Energy Medicine

I changed my usual policy and left a spam comment on my previous post, because it links to an utterly outrageous fraud.

I don't spend a lot of time trashing quackery because there are plenty of people doing it with more time and resources, and a bigger readership, than me. (Viz., Science Based Medicine.) But I am curious about why so many people are attracted to so much hooey, and how is it that these malignant clowns manage to relieve said people of their hard earned cash.

One can discern a taxonomy of quackery. There is the herbalist/supplement group, which generally hews close to the scientific worldview but just doesn't bother with the facts. The claims are intrinsically plausible: that the nostrums do in fact contain biologically active chemicals which either fill nutritional needs or correct one or another form of bad chemistry in the body, just like pharmaceuticals. But they are purportedly better because they are "natural," "gentler," have fewer side effects, whatever. Big Pharma doesn't want you to know it because they aren't patentable and therefore don't bring in the big bucks.

You know what? This might be true. Sometimes it is true. Aspirin is a slightly modified form of a compound found in willow bark, which was known to the ancients. Statins are versions of a compound found in a fungus which was used by the Chinese to treat heart disease. Presumably you know about morphine, etc. Lots of drugs are derived from plant compounds. But you don't make willow bark tea, you buy aspirin, for a good reason -- you know exactly how much you are getting of a pure compound. And most of the junk on the shelves of the GNC doesn't do any good. It's almost all a ripoff. But that can be determined on a case by case basis -- the claims aren't inherently nonsensical. People have good reason to distrust pharmaceutical companies and it isn't that hard to see why they fall for the blandishments of the supplement industry.

Energy medicine is another matter. This encompasses Reiki, therapeutic touch, and acupuncture, along with some more obscure or localized shamanistic systems. It derives from a category of pre-scientific belief called vitalism, essentially the idea that life is a kind of energy or mystic force that imbues living things. In acupuncture, it is said to flow through specific channels in the body called meridians, which connect organs and locations in the body with others. These flows become blocked or diverted, and sticking in the needles is supposed to correct them. In Reiki, the practitioner "realigns" forces with his or her hands.

It is much more difficult for me to see why anybody falls for this nonsense. The "vital energy,"  the chi of acupuncture, do not exist. The meridians do not exist. These ideas are purely imaginary. Life is not in fact precisely definable, nor is the border between life and death sharply defined, but life processes are based on the same forms of energy found independent of living things. Chemistry and physics give a complete account of life. Of course we haven't filled in the innumerable details of every life process, but there is no missing or mysterious form of energy. Chemical bonds break and form, heat (and yes, a little bit of electricity) flows, gravity pulls down (to put it in vernacular terms, sorry Dr. Einstein), electromagnetic radiation strikes the cells and has readily describable effects. (Some life forms produce electromagnetic radiation, but as far as I know we don't. We do have a weak electrical field, but it doesn't particularly do anything.)

There is, to be sure, growing interest in using electrical stimulation for various healing purposes, from orthopedics to neurology. But that's plain old electricity, folks, not the mystic force field. You don't make it by waving your hands around or sticking in needles. The useful therapeutic inputs include chemicals, heat (or cold), light, physical manipulation (e.g. compression, immobilization, mobilization, stretching, surgery), electricity. The same old boring energy that pertains to dead stuff.

Okay, it's not boring. It's science. Why isn't that good enough for folks?

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

Last time, I mentioned that lots of people take calcium supplements for "bone health." Well, you might want to think again. The linked article presents very complex statistical analysis, but to make a long story short the authors have done everything they can to control for potential confounding in an epidemiological cohort study. (They took advantage of a cohort of Swedish women recruited originally for a study of the benefits [or lack thereof] of screening mammography.)

The bottom line is that the body regulates the level of calcium in the blood very closely. Unless you have a real calcium deficiency, more calcium won't make your bones stronger, it will just be excreted. Up to a point, that is. The basic conclusion of this study is that calcium supplementation at low levels -- say from a multivitamin -- is probably harmless, but doesn't do you any good either. However, once you get above a certain threshold, about 1400 mg/day, which you can get from taking a specific calcium supplement, it sharply raises your risk for heart attacks and death.

So once again, the same message. Eat a half decent diet. Skip the supplements, you're wasting your money and more likely to be harming yourself than helping yourself. If you have a specific nutritional deficiency, it may be a different story. Talk to your doctor.

On another subject, Merck has agreed to pay investors $688 million for keeping secret the results of trials showing that it's highly profitable blockbuster drug Vytorin doesn't reduce the risk of heart disease. The company previously paid out a mere $41.5 million to consumers in a class action suit, and $5.4 million to state attorneys general. You may remember the advertisements featuring people dressed up to look like various foodstuff, touting the useless snake oil.

Sounds like a big victory for the good guys, right? Not so much. It's chump change. In its heyday, Vytorin was being prescribed at the rate of 800,000 new scrips per week, bringing in $5 billion in one year (2007). They made a ton of money, and had to cough up a few percent. That's why they keep doing it.

Firearms policy on Earth 2

A couple of essays in the new JAMA on gun violence: one by Kellerman and Rivara on Republicans' successful efforts to defund public health research on the subject; the other by Mozffarian and colleagues on possible effective public health measures based on analogy with other health hazards. (And props to JAMA for making these available to y'all commoners.)

What is astonishing about both of these ruminations is that they are simultaneously the very paradigm of common sense; and so politically naive as to be risible. I expect the authors know that, but they figured, what the heck?

As K and R recount, Congress in 1996 tried to de-fund the CDC Center for Injury Prevention altogether, because they were figuring out that keeping a gun in the house makes you more, not less, vulnerable to violence and death. They ended up backing off slightly, but the amount of funding originally spent on gun violence was earmarked for other purposes, and language inserted in the appropriation that forbade funds being used  to "advocate or promote gun control." Not wishing to risk their agency's existence of their own careers, CDC employees have assiduously avoided the issue ever since. The restriction was later applied to NIH.

As always, Republican epistemology is "If evidence might show that we are wrong, make sure we don't get any evidence."  Reality has a well-known liberal bias.

So, what do Mozaffarian and the gang propose? Noting that 85 Americans are killed by guns every day, they look to public health successes in the areas of tobacco, unintentional poisoning, and motor vehicle safety. We have made major progress reducing harm from all of these sources.

So why don't we tax firearms and ammunition to incorporate their actual social cost in the price and fund gun safety programs, as we have done with tobacco? Riiiigght.

Why don't we require keyed or code locked security devices on guns, analogous to childproof safety packaging on drugs and chemicals? Ha!

Why don't we require mandatory gun safety classes and licensing, as we do with drivers? In your dreams.

Why don't we have a sustained media campaign to de-glamorize guns, as we did with cigarettes? Instead of being manly and cool, in other words, guys who have to go around armed all the time are wimps. Uh huh.

The fact is that of all the measures they discuss, only restrictions on large capacity magazines are under any sort of serious discussion, and that's not going to happen. (And in case you think we're talking about restricting rapid fire semi-automatic weapons, no we aren't. We're only talking about restricting "assault weapons," which just means rapid fire semi-automatic weapons that have a certain bad ass look about them. Tone down the bad ass look, and the president's proposal is inapplicable.)

If we did even half of the above, we could significantly cut down on the carnage. And in case you're wondering, so far the Supreme Court would have no problem with any of it. (The media campaign would have to be conducted by private organizations, presumably, although the government could fund more straightforward educational messages.) But should I be spending my bandwidth on a hopeless cause?

Not that the corporate media will notice . . .

or in any way change its conventional presentation of the "Tea Party" as a) a party of some kind and b) a grassroots movement of down home regular murkins who are fed up with big gummint because they believe in freedom, but it is of course a phony astroturf movement funded by the Koch brothers, which grew out of the phony smokers' rights movement with its associated science denialism funded by the tobacco industry.

As I have said here many times, in the United States we do not have public political discourse organized around competing value systems, or competing analyses of facts in evidence. We have competing sets facts, classifiable by people capable of evaluating evidence as true and false.

E.g.

True: The federal budget deficit is not the cause of our recent economic collapse and current sluggish recovery. Federal borrowing is not "crowding out" private investment. We have a shortage of demand, the cure for which is more, not less, government spending.

True: Rich people do not "create jobs," and they do not create more jobs if they are taxed less. Jobs are created when it is worthwhile to produce goods and services because there are people who want to spend the money to buy them. Right now, giving more people to rich people destroys jobs, because they are not inclined to spend most of their money.

True: In the long run, the projected large federal deficits are not caused by big government or any form of discretionary spending. (In my opinion, most military spending is wasteful but for the sake of argument I'll stipulate that to be debatable.) In any event, projected growth in deficits is not based on growth in military or domestic discretionary spending. Nor are they caused by Social Security. They are largely a product of projected increases in spending on health care, and contingent on our having historically low rates of taxation by modern standards. But . . .

