of regulating interstate commerce; and that there is indeed a limiting principle in that a similar problem does not apply to any other good or service.

But if they just toss the mandate and leave the rest alone, the result will be a disaster, which will cause utter chaos and destroy the market for health insurance. The presumption by Reich and others is that at that point, congress will just have to do something, and the only something that's left which is clearly constitutionally legitimate is single payer.

Hah! The very same powerful interests that made single payer impossible in the first place and left the individual mandate as the only option aren't suddenly going to let that happen after all. They'll get congress to clean up the mess by repealing community rating -- and they'll probably get the medical loss ratio requirement repealed in the process. We'll just pretty much end up where we started, only three years further down the road to ruin.

Sorry to be a downer.

Million Dollar Idea

I'm going to print up some bumper stickers that say "I'm an ignorant idiot -- and I vote!" So many people nowadays are proud of being ignorant idiots, and are fully committed to political representation of their idiocy, that I know I could sell them.

Yesterday I got behind a pickup truck and the guy had a decal in his back window. It consisted of a confederate flag, and the legend "Why the hell should I have to press 1 for English?" That makes perfect sense because the noble cause of the confederacy was not having to coexist with people who speak languages other than English. As a matter of fact the Civil War started because the federal government was trying to force the God fearing people of the South to speak Yoruba and Fulani like their immigrant workers. I expect the guy bought the decal at a truck stop. I could sell my bumper stickers at truck stops and liquor stores.

I have another idea which is even better. I'd even buy this one myself. You know those giant foam hands with the upraised index finger, with "We're Number One!" printed on them, that they sell at the ballpark? I'm gonna have some made with the middle finger extended, print "Yankees Suck!" on them, and sell them at Fenway Park. I'll be richer than Mitt Romney in no time.

I'm not a constitutional law expert

But I do know something about health care policy. Having consumed a substantial proportion of the universe's supply of bits blogging about the Affordable Care Act and the underlying economic structure and ethical considerations of health care and health insurance markets, I will now state only a couple of points:

Health care and health insurance clearly and entail interstate commerce;
Congress compelled guaranteed issue and community rating in order to regulate the interstate market for health insurance in the public interest;
In order to do the above, the individual mandate to purchase health insurance is necessary. If you don't already understand why, Lawrence Gostin explains it to you, no worse than I already have.

It is my understanding that the great majority of people who are actual constitutional law experts think the act is constitutional. Indeed, in order to rule it unconstitutional the Court would have to find that everything from the EPA to restrictions on what can be sent through the mail is unconstitutional. Not only that, but the ACA is a conservative idea that was originally proposed by the Heritage Foundation and was the Republican's answer to single payer proposal (which, BTW, would be absolutely, no doubt about it, slam dunk constitutionally valid).

The problem, however, is that conservative jurisprudence means "coming to conclusions that conservatives like." As Andrew Koppleman explains here, the conservative majority on the Supreme Court cannot possibly find a principled way to hold the act unconstitutional without blowing up the modern state. But in the light of Bush v. Gore, you know they really, really want to. As Koppleman writes:

Its other option is to avoid those implications by surrounding its holding with the kind of obfuscation that [lawyer for the plaintiffs] Clement offers, so that no one will be able to figure out whether the case’s holding applies to anything beyond its specific facts. This second option, which is the only realistic one, is remarkably result-oriented: like Bush v. Gore, it adopts principles that it has no intention of adopting in any other case, just to reach a result it likes. Because no broader principles are being adopted, there’s nothing at stake beyond the chance to stick a pin in Obama – in a way that is likely to have a devastating effect on the very large number of people with preexisting conditions who were going to get affordable medical insurance as a consequence of the legislation, and who now won’t.

I don't expect honesty or integrity from this gang. Do you?

Christian faith

I believe I have mentioned before that I OD on NPR thanks to my long commute. This morning it got truly weird. It seems crowds have gathered in front of the Supreme Court to demonstrate for or against the Patient Protection and Affordable Care Act. Of course very few of them know anything about the legal issues at stake, they just want the court to vote their way.

The reporter decided to interview a single protester, and naturally she chose a guy who was against the act. Specifically, he was against it because he is a Christian. He and his friends had come to pray "that God will be enthroned in our hearts, and that he will intervene with the Justices" to make the right decision and rule the Act unconstitutional.

I certainly hope that the gentleman will choose prayer as the means to achieve all of his objectives. Pray on, my friend! Pray 24 hours a day! True, one might ask why, if God is all powerful and God hates the Affordable Care Act, he allowed it to become law in the first place. Given that he has the power to intervene in the decision processes of judges he presumably could have done the same with legislators. But I guess he was waiting for enough prayers.

That aside, the more interesting question is where exactly in Christian doctrine and morality one finds condemnation of open enrollment, community rating, and mandatory purchase of health care insurance with subsidies for affordability. I've been combing through the Gospels and the Epistles and I'm afraid I'm not finding it. Perhaps one of those sophisticated theologians can explain it to me.

Rick Santorum will never read this . . .

. . . but he should. Yeah, it's a little highfalutin', but it's what I'm reading right now so I thought I'd share a little. From Jurgen Habermas, The Theory of Communicative Action:

Actors who raise validity claims have to avoid materially prejudicing the relation between language and reality, between the medium of communication and that about which something is being communicated. . . . [M]ythical world views prevent us from categorially uncoupling nature and culture, not only through conceptually mixing the objective and social worlds but also through reifying the linguistic worldview. As a result the concept of the world is dogmatically invested with a specific content that is withdrawn from rational discussion and thus from criticism. . . .

Only against the background of an objective world, and measured against criticizable claims to truth and efficacy, can beliefs appear as systematically false, action intentions as systematically hopeless, and thoughts as fantasies, as mere imaginings. . .. To the degree that mythical worldviews hold sway over cognition and orientations for action, a clear demarcation of a domain of subjectivity is apparently not possible . . . In this connection it has been observed that members of archaic societies tie their own identities in large measure to the details of the collective knowledge set down in myths and to the formal specification of ritual prescriptions.

Alas, it appears that the United States, today, is in large part an archaic society. As I have said many times, the Republicans are not trying to lead us back into the 19th Century. They are trying to undo The Enlightenment, to restore the 14th Century.

Our socialist president

Not so socialist. Dr. Stephen Meltzer of Johns Hopkins informs us of the following:

I was on a recent conference call with Administration officials, during which research funding was discussed. It seemed to me that these officials did not fully understand the central importance of NIH funding to our national research enterprise, to our local economies, to the retention and careers of our most talented and well-educated people, to the survival of our medical educational system, to our rapidly fading worldwide dominance in biomedical research, to job creation and preservation, to national economic viability, and to our national academic infrastructure. In response to a question from a participant, they staunchly defended the proposed flat $30.7 billion FY 2013 NIH budget as being perfectly adequate, remarking that “The NIH receives more funding than any other research entity; it will continue to be strong; it will do just fine.”



Unfortunately, this is not the case. The proposed flat NIH budget will severely exacerbate a catastrophic crisis that has been ongoing since 2003, when growth in NIH funding fell (and has continued to fall every subsequent year) behind the rate of inflation. As a consequence of this deeply flawed public policy, promising careers have been cut short, amazing research projects have been aborted, hundreds of laboratories nationwide have shrunk or been shut down, established and accomplished senior researchers have been forced to abandon their programs, young scientists have departed from research of even left the country (even after many years of productive training), thousands of ancillary jobs have been lost, our worldwide medical research dominance has been eroded (ceded to China, India, and other nations), and a large support network of laboratory supply and biotechnology companies has been drastically attenuated.

I have discussed these problems here previously, but hearing about the administration's position is appalling. I still think Obama is a spy.

Oh yeah: You can sign Dr. Meltzer's petition here.

Plugola

No, they didn't actually pay me for these. First, from the HIV Prevention Justice Alliance:

Novartis, the Swiss-based pharmaceutical giant, continues its assault on India's generic pharmaceutical industry - legally challenging India's patent law that allows the nation to supply nearly 80% of the developing world's access to high-quality, affordable, life-saving medications.

India's patent law effectively stops evergreening, a tactic used by pharmaceutical companies to make minor tweaks on medications to extend their stranglehold on a patent that is about to expire.

Should Novartis succeed on March 28th, a dangerous precedent will be set...

With a chain-reaction of serious consequences.

The costs?