The reason we spend so much on health care is not because people have insurance, or we don't have a "free market." It's because we have too much of a free market. Countries with socialized health insurance spend half as much, and get more. Ideology can't trump that fact.

True: Human activity, principally burning fossil fuel but also cutting down trees, is causing the climate to change, increasing the frequency and severity of storms and droughts, making the seas rise, and otherwise wreaking havoc.

True: Sugary soft drinks and other heavily marketed elements of the U.S. diet cause people to have diabetes, and other diseases.

And so on. The only reason we pretend to have a "debate" over these issues is because rich psychopaths pay to create phony controversies. A truly independent, professional and competent journalistic establishment would tell that story, and only that story, to the American public.

Boring academic wankery

Our latest paper has been published on-line, and you can read the abstract here. If you really want to read the whole thing, which I doubt, send me an e-mail and I'll send you the PDF.

The abstract doesn't really do it justice. What we've done is break some outpatient visits into pieces -- all of the various issues that come up -- and keep track of how they are processed. It turns out, among other observations, that about half of them either don't require that anything be done, or there is in fact nothing that can be done. This isn't necessarily bad -- docs need to check in on stuff, people need to bring up stuff that's worrying them even if it turns out to be not a problem. It's just what it is.

Also, there are huge differences in the way the interaction looks depending on what task is being done. While we're trying to understand what's wrong or what's going on, the physicians ask a whole lot of closed questions and the patients give information in response. This actually takes up the bulk of most visits. There is also some patient education/information giving, during which patients ask more questions than do providers, no surprise, but not a lot more. When decisions are being made about treatment, doctors do most of the talking, patients seldom express their own wishes or ask questions, and doctors pretty much just say "This is what we'll do." So shared decision making or patient choice are quite scarce, at least in this data.

So that's a lot of what I do. We're pressing on with these methods now in other contexts, and I'm actually hoping to learn something. Meanwhile, when you go to the doctor, don't be afraid to speak up, and ask for an explanation of why a particular treatment is recommended -- or just given to you -- and whether there are alternatives you might want to know about. It turns out, by the way, that when that happens, people tend to end up using less drugs and getting fewer procedures. Which is probably good for you.

A Good Death

Some of my colleagues have used Medicare claims data to track the trajectories of dying people in 2000, 2005 and 2009. The article in JAMA is a dense, hard to read recitation of numbers, basically, so let me just unpack it for you.

Superficially, it looks like good news: many fewer people died in acute care hospitals in 2009 than in 2000 (24.6% vs. 32.6%). Most people say they prefer to die at home, but failing that, a good quality nursing home is usually a much better environment than an intensive care unit. If you're shuffling off anyhow, you don't want to be hooked up to machines with weird noises and flashing lights and strangers shoving tubes into you and whatnot. And more good news: the percentage of people receiving hospice services at the time of death went up from 21.6% to 42.2%.

But, you knew there was a "but," right?

The problem is that despite what happened at the very end, more people were hospitalized, more often, during the last months of life, and many of those people who got hospice services got it for only a day or two. In other words, we're still putting dying people in the hospital, in fact more so than before, it's just that they don't stay there until the moment of death as often, they tend to get shipped out a day or two ahead. That isn't really progress.

Now it's not clear how many of these hospitalizations were "appropriate." It's hard to predict who is going to die soon and some percentage of them no doubt looked they had a chance to pull through. But most of them are people who were clearly dying, perhaps in a nursing home already, who got sent to the hospital to get an IV antibiotic infusion or emergency rehydration or some such essentially pointless treatment.

I don't mind telling you that my father could well be in this data. (It's a 20% random sample of all the deaths of people on fee-for-service Medicare in those years.) He died in 2009, in a nursing home, receiving only palliative care, and he was not hospitalized even once in his last two years of life. But it wasn't easy for my mother and I to achieve that. My mother had to write a letter (with my help) to the nursing home, stating that she did not want my father, who was severely demented, to be hospitalized or tube fed. She had to sit down with the nursing director and have a lengthy conversation in which the nursing director tried to talk her out of it.

There is, believe it or not, a financial incentive for nursing homes to hospitalize people. They get paid by Medicaid to hold the bed while the person is in the hospital, during which time they don't have to take care of the person; and then they may be able to get paid by Medicare for a period after the person returns, which is better money than Medicaid.

So until we straighten out our completely batshit crazy health care financing non-system, it's going to be very hard to fix this or any other problem.

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

Why you are wasting your money

A couple of days ago I posted about the uselessness of dietary supplements for most people. Right on cue, some folks writing in JAMA Internal Medicine let us know what people think they are doing when they take the snake oil.

It turns out that 45% of all U.S. adults say they take dietary supplements -- mostly multivitamins -- "to improve overall health," while about 1/3 say they do it "to maintain health." Other prevalent reasons include "to prevent health problems" (20%), for heart health (15%) to "boost immunity" or prevent colds (14.5%), for healthy joints or to prevent arthritis, (12.4%), for enhanced energy, skin health, eye health, mental health, weight loss . . .

Reality check: it is all bullshit. Dietary supplements for the general public do none of the above. These authors are a bit coy about that conclusion. They review evidence, all of which is negative, and then call it mixed or unconvincing. It's convincing, folks. What has happened to you is that people on teevee lied to you, and you fell for it. Unless your doctor has identified a specific condition for which you require a nutritional supplement, there is no reason to take vitamin pills, or iron (which can actually be quite bad for you in excess!), or fish oil, or even calcium. (I delayed mention of the bone health motivation, which 1/4 of people, mostly women, give because some women have been told by their physicians that they should take calcium supplements. I doubt this really applies to 1/4 of all people, or 40% of women, however, and it's somewhat controversial anyway.)

There are a couple of other gray areas or open questions. Some people, those with dark skin in particular, might benefit from vitamin D, although this has been questioned. There is maybe a little bit of a fuzzy zone between some specific foods and dietary supplementation, olive oil, very high fiber foods like bran, there are other examples. Some foods are routinely supplemented -- e.g. folic acid and iron in refined wheat, vitamin D in milk -- which replaces what otherwise might be supplements that might reasonably be indicated for more people. But really folks. Talk to your physician, and unless there's something specific going on, you should probably save your money.

Guns don't kill people,

people kill themselves. With guns.

I haven't had a whole lot to say about the big gun safety debate going on right now in part because, if I'm going to be contrarian, I want to take the time to get my ground under me.

First, I actually find highly offensive the repeated calls by people who are ostensibly progressive and ought to know better that a priority should be to keep guns out of the hands of the mentally ill. As I have repeatedly discussed here, according to the American Psychiatric Association, half of the population is mentally ill at some point in their lives, and almost 1/4 of us are "mentally ill" right now. I actually think that's preposterous and largely consists of fake "diseases," but that's more or less beside the point. It does happen to be true that rampage killers are usually diagnosable with something, but that's pretty much tautological. The question is whether psychiatrists or anybody else can actually predict who will act violently and the answer to that is, the only really useful predictor of violent behavior is past violent behavior.

So no, preventing "mentally ill" people from buying guns is a) useless and b) offensively discriminatory. Keeping guns out of the hands of people who have been convicted of violent crimes is potentially useful, but that's already generally the law in most states as far as I know. Whether this is actually possible, however, given that guns already outnumber people in the U.S., is another question.

Second there is the nonsensical issue of assault weapons. An assault weapon is just a semi-automatic rifle with certain largely cosmetic features, such as a bayonet mount. There is something culturally repellent about them - the only reason people want to own them is so they can fantasize about being soldiers or committing mass mayhem. But they aren't functionally more dangerous than other semi-automatic weapons. Rifles in general are far more accurate at more than modest distance than are handguns, but handguns are actually responsible for most gun injuries and deaths in the U.S. I just don't see banning the sale of particular categories of firearms as being meaningful.

Large capacity magazines? Okay, those have no purpose other than killing large numbers of people in a short time. There's a perfectly good case for banning them, although again, it's probably too late to stop people who want them from getting them on a secondary market, given how many gazillions are already out there.

But now here's the real truth about gun violence. Congress has prevented the CDC or NIH from funding studies of gun injuries, because ignorance is patriotic, but people study the issue anyway. Most gun deaths in the U.S. are suicides, not homicides. If you have a gun in your house, I don't know exactly what the chances are that you will ever use it to defend yourself against an intruder. As we've seen lately in too many cases, the intruder you shoot is likely to turn out to be your own spouse or son, but that aside, I'm going to take an educated guess and say that the likelihood you will kill yourself with your gun is at least 4 orders of magnitude, i.e. 10,000 times as great, than the likelihood you will successfully defend yourself with it.