Crippling the generic pharmaceutical industry

Making essential medications even more cost-prohibitive

Cutting off the supply of medications used by NGO's worldwide

Millions of lives that are dependent on these drugs to fight diseases like HIV/AIDS.

Say NO to Novartis

Send the message to Novartis that no loss of human life can ever be tolerated for profits, by signing a petition here.

Learn more on how to Occupy Pharma by joining our working group.

Rather shrill, aren't they? I also got this:

FOR IMMEDIATE RELEASE CONTACT: David Merchant

19 March 2012 202.408.5565 dmerchant@citizensforethics.org

CREW WITH ADVOCACY GROUPS ASK FTC TO INVESTIGATE ANTI-COMPETITIVE PRACTICES OF VACCINE MAKERS

Washington, D.C. – Today, Citizens for Responsibility and Ethics in Washington (CREW), the National Legislative Association on Prescription Drug Prices (NLARx), the Campaign for America's Future (CAF), and the U.S. Public Interest Research Group (U.S. PIRG) called on the Federal Trade Commission (FTC) to immediately investigate the vaccine bundling practices of Sanofi Pasteur and Merck, which make it harder for pediatricians to use the best vaccines for children. Sanofi and Merck force pediatricians to buy vaccines in a bundle at a discount, or pay exorbitantly high prices to purchase vaccines individually. As a result, some children may not receive the vaccines most suitable for them.

CREW Executive Director Melanie Sloan stated, “When parents take their kids to the doctor, they expect the best medical care available, not the care dictated by drug companies seeking to maximize their profits. Basically, doctors are asked to make a choice they can’t refuse.”

CREW first wrote to the FTC about this issue in 2010, but a whistleblower has now provided new details about the practice. Vaccine discounts are conditioned on an express agreement that healthcare groups will purchase only a particular company’s vaccines. If any member of the practice fails to comply with this exclusivity requirement, the entire practice loses the discounts. These exclusivity contracts deprive consumers of the best healthcare, suppress competition, and prevent new and potentially more effective vaccines from entering the market.

This has real world consequences. For example, pediatricians who agree to purchase vaccines from Merck cannot offer their patients Cervarix, which is produced by GlaxoSmithKline, and is more effective than the better known Gardasil, produced by Merck, at protecting against the human papillomavirus. A meningitis vaccine studies indicate is more effective for certain patients similarly is unavailable.

Sloan continued, “Parents assume doctors are making drug decisions based on the patient, but in fact, they are making decisions based on the price. That will be cold comfort to a young woman who discovers she might have avoided cervical cancer if only she’d received the right vaccine as a girl.”

Click here to read this release on CREW’s website.

Click here to read the letter to the FTC.

Also shrill. The pharmaceutical industry giveth -- no antiretroviral medications and vaccines without them -- but it wants to taketh away far too much in exchange.

With little comment . . .

Except to say that there seem to be no limits to human credulity, this landed in my in-box:

Good afternoon, Michael-

As you may have seen or experienced, we’re in the midst of the worst allergy season in years due to the mild winter. On behalf of Dr. Steven Lamm, “the house” physician for The View, we’d like to gauge your interest in attending a fun, intimate online media gathering to learn about the natural health benefits of Dead Sea salt, particularly for allergy and sinus treatments!

DATE: April 25, 2012

TIME: 4:00pm

LOCATION: Midtown, NYC



The details of the event are still being finalized, but please reply back to this email as soon as possible if you’d like to enjoy amazing cocktails, hors devours and spa-like goodies inspired by the Dead Sea!



Thank you!

Kelsey

Dead Sea salt is otherwise known as salt.

Remember reality?

You know, the actual true world in which we live? That old place? Via Climate Progress, I came across this very sad essay by Jeff Turrentine. You may have noted the recent passing of F. Sherwood Roland, who discovered that chlorofluorocarbons used as coolants in air conditioners and other heat pumps were eroding the stratospheric ozone that protects us tender organisms from the earth's ultraviolet radiation.

Back then, when Ronald Reagan was president, we argued a lot over public policy but we largely inhabited the same reality. Although there was the usual denialist reaction by industry, the countries of the earth came together to write the Montreal Protocol that banned chlorofluorocarbons and Ronald Reagan -- yep, the conservative hero that all Republicans today want to compare themselves to -- signed it. Why? Because back then, the future of human civilization and of all life on earth was considered more important than somebody's short term profits, even by conservatives.