Most people who haven't studied the issue assume that people who commit suicide are determined and will spend time and effort to find a way. Mostly, that just isn't so. It's an impulsive act. It's also usually unsuccessful -- unless you use a gun. The reason is pretty obvious. The purpose of guns is to kill people. They work very well. And they work quickly. Grab the gun, point at your temple or put it in your mouth, and shoot. Badabing badaboom. You haven't been convicted of a felony, you haven't been committed to a secure mental institution as a danger to yourself and others, and the gun you're using is perfectly legal, probably a handgun with six rounds. You only need one. If you had been forced to take time to plan a way, or tried a less effective method, you would probably be alive.

That's the real truth about gun violence. The best way to keep yourself safe is not to have one; or failing that, keep it locked in a safe and unloaded in between bouts of shooting cans off the top of the fence. Really. Other than that, I can't see banning any particular products as making much of a difference.

Vitamin pills: Nothing will come of nothing

This meta-analysis in the new BMJ is the most zero finding ever. I mean to tell you, the bottom line is zip, zilch, nada, bupkis, totally nothing: taking vitamin supplements, be they specifically anti-oxidant vitamins or multi-vitamins or whatever you want absolutely, positively, does not prevent heart disease or the bad consequences thereof based on a huge amount of unusually consistent evidence.

Other reviews have found that vitamin supplements don't prevent cancer -- in fact certain vitamin supplements actually increase the risk of cancer in smokers. Taking vitamin supplements doesn't make you live longer, doesn't stop your hair from falling out, doesn't do a damn thing for you as long as you eat a half decent diet and don't have a specific disease (such as pernicious anemia) that requires supplementation.

These products are heavily marketed, you see them on teevee all the time. Ignore the advertisements. Save your money. Eat your veggies.

That is all.

Surrealism in DC

This little post on Josh Marshall's site really made me take notice. The confirmation hearings for Chuck Hagel have been all about how he's a traitor for opposing the ultimately futile and failed "surge" in Iraq, which allowed the U.S. to get the hell out under a fragile fiction of stability so that all hell could break lose last year -- not that anybody in the U.S. has been paying attention. Trust me, Iraq is now coming apart at the seams. Also too how he is an insufficiently mad dog Zionist.

So far nobody has asked about, say, Syria, but the key point of the linked piece, and what has me quaking in my boots, is that nobody has asked him about the sequester, which it increasingly appears is going to happen because Paul Ryan evidently wants it. Or so he says. I personally don't think an 8% cut in the military budget would be a national security disaster, in fact I think it would be good for both national and global security; but I'm worried about everything else that will get trashed, including funding for my own research of course, but more than that, Great Depression II which will very likely ensue.

Of course nobody who brought this disaster on us will ever be held accountable.

Or as RL Borosage puts it  (more or less as I put it myself a few days ago:

We need a return to sensible governance. Repeal the sequester -- sudden and deep across the board cuts are idiotic. Promise to pay the debts already incurred and stop threatening a default that would shake global finances. Fund the government while working on a budget reflecting new priorities.
Commit to growing our way out of the hole we are in. Invest in areas vital to our economy and to our people. Pay for those commitments in ways that makes sense. Put people back to work and watch the deficits and debt burden come down.
That means launching a major five-year initiative to Rebuild America -- modernizing our decrepit infrastructure to make it a competitive advantage while creating jobs. Make the investments needed to provide every child with a world-class education -- from universal pre-school to skilled teachers to affordable college. Invest in research and development and sustain America as the global hotbed of innovation.
Pay for these and other vital priorities by ending the war in Afghanistan and reducing our empire of bases. Crack down on overseas tax dodges. Raise taxes on millionaires and tax the income of investors at the same rate as that of workers. End the obscene subsidies to big oil, big Pharma and big Agra.
This isn't rocket science. It is common sense. Yet, at this point, it can't be heard in the bedlam of a Washington afflicted with deficit delusions and austerity hysteria.

Why bother to offer any specifics?

What with the Republicans in Congress demanding drastic cuts in federal spending and "entitlement reform," but refusing to say what exactly the heck they are talking about, and president Obama saying that Medicare can save money without hurting beneficiaries but not bothering to say exactly how, it's obvious that all you have to do to be a successful politicians is spout empty rhetoric.

Here, the Center for American Progress proposes what it says are $385 billion in Medicare savings over 10 years without taking one single benefit away from seniors. I can't vouch for the arithmetic, but it's true that most of these reforms would definitely save some money. However . . .

They mostly save money by making suppliers -- drug companies, medical device manufacturers, hospitals, specialist physicians -- compete for their business or outright cutting payments. There is some other waste they want to wring out of the system but that's also somebody's income. That's our problem -- it isn't really Medicare beneficiaries who politicians are worried about, they don't have any money, don't contribute billions to political campaigns or superPACs or for that matter work for the news media. It's all those people who are profiting from Medicare spending. CAP can say "Hey, let's shut off the gravy train and take care of people cost-effectively," but where is the organized, financed, effective constituency for that?

Evidence based medicine

Sounds like a good idea, it's the right way to go but, it ain't easy.

Here's a problem I've been working on. Suppose you wanted to search all the relevant scientific literature and do a systematic review and metanalysis to figure out the best way to diagnose acute appendicitis. (I'll leave the definitions of unfamiliar terms in the preceding sentence for later; suffice it to say we'll be applying the best available methods for combing information from all of the good quality studies that have been done on the subject.) Then you can write a report and tell doctors how to do this. Fewer people get sent home only to have their appendix rupture; fewer people get surgery unnecessarily. Yeah!

Oh my gosh is it not nearly that easy. First of all, why are we trying to diagnose acute appendicitis in the first place? There are a lot of different tests you can use, but before you use any of them, you have to decide who to use them on. The facile answer is, people who show up at the ER with pain in the lower right quadrant of the abdomen. Then there are various other more specific clinical indicators that will raise or lower your suspicion that this really is acute appendicitis. But are we trying to diagnose appendicitis, or figure out whatever the reason might be that they have this symptom? If we go straight to question 1, maybe we're missing something else we ought to be thinking about.

And is this person a child, a woman (or for that matter a 14 year old girl) of reproductive age not known to be pregnant, a woman known to be pregnant, an adult male of [insert age category], or a very old person? How long have they had the pain? Every one of these variables means you're looking at a whole different kettle of fish.

Does the person have insurance that will pay for a CT scan or will they have to pay out of pocket -- or maybe the hospital will have to eat the cost. This is a medical emergency, potentially, so they have to treat you whether or not you can pay, but what does "treating" you mean? If you do have appendicitis, the cheapest thing to do (in hindsight), and the best from your point of view as well, is to go straight to surgery. On the other hand the totally cheapest thing to do, and the best from your point of view if you don't have appendicitis, is to send you home with advice to come back if it doesn't get better. But in either case, the wrong decision is likely to cost more and result in a much worse outcome.

You can always diagnose appendicitis, with almost perfect sensitivity and specificity, by opening up the abdomen and removing the appendix and having a pathologist look at it. But that's not really the question after all, is it? The question is, should I open the abdomen of this person with lower right quadrant pain. Maybe I'll find out they don't have appendicitis but there is some very good reason why I should have opened their abdomen. On the other hand, maybe they have an ectopic pregnancy or an ovarian tumor or colon cancer, and the wrong kind of surgeon is looking at it, who doesn't know what to do.

You can start with ultrasound, which has essentially no risk, but it's often equivocal. Then you can go to a CT scan, which does irradiate you with potentially some small long term risk, unless you're in early pregnancy in which case there may be greater risk to the fetus; you might also be less inclined to do a CT scan on a young child. If your hospital has an MRI scanner, there's no ionizing radiation but it's more expensive. And the hospital might not have one.

I could go on but you get the idea. You might be particularly averse to post-surgical pain, or you might not care so much. You might have known someone who died of a ruptured appendix so you're really anxious about it, or you might be happier to go home and wait. Whatever.

So . . . Doctors don't generally "know" what they're doing. They're just muddling through, hopefully for the best. As are we all.

Plugola

Not really, they didn't have to pay me. The Laborer's Union wants you to sign a petition asking the White House to end the delay in promulgating standards to protect workers from silica dust. Silicosis is a serious, often fatal lung disease caused by this exposure. Here's the background:

OSHA began working on new silica rules in 1997. A proposal was drafted and sent to the Office of Management and Budget (OMB) for review in February 2011. Normally, OMB has 90 days to review proposals before they are made public. However, publication has been delayed for nearly two years. Releasing the proposal for publication is just the first step in a lengthy review process. OSHA rulemaking requires public hearings and extensive opportunities for public input.