I have to say, global climate change denialism is the greatest evil ever perpetrated. Yeah yeah, Godwin's law, but Nazis only committed mass murder and genocide. How does that stack up compared to civilizationocide and biocide? And how is it possible that our culture is so tolerant of the unimaginable horrors that lie ahead -- that are already starting to happen, in fact -- and the psychopaths who are demanding that we allow them to occur? I mean you, James Inhofe, David Koch, Charles Koch, Rick Santorum, Mitt Romney -- yes you. There is no circle of hell deep enough for you.

What, Me Robot?

It seems a hot subject in moral philosophy these days is robot ethics, which partly means the ethics of humans employing robots, but also means the ethnics which which autonomous artificial intelligences should be equipped.

When it comes to robots, the future isn't what it used to be -- or rather, the present isn't what the future used to be. The Jetsons had a humanoid robot maid complete with frilly apron and cap. Commander Data, apart from his sickly pallor and weird eyeballs, was indistinguishable from Brent Spiner. Isaac Asimov's universe was filled with humanoid robots employed in every sort of job, their autonomy constrained only by the famous Three Laws of Robotics.

As it turns out, robots, so far, don't look anything like people. In fact most of them don't look like anything at all, their existence is purely virtual. Siri's only physical manifestation is a voice. Watson is a voice plus a lever that presses a button. The Google driverless car doesn't have a humanoid machine sitting in the driver's seat. The roomba doesn't consist of the Jetson's maid pushing around a vacuum cleaner, it's just a vacuum cleaner that runs around the room on its own. Assembly line robots don't look like UAW members, they consist of specialized implements mounted on retractable turrets.

Most of these devices don't pose much of an ethical problem. Watson has already violated Asimov's First Law by beating humans at Jeopardy! and thereby depriving them of cash winnings. The Google car presumably must obey the traffic laws, but I don't know exactly what it will do at a four-way stop sign or in a dispute over a parking space. Anyway these are not profound problems.

I tried to think of an application for which a humanoid robot would actually make sense, and that seems feasible in the near future given current technology. The only thing I could come up with is playing golf. The rules of golf require that professionals under age 50 walk the course, so it does indeed need to be bipedal. You have to use approved clubs, so it has to swing from shoulder height. You might as well use two arms for esthetic reasons, and maybe two hands do give some mechanical advantage. It makes sense to put the visual and communicative apparatus on top, so it might as well have a head. So, a basically humanoid body plan.

The rules of golf give a huge advantage to the AI department because it's perfectly legal, indeed customary, to have a caddy who can provide information and advice. This greatly eases the demands on the machine as a human can help it find its way around the course and correct any mistakes in judgment. The bot would need learning capability. It would have the basic swing motions for the various kinds of shots programmed initially, and then it would work out on the range, trying modifications until it gained accuracy. It would need an understanding of the basic components of the game: the drive, where the object is generally to hit the ball as far as possible while ending up in the fairway; the approach shot using an iron, trying to end up as close to the flag as possible; and putting; plus the assortment of pitches and chips from various lies and sand, although I expect it would play so consistently it would never need those, except perhaps in high wind.

It would need pattern recognition ability so it could distinguish the fairway, green, and flag; perceive the ball and the lie; and read the greens. All that, if you can already make a driverless car, seems quite doable. But the big challenge would be social skills. It would need to distinguish among various categories of human and interact with them appropriately, and in context, i.e. during a golf game, during a practice round or on the range, and while not playing golf.

The caddy is a unique individual who the bot would have to recognize, and accept input including instructions. The caddy's evaluation of shots and behavior would be essential input for machine learning as well. It would have to recognize competing golfer and their caddies, and behave toward them appropriately, knowing whose turn it is to play, not creating distractions while the competitor is playing, not stepping in the line of the competitor's putt, etc. It should be programmed to congratulate good shots, but it needs criteria for judging them so it doesn't appear to be mocking. Then there are marshals and rules officials, and fans with whom it can slap hands or sign autographs while waiting for the fairway to clear.

Asimov's three laws clearly don't work. Its very purpose could harm other humans, at least psychologically, by beating them at golf, although I don't suppose it would be eligible for prize money. It has to obey its caddy, but nobody else. Unfortunately, I think the world would quickly lose interest because it would consistently shoot in the low 50s, hitting every fairway, knocking every iron stiff, and making every putt.