I've known about this for several years because some of my former colleagues at Tufts studied the problem. This has been crippling and killing American workers literally for centuries. There's no excuse for it to continue.

The doctor is out . . .

. . . but it's okay. Many have been viewing with alarm the current shortage of primary care physicians, and predicting that it's just going to get a lot worse. This is one argument advanced against the affordable care act. What's the use of giving everyone insurance if there aren't enough doctors for them all?

Green, Savin and Lu in Health Affairs (at least you can read the abstract) aren't so worried. Although insuring timely access to care -- it can take months to book a routine appointment nowadays -- would seem to make the problem even worse, it turns out that most analyses have been based on an overly simplistic assumption: that the supply of medical services is equivalent to X number of physicians per Y number of people. (1 per 2,500 is the popular choice.)

Actually, physicians nowadays are less and less likely to come as indivisible units; they more and more practice in teams, which makes it easier to match day-to-day demand with an available provider. Yeah, it might not be your regular doc but you don't necessarily need her for an urgent care visit. Even better, you don't need a doctor at all -- Nurse Practitioners and Physician Assistants can do 90% of the visits. It takes much less time and money to produce one than it does to put a doctor through 4 years of medical school and 3 years of residency; and even yet better, their salaries are lower, which is not entirely unjust since they don't need to repay $250,000 in loans or give up 7 years of their lives.

This is just one of many ways we can make health care better and cheaper in this country, while making it accessible to everyone. If we have the will, and if the people get it through their heads that nobody in his or her right mind would ever vote for a Republican.

The Speech

Okay, I'll drop the cynicism for a moment and give the prez some props for delivering the straightforward ideological manifesto he should have provided a long time ago. He's finally stopped believing his own bullshit about bipartisanship and One America yadda yadda, and apparently (although it has yet to be demonstrated) abandoned the strategy of negotiating with himself and pre-caving on every confrontation with the Republiwackos.

Strong words on climate change; direct debunking of libertarianism; repudiation of militarism (rhetorically anyway -- see below); historically correct representation of civil rights and justice as a historically unfinished process, not an inherent feature of American society and -- to many people's surprise -- making the struggle for lesbian and gay equality part of a triumvirate with  the women's movement and the Civil Rights movement of the 1960s; promising to protect the vulnerable and needy; promising to invest in public goods and regulate commerce for the common welfare; some talk about gun safety; immigration reform.

Not everyone on the portside is completely happy, however. No mention of the horrifically destructive and pointless war on drugs and the prison-industrial complex. In fact, he has shown every sign of continuing it and ramping it up. As for the military-industrial complex, he spoke of peace but not of a peace dividend; did not even mention the vast archipelago of overseas military bases; did not mention the undeclared drone war in Pakistan and Yemen and the extrajudicial executions done on his sole authority. No mention of the surveillance state and the absurdly bloated, largely secret national security establishment.

Talk of saving money on health care was vague. The true debate right now is whether we do it by hurting Medicare and Medicaid beneficiaries, or by making health care more efficient and effective by hurting drug and medical device companies, hospital and nursing home chains, and wealthy sub-specialist physicians, all of which are fattening on our own flesh. The entire argument about deficits and entitlements is actually between these two entirely different definitions of the problem, but he failed to clarify that.

Talk of inequality was also vague. We need to tax the wealthy even more, not necessarily by further raising marginal tax rates but by taxing investment income the way we tax wages. We need to insure a full employment economy through our public investments, a goal he did not state. We need universal access to affordable higher education, also not specified. We need to break up the big financial institutions, tax financial transactions, insure workers' right to organize, and strengthen shareholders' rights and create executive accountability. All unmentioned. Corporations are legal fictions, chartered by government; government can take their charters away, after all, but that power is never exercised.

So it's better than what we've been hearing, but not quite there yet. So sez me.

Ignoring the moment

Yeah, it's MLK day, and the inaugural ceremony/speech. I should probably say something profound. But . . .

Call me old fashioned, but back in my day the definition of "girlfriend" included physical connnnnnntact. Let me tell you, it's something you really miss when they aren't around.

Why do we call that thing in the basement the "hot water heater"? That's redundant and repetitive. It's just a water heater, okay?

Okay, I won't ignore the day entirely.

I believe I have previously mentioned my friend who thought Lance Armstrong was being persecuted. Sports heroes are not generally the kinds of people I look to for inspiration -- their accomplishments are essentially arbitrary, the mastery of invented feats. When they turn out to be personally flawed, there's nothing left. (Armstrong of course is more than just flawed - he turns out to be one of the ugliest narcissists ever.) Dr. King was a deeply flawed person in some ways, but it doesn't matter -- his personal life was irrelevant to his greatness. I'm not sure everybody totally gets that distinction.

People is puzzling

The news is dominated today by the chemically enhanced cyclist and the linebacker with the imaginarily dead imaginary girlfriend. Both stories have a certain amount of intrinsic weirdness but it got me to thinking that all the world over, people are obsessed with sports. The popularity of particular games is as definitive of cultures as religion and cuisine; and the civic unity of cities and nations is as much about sporting teams and iconic athletes as it is about political institutions and nationalist mythology.

I don't have any deep explanation of this. It's like music -- nobody really knows why we like it so much or what it really means. I'm as much a fan as anybody, looking forward to the AFC championship game on Sunday even knowing the awful truth about what it's doing to my heroes' cerebrums. Oh well.

American Exceptionalism

All this is old, old news to readers of this blog, but we might as well keep chopping away. The National Academies of Science commissioned yet another panel on the health of the U.S. population compared to civilized countries, and they reach the same depressing conclusion: we're not the Greatest Country on Earth; God doesn't bless America; we aren't a Shining City on the Hill; we aren't Number One. We are the uttermost piece of crap. E.g.

• For many years, Americans have had a shorter life expectancy than people in almost all of the peer countries. For example, as of 2007, U.S. males lived 3.7 fewer years than Swiss males and U.S. females lived 5.2 fewer years than Japanese females.

• For the past three decades, this difference in life expectancy has been growing, especially among women.

• The health disadvantage is pervasive—it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries.

  
  The wise people don't know exactly why, or they kind of do but they're coy about it. We have much more gun violence, we die more in car crashes mostly because we drive more, we have more people who are depressed and addicted and oh yeah -- lots of people don't have access to health care and the health care they do get isn't as good even though it costs 2 or 3 times as much.
  
  A funny thing happens when we turn 65 though -- the life expectancy gap stars to shrink and it goes away by age 75. What else happens at age 65? Oh yeah -- you get, for the first time, universal, comprehensive, single payer national health care.
  
  By the way -- it's also a lot cheaper. Even though it's better.

Aaron Swartz

I've written before about open access, perhaps to a degree obsessively, and I try not to repeat myself too much here (which is getting difficult as the years go on, to be sure). But I do have to take this occasion to once again say how very important is this issue, how very fundamental to what ought to be the ethic of science.

Some readers may be fully involved in this issue, may completely understand what was at stake for this young man who took his own life this weekend, and why he did the deed that had MIT and the U.S. attorney pursuing him like the furies, trying to destroy his life and career by imprisoning him for 35 years. Here's his manifesto.

In my own words, subscriptions to scientific journals cost hundreds of dollars a year -- or more. In fact, the library at my own elite Ivy League university has cancelled many of them recently because we can't afford it. Nevertheless, we still have thousands of journal subscriptions and I get to read them all because I have the magical powers of a college professor in a wealthy country at a wealthy university. You, however -- be you the common rabble in our wealthy country, or an academic department chair in Kenya or the Dominican Republic, do not get to read them. Most of the research that they publish was paid for by taxpayers, but it does not belong to the taxpayers. It belongs to people who own for-profit academic publishing companies, that in turn sell it -- for their own profit -- only to those institutions that can afford the exorbitant prices their monopoly power enables them to charge.

This is wrong. Scientific knowledge is the common property of humanity. The right way to do this is to include the cost of publication in the original grant that funds the research. That's how the Public Library of Science, BMJ Open Access, Dove Press, Biomed Central, and other completely legitimate open access scientific publishers work. Yes, we pay them to publish our stuff, but they still have rigorous peer review and high editorial standards -- higher, in fact, than the subscription model publishers in many cases. The reason for that is obvious: they have to spend the money on editorial costs instead of lining their owners' pockets; they have to compete for the best research because the people who do that excellent research are paying for publication; and they have to prove their quality and integrity every day. Best of all, everybody in the world with an Internet connection can read the work.

Mr. Swartz downloaded thousands of copyrighted academic publications from an archive called JStor. But he didn't try to sell them, he just tried to make a point. Knowledge belongs to humanity. For this, the U.S. Attorney and the Massachusetts Institute of Technology hounded him to death. Rapists and murderers don't get 35 years.

Update:  In response to an anonymous commenter, I should also add that I, like almost all researchers, freely share my own work with anyone who asks for it. You can go to my academic web page, see my publications, and if you send me an e-mail, you'll get the PDF. That's just one more thing that's ridiculous about this entire issue.

What Bernie Says

Right here. It's been hard for me to post lately because it feels like biting granite. Our political debates are all completely phony, and the corporate media are making us all live in that phony world. For whatever reason (and I'm not going to get into the Obama mental telepathy game that so many people like to play) the president is not puncturing the fake scenery, he's playing right along.

Yes, we have a spending problem. Specifically, the more than $700 billion a year we're spending on the military, which is more than we spend on Medicare.

Yes, we have a tax problem. Specifically, as Bernie says, federal revenue is a lower percentage of GDP today than it was 60 years ago, and it's somewhere around half of what the rest of the wealthy countries raise -- you know, totalitarian dungeons like Canada and Sweden. We have the most unequal distribution of wealth and income of any developed country, and in fact we're back to where we were in the Gilded Age, just before the Great Depression.

No, privatizing everything and turning it over to profit-making corporations doesn't make it efficient, competition doesn't make the consumer sovereign, and it doesn't make us freer. As Eduardo Porter convincingly demonstrates, in the case of health care it leaves us ripped off, ill served, and unhealthy. You know what does work really well? Universal, comprehensive, single payer national health care. Ask any country where they spend half of what we do, and have healthier people.

Right now, we don't have a deficit problem, we have a problem of insufficient aggregate demand, which means we have a lot of unemployed people. We need to spend money to put them to work. Then, if we want to eliminate the federal deficit long term (not that we particularly need to do that), all we need to do pay taxes the way we did under Ronald Reagan, eliminate the cap on social security taxes, and create a Medicare for All system that is funded by the money people are paying in health insurance premiums now, that pays for results, and not for doing unnecessary, useless and harmful procedures.

If we want to be affluent in 2025, we need to spend money on good quality education and universal access to vocational training and higher education, for everybody; renewable energy, mass transit, a smart electrical grid, and energy efficiency and conservation; and scientific research and development; and less money on the military.

Who the hell is talking about this -- what we absolutely must do. Not Barack Obama, that's for sure.

Money money money

I presume y'all have encountered the tidal wave of blather about the trillion dollar platinum coin. Paul Krugman is for it, in case you need an intro, so it can't be all bad. Most people are having a very hard time grasping this concept, and it I guess it does seem kind of ridiculous. But that's because most people don't know what money is.

It's fairy dust. It's fiction. It's purely symbolic. And that is true, by the way, whether it's made out of gold, or paper, or nothing. The proof? There's a society that already uses money which, like the trillion dollar platinum coin, never leaves the vault. The people of Yap, a real fantasy island, have two-ton rocks, mined from a distant island, which are money. But they never move. They just change ownership. One of them, in fact, lies at the bottom of the ocean, due to a transportation accident, but it still counts. Somebody owns it, and they are accordingly affluent.

The little pieces of paper with dead presidents are just an accounting convenience, as you have learned since you started paying for everything with a credit card. In fact, if you didn't have your wallet on you, or you were between paychecks, in the old days you might write an IOU to your friend or your grocer. Guess what? You printed money, just as surely as the government does. That's all money is -- a symbol.

One of the enduring, and mysterious quirks of conservative ideology is that they just can't grasp this idea. It offends something deep in their psyche, that money isn't actually worth anything but a promise. They somehow believe that gold and silver have "real" value and therefore should be money. But think about it for a second: the value of all the stuff that people buy and sell, all the debt they owe, is far more than the ostensible value of all the gold and silver in the world. All money is backed by real assets, it just doesn't happen to be gold. If I can buy a car or a house or lunch with a sum of money, the sum of money is worth that much, identically as it's worth whatever amount of gold it can buy. There is no difference.

Once Ron Paul gets his tiny brain around that idea, the rest of his nonsensical worldview will melt away like the snows of March.

Ozymandias

That is the famous poem by Shelley, of course. I thought of it when I read this essay by Bill McKibben, which has been reposted just about everywhere in a coordinated cyber-bomb. So if you haven't come across it yet, go check it out.

Now you're back. Let me tell you why neither Barack Obama or anybody else in power is doing anything meaningful about the existential threat facing our civilization. I have a writer friend who got an assignment from Harper's to write about climate change as a kind of eschatology. He kept asking me what it was like to live in the End Times and he got a little bit miffed when I wouldn't buy into the concept. It's not the end times. Civilizations come and go. The world goes on. So far, as a matter of fact, so has Homo sapiens. The collapse of classical Greece, the Roman Empire, feudal Europe and the Kingdom of Ouagadougou haven't even slowed us down.

Industrial civilization is built on fossil fuel, just as Mesopotamia was built on its irrigation system and the Holy Roman Empire on the Catholic religion and steel swords, spears and armor. If some scientist had come along and told them those bases for their civilizations were doomed, and they just had to try something else, what do you think would have happened? I don't know about Mesopotamia, but in Europe, you got burned at the stake.

To say that we have to give up fossil fuel is to say that our civilization must go the way of Ozymandias. It's just not clear to me that it can happen until it all comes crashing down. We are Homo petroleus. Eventually, we won't be any more. The times will be very trying, filled with catastrophe and pain. Then we'll be something else.

Another of those competing liberty things . . .

For what are to me quite mysterious reasons, every year we have these whoop dee doos about health care workers refusing to get flu shots. This particular nurse -- who got fired from a long-time hospital job -- claims it's for "religious" reasons but apparently, at least from what her lawyer seems to be saying, the only religion in question is that it's her religion not to get the flu vaccine. Beyond that, she offers no explanation for her refusal.

Okay. I may get some pushback on this but here's the whole story as far as I'm concerned. Yes, the flu pandemic hoax of three years ago had me foaming at the mouth, and particularly got me up in the face of Daily Kos's Greg Dworkin. Influenza is not, in fact, all that big of a public health issue. Most of the 36,000 people or so in the U.S. who are are officially tagged as dying of flu are already debilitated and it just finishes them off. There is a much smaller number of unlucky folks whose lives are definitely cut short by it, including some children, but it's a far smaller number than are killed from car crashes, or even homicide. Most of the so-called Flu Like Illnesses (FLIs) that people get aren't flu at all, they're other viruses. Also, the flu vaccine isn't as effective as it's been touted to be, maybe about 60% effective, i.e. you can still get the flu even if you've been vaccinated.

All true. On the other hand . . .

The risk of any serious complications from flu vaccine is as close to zero as it can possibly be. It may even be zero. Possibly there is a 1 in a million risk of Guillan-Barre syndrome, or possibly there isn't. Virus for flu vaccines is grown in eggs, so people with allergies used to have a problem, but now there is egg free vaccine. So the worst you can get is a sore arm. Getting the vaccine benefits you personally, because it might let you avoid a case of the flu or have a more mild one if you do get it. That's not all . . .

It benefits everybody else, particularly people who are immunocompromised, pregnant women, and old folks, who are at high risk for flu complications, because by weakening the chain of transmission, it helps prevent other people from being exposed. (That's called "herd immunity," and maybe you don't like that term as applied to people but it's accurate.) So . . .

Obviously there's a basic interest in not forcing people to do what they want, in general, but if you work for a hospital you are obliged to act in the interest of the patients. You aren't allowed to smoke in the workplace, you aren't allowed to come to work while you're sick and know you are contagious, you aren't allowed to slack off and not pay attention to your duties, you may be required to do regular tests to establish that you retain the skills to do your job, you may have to get certain physical examinations -- as pilots and school bus drivers, for example, must do. Flu may not be the biggest problem in the world but it's a big problem for somebody who is already sick and in the hospital. So, if the administrators of the hospital require you to get a flu shot, they are well within their rights. Refusal is irrational, irresponsible, and nonsensical.

I feel no sympathy for this woman whatsoever. Zip. Zilch. Zero. Fire away.

Pleasingly Plump

Sorry for the long hiatus, I was distracted by a (very wonderful) personal matter. It turns out blogging isn't necessarily the most important thing in the world after all.

Anyway, despite the new year and all the ongoing political sturm und drang, I'm going to re-enter the blogosphere with a conventional Stayin' Alive post. Flegal and colleagues in the new JAMA present a very careful meta-analysis of studies linking body mass index with mortality. Their findings confirm what has been the general trend in observations over recent years: the categories of overweight and obesity set by NIH consensus panels may define healthy weight a little too stringently. People in the current "overweight" category (BMI between 25 and 29) actually seem to have slightly lower all-cause mortality than people of ostensibly "normal" weight, and people in the lowest category of "obesity" (BMI 30-34) do not appear to have higher mortality rates. Above that, however, obesity is most definitely associated with sharply higher risk of mortality.