Okay, we've developed this great toy. Watson now goes on to provide expert advice to doctors, but what does out golfbot do? Sure, you could adapt it to work in the carwash or tend bar or hang seamless gutters, but I suspect it's cheaper in the long run to hire humans for those jobs. I can imagine that it's really only good for two things: being a soldier and killing people, or being a sex partner. And as you can see if you read the link at the top of this post, those are the main problems that seem to concern robot ethicists nowadays. For the first function, Asimov's laws won't work at all.

Health care reform for dummies

One of my great and enduring frustrations is that the problem of health care organization and financing, and the reasons why 90% of what politicians say about it is baloney, are just too complicated for a sound bite or a bumper sticker. I wrote a long series on this subject a while back. You can start here and then keep clicking the "newer post" button to continue. There are also two essays in the new NEJM, which they have kindly made available to the Great Unwashed. Victor Fuchs discusses the history of the U.S. health economy since 1950, and Harvey Fineberg discusses why our health care non-system is messed up and what he would like to do about it. Both of these assume that you already know and understand what most politicians don't want you to know and understand (assuming they understand anything themselves), so let me lay out what I would say if I were running for office.

Health care isn't like most goods and services. Everybody needs approximately the same amount of food, clothing and shelter, and other basic goods. Beyond that, if you're lucky enough to be able to afford it, you might by more and better stuff and exactly what you buy will be according to your own taste and desires.

Your need for health care, on the other hand, goes up and down throughout your life and is much different from other people's need. That might have something to do with choices you have made (i.e. tobacco or chicken fat) but it also has a whole lot to do with circumstances completely beyond your control, such as your genetic endowment, the family you were born into, where you live, being hit by a bus, and just plain luck, not to mention how old you are. So you may just end up with a need you can't afford to pay for, and that can happen to just about anybody except really, really rich people.

Second, the reason you go to a doctor is because the doctor is an expert about medical care and you are not. You don't know what you need, the doctor has to tell you. If you are lucky you may meet a doctor who explains what's going on in a manner that you can understand, and makes clear the alternatives, and empowers you to make an informed choice in your own best interest. As I say, if you are lucky. But a) that probably won't happen, at least not in 2012, although we're working on it; and b) even so, you still might need something you can't afford.

That's why the whole idea of a hypothetical "free market" putting you in the driver's seat is utter nonsense. The only way to make the world more just is for everybody to have health insurance that makes it affordable for them to get the care they need, should they happen to need it. And making people pay out of pocket till it hurts won't cause them to make the right decisions about their health care because they don't know how. On the other hand, not having to pay isn't going to cause you to get health care you don't need, because medical procedures are generally unpleasant at best. I'm not going to check in for a triple bypass just because my insurance will pay for it. What will make you get health care you don't need, however, is your doctor telling you that you do need it.

Unfortunately, doctors do that a lot, because they get paid to do stuff. It's usually an unconscious bias, but it has been proven again and again that it exists. So we have two problems: people who don't get care they really do need, because they can't afford it; and people who get care they don't need, because there's an economic incentive. There are many other sources of waste and inefficiency in the system, as Fineberg details, but those are the core problems.

Republicans want to control health care costs by just not paying for health care that low and moderate income people can't afford. They're the real death panel. Democrats are all confused and conflicted, in part because hospitals and doctors and drug companies all give them money to keep the gravy train flowing.

What we really need to do is:

1) Make sure everybody has adequate, affordable health insurance. That requires:
a) Regulation of the insurance market so that insurers compete by offering better benefits and friendlier service, instead of by only enrolling the healthiest people. (Single payer national health care would be much better but I'm not dreaming right now.)
b) Providing subsidies for low income people who cannot otherwise afford the above. And by the way, however smug you are about being successful and well-to-do, and however much you think that poor people are moochers and should drift off on an ice floe, if you should happen to get seriously ill you might just find yourself among them. Yes you can.

The affordable care act does that. It can't do it without the individual mandate because otherwise, (a) could not happen.

2) Change the way doctors and hospitals get paid so that they make money by keeping people healthier at lower cost. Yes, both are possible.