But . . .

It's complicated. Underweight individuals have elevated mortality, probably mostly because the reason they are underweight is that they are already sick. Mildly overweight people may have good cardiovascular fitness and good muscle mass, or not: being both overweight and unfit is probably bad. Also, staying svelte in youth is probably a good omen for your later years. People tend to gain weight with age, but very few young people die, so when we're talking about mortality risk, we're talking about older folks who are naturally a little bit more zaftig than their younger selves.

Anyway, the point of all this is, if I were a real doctor, I'd tell you to pay more attention to being physically active and fit, and eating a well-balanced diet, than whether you're five pounds overweight by the standard measure. However, if you're much more overweight than that, you should try to trim down. And how can you do that?

Well, this one is abstract only for the rabble, but: the high fructose corn syrup and table sugar thing is probably real. It turns out that fructose -- of which there are similar amounts in both of the above-named products -- is the worst form of calories. Not only does it have a high glycemic index, it doesn't satisfy hunger, in fact it appears to make you hungrier. That's the crap in soda and supermarket sweets and the sugar bowl on your table. It's increasing prevalence in the American diet may have a lot to do with the obesity epidemic. Do not eat it! Have a piece of fruit.

Back to a normal schedule now, I hope.

Riiiiiiggghht!

As Noah says to the Lord in the famous Bill Cosby routine. As I may have mentioned before, I'm a lifelong -- well, since age 13 -- subscriber to Scientific American, which is probably why I'm such a know-it-all, even though they've been assiduously dumbing it down for the past few years.

Anyhow . . .

Michael Dettinger and Lynn Ingram this month tell us that once every couple of hundred years, California has been visited by the real, diluvean deal. Starting on Christmas eve in 1861 it rained not for 40 days and 40 nights, but for 43, after which the Central Valley was "an inland sea 300 miles long and 20 miles wide." Sacramento was 10 feet under. It took 6 months for the water to drain.

The most incredible fact about all that is that I had never heard of it before. Cal was relatively sparsely populated at that time, nevertheless thousands of people died. If that were to happen today . . .

Guess what. It will. They've been able to trace the record of such events in the sediment going back to 1150 or so, and they have convincing evidence of 5 of them. It turns out that great rivers of water vapor form in the atmosphere and west coasts generally are vulnerable to these events. And of course you know the kicker . . .

Global climate change should make them more frequent, by increasing the amount of water vapor in the atmosphere. If you thought Katrina and Sandy were exciting, well now. Words fail. A simulation of a lesser event -- only 23 days of rain -- found that 1.5 million people might need to be evacuated, with total economic costs of $700 billion. Given that nobody's getting 1.5 million people to high ground very quickly, again, well now. You figure it out.

That's why I'm not making any predictions for the New Year. Shit will happen.

Merry Christmas

Really. I believe I posted many moons ago about Richard Dawkins's idea to make "Atheists for Jesus" T-shirts.

I was just talking to a friend yesterday about the ascendancy of I-got-mineism in our politics, and the delusions that come with it -- that everything you have you deserve, nobody and nothing outside of yourself contributed to your deserved fortune, and every penny you pay in taxes is stolen to give to lazy parasites. That's not so weird in itself, but the alliance of this philosophy with the predominant form of Christianity in the U.S. is pretty strange.

My uncle was a preacher -- the pastor of Trinity Church on the Green in Branford, Ct, which is a national historical landmark. My mother was a Sunday school teacher. I got several perfect attendance medals for Sunday school, and I was talking about getting confirmed when I got old enough to figure out for myself that religion is bunk, i.e. thirteen years old.

But, the Christianity they taught me was the exact opposite of Rich Warren and Pat Robertson and Franklin Graham. They claim to interpret the Bible literally, and live by it. So how do they interpret this?

Matthew 25:31

³¹ “When the Son of Man comes in his glory, and all the angels with him, he will sit on his glorious throne. ³² All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats. ³³ He will put the sheep on his right and the goats on his left.
³⁴ “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. ³⁵ For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, ³⁶ I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’
³⁷ “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? ³⁸ When did we see you a stranger and invite you in, or needing clothes and clothe you? ³⁹ When did we see you sick or in prison and go to visit you?’
⁴⁰ “The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’
⁴¹ “Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels. ⁴² For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, ⁴³ I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me.’
⁴⁴ “They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’
⁴⁵ “He will reply, ‘Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.’
⁴⁶ “Then they will go away to eternal punishment, but the righteous to eternal life.”

Or this?

^{Mark 12}

¹³ Later they sent some of the Pharisees and Herodians to Jesus to catch him in his words. ¹⁴ They came to him and said, “Teacher, we know that you are a man of integrity. You aren’t swayed by others, because you pay no attention to who they are; but you teach the way of God in accordance with the truth. Is it right to pay the imperial tax^[b] to Caesar or not? ¹⁵ Should we pay or shouldn’t we?”
But Jesus knew their hypocrisy. “Why are you trying to trap me?” he asked. “Bring me a denarius and let me look at it.” ¹⁶ They brought the coin, and he asked them, “Whose image is this? And whose inscription?”
“Caesar’s,” they replied.
¹⁷ Then Jesus said to them, “Give back to Caesar what is Caesar’s and to God what is God’s.”
And they were amazed at him.

Or this:

Matthew 19

¹⁶ Just then a man came up to Jesus and asked, “Teacher, what good thing must I do to get eternal life?”
¹⁷ “Why do you ask me about what is good?” Jesus replied. “There is only One who is good. If you want to enter life, keep the commandments.”
¹⁸ “Which ones?” he inquired.
Jesus replied, “‘You shall not murder, you shall not commit adultery, you shall not steal, you shall not give false testimony, ¹⁹ honor your father and mother,’^[c] and ‘love your neighbor as yourself.’^[d]”
²⁰ “All these I have kept,” the young man said. “What do I still lack?”
²¹ Jesus answered, “If you want to be perfect, go, sell your possessions and give to the poor, and you will have treasure in heaven. Then come, follow me.”
²² When the young man heard this, he went away sad, because he had great wealth.
²³ Then Jesus said to his disciples, “Truly I tell you, it is hard for someone who is rich to enter the kingdom of heaven. ²⁴ Again I tell you, it is easier for a camel to go through the eye of a needle than for someone who is rich to enter the kingdom of God.”

Now, I know that the scammers have all sorts of arguments as to why these passages don't actually mean what they appear to mean. But why don't we ever hear from other Christians who do believe in the words attributed to Jesus in the Gospels? Why do they cower under the pews? Just askin'. 

Not all massacres are alike

Via Balloon Juice, I came across this essay by Mark Ames, who apparently is something of an expert on rampage murder. His main focus in the linked piece is on the NRA, and I recommend it for that reason.  Basically, he argues that by being batshit crazy, the NRA actually insures intense loyalty and passion on the part of its members, because it reinforces their tribalism and paranoia.

That's worth thinking about, but the point I want to make for this post is that the Newtown tragedy was not typical, in that the perpetrator had no evident connection to his targets. I have mentioned previously the socially isolated men who shoot up their workplaces when they are in one way or another robbed of their only source of dignity through their employment. The kids who attack their own schools also typically, in one way or another, feel humiliated or socially excluded.

Now we find the question of access to mental health services entering prominently into the post-Newtown debate. I'm afraid that while I agree we have problems with mental health services, that's largely an irrelevant distraction. The typical workplace or school shooter would not have contemplated getting mental health services. Workplace shooters often erupt after being fired, or disciplined, or having a conflict with their supervisors. There is seldom any indication in advance that they ought to get mental health treatment, and even if somebody thinks there is, there's no way to make them do it. Similarly, the school shooters are generally entirely unpredictable.

Now, it just so happens that Jared Loughner and James Holmes were recognized in advance as having serious mental illness, in both cases as it happens by school authorities. And their respective institutions reacted by expelling them and washing their hands of the matter. Loughner already has an official diagnosis of schizophrenia and obviously, Holmes will get one too. The Newtown shooter was also manifestly somehow wrong in the head, although we'll never get to slap a specific label on him. It's this run of bad luck which has apparently made mental health a big player in the current debate.

However. None of these people sought treatment. Putting a free psychiatry kiosk on every street corner would not have helped. The only thing that would have helped is making it impossible for them to acquire large capacity ammunition clips.

QED

Update: An armed society  is a polite society, right Mr. LaPierre?

About that Second Amendment

Jeffrey Sachs is of course correct. The amendment has to do with an archaic debate about federalism. It protects the state militias, not some bozo who wants to walk around the shopping mall with a gat on his hip so he can shoot any black kid who looks threatening, or a bunch of louts who think they can resist "tyranny" by taking on the United States army. The state militias are now the National Guard. That's the well-regulated militia. Back in the day, the militia members owned their own muskets, and kept them at home, which is why the amendment reads as it does.

The Supreme Court, in decreeing that a) this has anything to do with a "right" that pertains to individuals and b) has any application at all in the United States post about 1800, is legislating from the bench. This "interpretation" has nothing to do with conservatism or "original intent" or even jurisprudence. It's just a fraud. There is no such thing as gun rights, or gun owners rights, or a right to bear arms, deriving from the Constitution of the United States.

None. It's all nonsense.

On Liberty

It's not exactly a revelation that you get a huge political advantage from attaching a label with positive associations to your cause. Rights, liberty, life, freedom,choice -- who could be against any of those? Respecting the right to bear arms gives us more liberty, more freedom, more choice, and we can defend our lives and our property. If you want to restrict that right, you want to take away my freedom. Obviously.

What's wrong with this picture? I shouldn't even have to point it out, yet somehow our public discourse can't arrive at the obvious.

People walking around with guns on their hips may feel that they have liberty and freedom, but they diminish the freedom of others. Who would dare to offend a belligerent character with a gun in his hand? Are the people of Newtown, and every other school district in this country, freer because their neighbors own high powered rifles with 30 round magazines? Of course not. They are forced to take all sorts of measures that restrict freedom in order to protect themselves. They have to make their schools, libraries, town halls and court houses less accessible. They have to tax themselves more to pay for police and security systems. Even so, sometimes their children get murdered.

I could play this argument out at greater length but others have done so better. The point is, liberty is always a problem of balance. Whatever liberty is granted to one person may take away from the liberty of another. Your liberty to dump your waste in the river deprives me of the liberty to swim in it.

Here's another powerful example. Banning smoking in public places turns out to have a huge effect on the incidence of heart attacks and acute respiratory distress. Huge. A twenty-one percent decrease in hospital admissions for acute myocardial infarction. That means smokers aren't poisoning other people, and the rest of us don't have to pay as much to take care of people who have heart attacks.

Libertarianism is sophomoric nonsense. Rand Paul and Ron Paul and everybody associated with the Cato institute are mindless. We must root this delusional thinking from our political discourse. 

Why?

Connecticut is a relatively small state in geographic extent, but Newtown is pretty far from me in Connecticut terms. I have never been there, and I had to look it up on a map. As it turns out, though, my brother-in-law's niece attended Sandy Hook, and her baby sitter's daughter was killed. And seeing my governor and senator on TV talking about it makes it seem somewhat close to home anyway.

As for why the guy did it, the answer to that is easy: he was batshit crazy. Nobody is worried about asking Jared Loughner, for example, why he shot the congresswoman and all those other people, because we know he can't give a meaningful answer. As this story by AP's Helen O'Neil discusses, we can't say there has been an increase in these rampage killings recently. The first one I remember was Charles Whitman, who climbed a tower at the University of Texas in 1966 and shot 45 people, killing 13. I was 12 years old at the time. When I was in college, a woman in combat fatigues shot up a nearby shopping mall, and 16 year old Brenda Spencer shot up a school yard in San Diego in the "I don't like Mondays" assault. Usually they're men of course: the Luby's cafeteria massacre, the McDonald's in San Diego, that Vietnam vet who attacked children in a schoolyard, the epidemic of postal service massacres, and more recently Columbine, Virginia Tech  . . .

(As I write this, my neighbor is emptying a 12 round magazine. He needs to do that every morning.)

So these keep happening. The distribution in time may not show any obvious pattern, but the distribution in space does. The U.S. seems to be where it happens most often. Sure, there have been massacres in New Zealand, Scotland, and Canada in my memory, but each of them is unique in its particular country. (I'm leaving politically and economically motivated crimes, such as the Mexican drug cartel massacres, for another day. I'm just talking about rampage killings by unconnected individuals.)

Is it something in the culture? I don't really see any evidence of that. Charles Whitman, on autopsy, was found to have a brain tumor. Many of the perpetrators, including Loughner and James Holmes, are manifestly psychotic. We don't understand psychosis well at all; it isn't clear how the zeitgeist influences psychotic fantasies. Obviously you have to know that the CIA exists to believe it has implanted a chip in your brain, or to have heard of Alpha Centauri to believe that extraterrestrials are beaming messages at you from that particular location, but otherwise the form of the delusion is probably sui generis, in other words you could believe you were possessed by a demon. Same idea. So whether violent movies or video games actually make psychotic people violent is far from proven.

There is a pattern of workplace rampages by socially isolated men whose work is their only claim to dignity and who react when something goes wrong there, but I don't know that that is unique to the U.S.

But we all know what is unique to the U.S. The only time I have fired a rifle was at boy scout camp. The weapon had a bolt that you pushed up and pulled back to open the chamber. Then you inserted a single cartridge, pushed the bolt forward and down, and took your one shot. Guess what? If you're hunting deer, that's just as good as a semi-automatic Bushmaster with a 30 round magazine. You only get one shot and if you miss, and try shooting again at the fleeing animal, you are an irresponsible idiot. There is absolutely no reason for people to own semi-automatic weapons or large capacity magazines. They have nothing whatsoever to do with hunting or sport of any kind. They are designed for exactly one purpose, and that is to kill humans. That is the only purpose they are good for.

The arms which the well-regulated militia had the right to keep and bear were muzzle loading muskets. You'd pour black powder down the barrel from your powder horn, then shove a wad of paper down the barrel with a rod, then drop in a ball. Then you could aim and fire, once.

If I want to shoot the chuck that's eating my garden, or bag a turkey for dinner, the most I need is a double barreled shotgun. Break it at the breech, put in two shells, and you're good to go. If I had one, and I lost my marbles, I could maybe shoot two people. Not 26. It's that simple.

You might want to play with this

An on-line app from the Guardian that let's you look at death rates globally or regionally, by age, from various causes, in 1990 and 2010.

Worldwide, heart disease and circulatory disease are by far the leading cause of death. No surprise there, but you might be surprised by the importance of chronic respiratory diseases in carrying off the old folks. Unintentional injuries -- falls -- aren't way up there in the rankings but they're pretty important. A broken hip is very often the beginning of the end.

There have also been some big changes since 1990. HIV of course has jumped way up, while other communicable diseases have tended to go down in rank.

Anyway, you get to visualize it all sorts of different ways -- try it, it's very informative.

Big Gummint

Jonathan Chait has justly won a wanker of the day award or two, but I'll give him props for this. (No endorsement of the Puffington Host implied or intended.)

I'll put a slightly different spin on it, but the basic idea is correct. The reason the weeping orange man won't specify the spending cuts he's demanding in return for the revenue increases he also won't specify is that he cannot. The United States has a far less generous social safety net than other wealthy countries, our infrastructure is crumbling, our regulatory agencies are underfunded (and they spend little money anyway) -- the one place where we can actually find substantial savings is in the bloated military, while the Republicans have been running around screaming that it's dangerously underfunded since Obama took office. They also campaigned against Obama for cutting Medicare, and now they're complaining that he doesn't want to cut it enough. Not that simple logic ever mattered in political discourse but . . .

The fact is that at some point, Congress is going to have to sit down and pass appropriations bills, and reauthorize the major entitlement programs. Fiscal cliff or not, debt ceiling or not, Orange Julius's House of Representatives is going to have to specify how much the federal government will spend on each and every one of its functions. They can cut funding for stuff they don't like, such as the EPA, but that will have a trivial impact on the budget deficit. They can cut spending on Medicare, but there are only two ways to do that:

1. Payment reform and cost-effectiveness guidelines. They claim that is equal to "death panels," so they won't do that.
2. Reducing benefits. That's not going to win them any love in 2014. 

 They could try cutting Medicaid benefits and tightening eligibility standards. That won't pass the Senate and if they did it, they would get the blame for horrendous consequences. At some level, the sane among them know that.

And they can cut the military budget, but they won't do that.

So they're stuck. The low IQ members may not understand that, but Boehner does. He knows it perfectly well.

When everything changes

Our new article in Patient Preference and Adherence is now available open access. (I try to publish open access when I can, but don't always have the funding.)

I really like this piece because we gave voice to people who have been through really tough times and in most cases, overcome. But it required fundamentally changing how they thought of themselves and how they related to the world.

This is one of the consequences of a chronic disease diagnosis -- in this case HIV, but it happens to some extent with heart disease, chronic kidney disease, cancer. The doctor pronounces the word and the world changes. You are still the same person, but in a sense your identity is altered, where you are in the world is different.