The affordable care act makes a modest start in that direction, but doesn't go far enough because of the Death Panel horseshit. If Democratic politicians (and that includes the president who for some reason has no interest in defending his signature achievement in public) would start making an effort to explain this, the world would be better.

Mad or Bad?

The horrific events in Kandahar province on Sunday remind us of a couple of perplexing moral problems. Leon Panetta says of the massacre of 17 Afghan villages, purportedly* by a single "rogue" American soldier, "War is hell," and as reported by CBS, "He said this "wasn't the first and won't be the last" of this kind of horrible event, adding "I do not believe there is any reason to change our strategy at this time." Well yes. In wars people kill each other. Under specific circumstances it's considered not just okay, but heroic. And it's perfectly alright to kill non-combatants as well, so long as you didn't really mean to, even if you knew it was going to happen but it wasn't your actual purpose. Since war, according to the U.S. Secretary of Defense, expectedly and inevitably means that event such as this will happen, maybe they aren't such a good idea after all?

That said, we have a muddled and inexplicable view of moral culpability when people commit such unimaginably atrocious acts. Charles Whitman, who climbed a tower at the University of Texas in 1966 and shot 16 people to death, was found on autopsy to have a brain tumor. No-one can say for sure, of course, but it is entirely possible that tumor was a necessary cause of his actions. (Behaviors are complexly caused, of course. What I mean to say is that given the counterfactual that he did not have the tumor, he would not have committed the crime. We cannot do the experiment, but I would still say the statement is meaningful.) If that is so, was he responsible? Was he culpable?

Then consider Jared Loughner, who attempted to kill Representative Giffords and did kill 6 people. He has been diagnosed as paranoid schizophrenic by court-appointed psychiatrists. Based on published reports of his behavior before, during and after the crime, he is what we technically call completely nucking futz. He is as profoundly psychotic as anyone can be, and was clearly fully inhabiting an alternate reality. Does it make any sense for him to have a criminal trial and sentence, presumably death? Or is he also not responsible and not culpable?

Some people will say it doesn't matter, that we are what we do, but most people do not. The law obviously recognizes brain disease as at least mitigating, and sometimes entirely exculpatory, based on a conclusion that the person was unable to comprehend the wrongfulness of his or her actions, or unable to conform to the law.

But what does it mean for someone to be "able" to behave in a way other than the way the person actually does behave? Consider Sergeant X. We are told that he was on his fourth combat deployment, had suffered a brain injury, and was having marital problems. There seems little doubt that he merits some sort of psychiatric diagnosis. Suppose those things had not happened to him. Presumably he would not have committed atrocity. Okay, how is that different from Whitman's brain tumor and Loughner's schizophrenia?

Now let's consider Timothy McVeigh, who blew up the Murrah Federal Building in Oklahoma City. Perhaps he got labeled with a personality disorder, but he was certainly not psychotic. He explained his own motives in affirmatively moral terms: he believed what he did was not only right, but admirable. The vast majority of us see that as preposterous. Even if you are deeply offended by government actions at the Branch Dividian Compound, the workers in the Murrah Building had nothing to do with it. Deciding that they were guilty because they work for the federal government makes about as much sense as going around killing everybody you could find with the last name of Reno, or the first name of Janet; these categories are just irrelevant.

But it made sense to McVeigh, not because he created himself as somebody who believed such a thing, but because the sum of his experiences as they interacted with his neural network created that belief in him. The point is, none of us creates ourselves or could, in a meaningful sense, have done anything than what we have done. The history of the universe leads to each point in time and makes it what it is.

The useful way to think is not to assign blame and seek retribution, but to look for ways of preventing such terrible events. Not going to war seems like a very good place to start.

* I say "purportedly" because there is a great deal about this story which is more than little bit fishy. For one thing, it's more than a little bit odd that a lone soldier could simply walk off the base, carrying a weapon in the middle of the night. The official story that has trickled out seems to imply that the only sentries on duty were Afghans, who apparently didn't feel they could stop him. When they reported it (To whom? The American Sergeant of the Guard? What the hell was he doing?) the response was a head count and a bed check. Really? Nobody saw him leave the barracks? And how did he set fire to the children's bodies? Was he lugging a can of gasoline along with his rifle as he supposedly hiked to the villages on foot? And is it really possible that nobody in this highly confined and intimate space noticed that there was something wrong with the guy? We may never know the real truth, but whatever it is, lots of people are never going to believe the official story. The commanding officer and the OD, at the very least, should be court martialed for dereliction of duty and dishonorably discharged. Want to be that will happen?