Most of these folks, ultimately, made the most of it. But I don't know what the magic pixie dust is that can get people to successfully incorporate the new reality and move ahead courageously. Nor can they say what it was. At some point, it just happened.

Not really the end of the world

While it is true that only a few people are convinced that the apocalypse will occur on a specific, known date, it is tragically also true that there are a lot of people -- I don't specifically remember the polling on this and maybe somebody can come up with a number, but it's close to half of Americans -- believe that it will happen sometime soon, they just can't say exactly when.

You may be old enough to remember that Ronald Reagan's Secretary of the Interior, James Watt, believed that, and said so publicly. He said that environmental conservation was pointless because the environment wasn't going to be around much longer anyway. Yes, that really happened. And maybe that's one reason among several that the looming catastrophe of climate change is largely ignored.

The failure of the Doha climate conference ought to be the top headline in every media outlet. It was buried in a small item inside the NYT this morning and is basically nowhere to be seen on the web sites of the major news networks. But the Reuters story (linked above) gets it right.

At the end of another lavishly-funded U.N. conference that yielded no progress on curbing greenhouse emissions, many of those most concerned about climate change are close to despair. . . .

The conference held in Qatar - the country that produces the largest per-capita volume of greenhouse gases in the world - agreed to extend the emissions-limiting Kyoto Protocol, which would have run out within weeks. But Canada, Russia and Japan - where the protocol was signed 15 years ago - all abandoned the agreement. The United States never ratified it in the first place, and it excludes developing countries where emissions are growing most quickly.

Delegates flew home from Doha without securing a single new pledge to cut pollution from a major emitter. . . . A series of reports released during the Doha talks said the world faced the prospect of 4 degrees Celsius (7.2F) of warming, rather than the 2 degree (3.6F) limit that nations adopted in 2010 as a maximum to avoid dangerous changes. According to the World Bank, that would mean food and water shortages, habitats wiped out, coastal communities wrecked by rising seas, deserts spreading, and droughts both more frequent and severe. Most impact would be borne by the world's poorest.

No, this is not the end of the world. It's not the end times. The universe will go on. But it will be hard times indeed, harder than we have ever known, and that includes World War II and the Dark Ages. Wake the fuck up.
 

What with the end of the world approaching . . .

. . . in just a couple of weeks, my curiosity has again been awakened about why so many people believe in this particular category of balderdash, continually through the ages. This story about the followers of Harold Camping casts a bit of what little light there is to be found, but leaves me unsatisfied. (The on-line magazine Religion Dispatches, from which this is taken, is a good resource, BTW. They write about religion from the outside, without hostility but with appropriately critical thinking.)

As you may recall, Camping was the radio preacher who convinced thousands of people that the apocalypse would occur on May 21, 2011. They quit their jobs, spent their savings promoting the truth to the world, left their kids without college funds, abandoned their homes . . .

Spoiler alert: It didn't happen. The universe sailed on as serenely or tumultuously as ever. But why did they believe this? They weren't just betting on it. They were absolutely certain, as certain as the sun would rise on that day, the earth would be devastated by massive earthquakes, and then the rapture and the end of the universe would occur in October. Which also didn't happen, by the way.

It turns out that many of them are engineers or otherwise mathematically trained. They figured it out, by elaborate reconciliation of scriptural passages. The numerological and textual relationships they found in the Bible could not possibly have been coincidences, they were irrefutable evidence of the truth of the prophecy. Well, okay, but you really have to try very hard to get to that conclusion. Confirmation bias can't happen until you already believe. There's still a piece missing here.

But come to think of it, the same can be said of all religious belief. It's just that much of it doesn't smash to pieces against observable reality quite as hard. Anyway, I'm puzzled.

Unpopular Legislation

As you have no doubt heard, while Americans tell pollsters they like various specific provisions of the Affordable Care Act, the act as a whole still gets less than 50% approval.

Maybe this is why. (PDF -- scroll down to page 8.)

Two and a half years after the law’s passage, six in ten Americans either believe that the health care law establishes a government panel to make decisions about end‐of‐life care for Medicare beneficiaries (39 percent) or are not sure whether or not this is a provision of the ACA (22 percent). The numbers among seniors are very similar: 32 percent of seniors believe the law sets up such panels, 28 percent are not sure. Two in three seniors say the law cuts benefits for people in the traditional Medicare program. In fact, there are no actual cuts in benefits for beneficiaries in the traditional Medicare program, though those enrolled in Medicare Advantage plans may see fewer supplemental benefits once reimbursements to those plans are reduced.

A lie is half way around the world before the truth gets its boots on. The Republicans have succeeded in lying to people, and the corporate media have enabled their lies. This must end, or there is no hope for us.

It's Open Access Time!

The new policy at NIH is that all publications resulting from NIH funding have to be posted to a repository called PubMed Central for open access after one year. Here's one of mine, that went live today.

Many people -- both doctors and patients -- complain that there isn't enough time in a standard medical visit. In order to make their boat payments, doctors typically average 12 to 15 minutes for regular outpatient visits. In fact, there isn't much evidence that visits used to be a lot longer, but medicine, and life, have gotten more complicated, and that amount of time seems less adequate than it used to. Of course a higher percentage of patients are older and sicker than in the past, and of those who are sick, there's usually more to be done. In addition, we're managing diagnoses that didn't used to exist - "pre-diabetes," high LDL, and so on.

The people in our study all had HIV, and they were visiting HIV specialists, but for these patients, as for most people with HIV, the HIV doc is also their primary care doc. Most of them were doing reasonably well, so these visits, on average, weren't a whole lot longer than 15 minutes. But, they varied a lot. Using a coding method of my devising, we found that longer visits tended to appear to be more "patient-centered" -- less physician verbal dominance (i.e., doctors normally talk more than patients but it was more even in longer visits), more patient questions, more patient expressive utterances, that sort of thing.

As you will often find with me, there's a "but" -- when we looked directly at the really long visits, many of them seemed more patient centered because a lot of what went on wasn't really medicine. In one, the patient spent most of the time griping about his siblings who were squabbling with him over his mother's estate. In another, the doctor spent several minutes teaching the patient about the history of South Africa. In another, the doctor tried to recruit the patient to go to church with her.

So it's not that simple. We're there on business. Most of us expect efficiency and likely value quality over quantity when it comes to interacting with our doctors. In fact, my own mother happened to volunteer to me the other day that she really appreciates how her ophthalmologist concentrates on business and doesn't get into a lot of chit chat. She adores him, but it's because she trusts him to take care of her eye (she only has one), not because he's all up in her stuff. That makes sense to me.

The end of football?

Okay, this study, partly paid for by the National Football League, has gotten a lot of attention. The NYT has a more lay-friendly discussion, but the Times coverage, like most media reports on this, is a bit misleading. Let me first unskew it, and then discuss it.

In a nutshell, the researchers sliced up the donated brains of a bunch of football and hockey players, and some combat veterans (many of whom had played football) and found most of them had brain damage that looked kind of like Alzheimer's disease. They were able to correlate what they saw under the microscope with reported symptoms that they maintain define four stages of traumatic encephalopathy.

Now to unskew. This is actually what we call an existential or phenomenological study. It does not give us information about the prevalence  of this sort of damage among football or hockey players. True, this sort of damage was not found in the (fairly small) number of controls they looked at, but these guys' brains were donated in the first place because the families were worried that something was wrong. What this study is telling us more about what can happen to people who suffer repeated blows to the head, but it does not mean 68/85 of football players (or hockey players or combat veterans) actually have this sort of damage.

We still don't know that number, and we don't know a whole lot about the details of what puts people at risk. Maybe some people are more susceptible for reasons of underlying physiology. Maybe particular patterns of injury -- with respect to frequency, age of occurrence, severity and specific physics of the blows, etc. -- are much more dangerous than others. Conceivably, growing awareness among coaches and policies to prevent repeated concussions in a short time have already reduced the risk. We don't know . . .

But. Clearly there is a risk. It seems based on casual observation at least to be quite substantial for professional football players but it also seems to be more than most parents would tolerate even for high school, and certainly for college players. This is quite unpleasant for me to face up to because I am a lifelong pro football fan. They're giving us cheap entertainment and yeah, some of them get fame and fortune but a lot of them only last a couple of years and end up with battered bodies, little in the way of marketable skills, and a few bucks to show for it. Then this disease -- first headaches and depression, then personality changes including angry outbursts, then loss of ability to plan and motivate, then dementia.

You can argue that grown men who take on this risk voluntarily can do what they want. Maybe. But if mothers won't let their sons play, the game will fade away. What other people think doesn't matter. That will be the end of it.