Call off the apocalypse?

What if Medicare costs aren't going to grow unsustainably after all? That's what Chapin White and Paul Ginsberg ask. I have mentioned here that the Affordable Care Act contains several provisions that promise to contain Medicare spending (while simultaneously improving outcomes, by the way) including the Patient-Centered Outcomes Research Institute, the Center for Medicare and Medicaid Innovation, and pilot projects to reconfigure the payment structure and reorganize health care. There was also some earlier legislative action that constrains costs.

Well, it turns out that for the past couple of years, Medicare spending per beneficiary has pretty much tracked inflation. That's partly because of the bad economy -- even Medicare beneficiaries have to pay something out of pocket -- and partly because of the retiring baby boomers who, for a period, will mean there is a higher percentage of "young old" in the mix. But White and Ginsberg think there's more to it, that we really are starting to get a handle on costs.

I think they're calling the game too early, but I also do think there is promise in the reforms that have been made so far and that if we can stuff a sock in the Death Panel wingnuttery and equally deranged "free market" fundamentalists, we can do this thing. But we need a much, much better press corps and a Democratic party that's willing to stand up and fight.

Bring on the giant meteorite

Public Policy Polling has surveyed Republican primary voters in Alabama and Mississippi. You can skip the horserace questions in the beginning and go straight to pages 3 and 4 where you will find:

45% say Barack Obama is a Muslim, 12% say he is Christian, and 41% are not sure.

21% say that interracial marriage should be illegal, and 12% are not sure.

26% say they believe in evolution, 60% say they do not, and 13% are not sure.

I must admit this forces me to struggle with the problem of representational government. There is no political communication or educational or organizing strategy that can result in these people understanding and voting in their own best interest. They are a lost cause. What is to be done?

Note: I posted this before Jed Lewison did at Kos, so there.

The Dreams of Reason

For reasons only tangentially related to the following discussion, I am reading The Theory of Communicative Action, by Jurgen Habermas. (I'm afraid I don't know how to make the two little dots over the "u".) Habermas's magnum opus was written over several years but published in 1981.

He begins by announcing (not in so many words but this is how I read it) that the triumph of empirical science has killed metaphysics, and that philosophy has essentially collapsed to epistemology. What this means in standard English is that, since we now expect truth claims to be verifiable, it's no use sitting in your study and making up fancy sounding jive about the ultimate nature of reality or the nature of existence. Whatever we may ultimately conclude about that will be figured out by physicists, or remain a mystery. Philosophy still has a role, however, in working through the puzzles of how we decide what is true, and that's called epistemology. We have decided, however, that argument by assertion is not valid, so forget about the Bible or Hegelian mysticism and so on.

Habermas's project is to understand how society produces and maintains itself in the Age of Reason, now that the authority of church and tradition has decayed. He is not a cheerleader for the Enlightenment - it's here, he's part of it, get used to it, but there has been a price. Humanity has lost something in the bureaucratization and commodification of life, and from that observation grows his famous dichotomy of lifeworld and system. Reason does not necessarily produce justice or humaneness or happiness, because it can be used for antithetical purposes, or have unintended consequences. I would say, however, that it's the only weapon we just, humane, and happiness-pursuing people have that's going to get us anywhere.

That said, I expect Habermas is quite surprised by the powerful reaction against reason now occurring, particularly in the United States. Back in 1980, it seemed to most people, me included, that reason was going to march on and conquer, for better or for worse. This may be a temporary setback. It's partly happening because many people are feeling those negative consequences. The economic system is grinding them down and their lifeworlds are impoverished. But, and this is extremely important, the crusade against reason is also being financed and waged by people who perceive that when the masses possess truth and the tools of critical thinking, their own privileges are threatened. They want to keep it all to themselves.

Am I Weird?

This whole 1950s retro debate about contraception is universally framed as an issue of women's health vs. religious freedom or something like that. It seems to me that there is a certain percentage of the male population -- vanishingly small, it seems, and not worth mentioning -- who like having sex with women who they like and care about, and only want to make babies by mutual agreement. Do we not vote? If you prick us, do we not bleed?