The Gray Tsunami

You may recall recent findings that the rate of dementia among people 65 and older has been falling in England and Wales, and this is likely true here as well. It's basically because people are generally healthier. But . . .

It's very strange how the general reaction seems to have been, "Oh well then, what have we been so worried about?" News that isn't quite as bad as you thought it was going to be is still bad news. And the fact is that the prevalence of dementia still rises with age, and we're still going to have a lot more people living with dementia in coming years. The estimate here of tripling by 2050 might be too high, but 2 1/2 times as many is still a whole lot.

Now the IOM raises the alarm about cancer, another disease that is strongly associated with increasing age and which costs a whole hell of a lot of money to treat. Here's a good example of why medical advances can drive medical costs: there aren't any effective treatments for dementia, so it's actually relatively cheap. Many people do ultimately need custodial care and that can bankrupt families and strains Medicaid budgets, but Medicare is going to have to pay for all this cancer care and new therapies can cost $100,000 and up. Even though the benefit is generally small, our laws and our cultural consensus say that we still have to pay for them.

IOM also argues that advances in the field are so rapid that many physicians and treatment centers aren't keeping up; and that we'll have a growing shortage of relevant experts. It's hard to predict how this will play out. Advances in what are called medical informatics may make it easier for providers to select the right treatment protocols and deliver the latest, proven technologies. Basically, they won't have to know everything, the computer will tell them. (They will have to ask it the right questions.) Treatments that are really curative may end up saving some money in the long run, or cheaper treatments may emerge, but I'm not going to bet on that.

We can save money by all the means I talk about here -- not overdiagnosing and overtreating, not using useless treatments and tests, not overpaying for specialty care. At least we can in principle, it's proving to be very difficult politically because all that waste is somebody's income. But even if we manage to do that, medical costs will continue to increase. We're a wealthy society, we can afford it, but it means young and healthy people will have to pay for the care of old and sick people. That's a granite hard fact of life. Are we prepared to do it?

Update: And right on cue, This lands in my in-box. (I swear, it was after I put up this post.)

PLAINSBORO, N.J. – Promising targeted therapies and immunotherapies for melanoma, used in combinations so advanced they have outpaced the nation’s regulators, offer hope of survival to patients suffering from a cancer once seen as a “hopeless” malignancy, according to experts convened by The American Journal of Managed Care. A. Mark Fendrick, MD, co-editor-in-chief of AJMC, led the discussion with the following experts:

• Jeffrey Weber, MD, PhD, senior member, H. Lee Moffitt Cancer Center and director, Donald A. Adam Comprehensive Melanoma Research Center.
• Antoni Ribas, MD, PhD, Jonsson Comprehensive Cancer Center, UCLA.  
• Jennifer Malin, MD, PhD, manager and medical director of oncology, WellPoint.

 “Melanoma has gone from being regarded by many oncologists in the community as an impossible-to-treat and hopeless malignancy to a disease that one might argue is the poster child for new targeted and immunologic therapies,” Dr. Weber said.
However, these drug combinations are not cheap, and the panelists warned that there is only so much that cancer patients, their employers and those who fund government health plans will be willing to pay. Already, Dr. Ribas warned, some melanoma patients lack access to cutting edge drugs like ipilimumab, depending on where they seek treatment and whether they have appropriate insurance coverage.

Is Our Journalists Learning?

Maybe so. David D. Kirkpatrick, in the NYT, has abandoned the practice of stenography to point out that three congressional Republicans, visiting Egypt, don't know their sphincters from the Sphinx. Michelle Bachmann, Louis Gohmert and Steve King all think that the Muslim Brotherhood committed the 9/11 attack -- really! Kirkpatrick, in gross violation of journalistic norms and traditions, points out that isn't true, and in fact the Muslim Brotherhood renounced violence decades ago and strongly condemns al Qaeda and all terrorist tactics.

Then there is this:

Representative Louie Gohmert of Texas, appearing with her and Representative Steve King of Iowa, compared the leader of the military takeover, Gen. Abdul-Fattah el-Sisi, to George Washington. Mr. Gohmert overlooked the new government’s mass shootings of hundreds of mostly unarmed protesters, its sweeping roundup of thousands of political opponents and its suspension of all legal protection against arbitrary arrest or other police abuse; instead, he commended General Sisi and the appointed civilian leaders for creating a government where the rule of law was “king.”

This appears on the same day that Paul Krugman's column decries conservatives' general lack of acquaintance with reality, e.g. Rand Paul insisting that government employment has exploded under Obama, global warming denialism, and so forth.

Alas, the New York Times is largely irrelevant. The TV news will never point out when a politician  is lying, in fact they tend to absorb conservative falsehoods as verities. We are in very grave danger with these deluded lunatics running congress, and a corporate media that treat them respectfully while decrying "partisanship" on both sides. You bet I'm partisan when the other side is crazy, but if Alan Grayson says something to that effect, he isn't to be taken seriously.

So it's tough to go on blogging into the wind. Oh well, might as well keep on as not.

 

I'm just befuddled

I think Barack Obama must have a brain tumor. What in the Alpha Quadrant would make him utterly determined, against overwhelming public opinion, the international consensus, and the most basic common sense, to blow up stuff and people in Syria?

Since I stated my own, entirely correct opinion about this proposal a few days ago, I've pretty much found that just about everybody with one neuron to rub against another agrees with me. Mr. Obama's bit supporters are the same people who brought us Iraq and waterboarding, being against which is the reason B. Hussein Obama is now president. And yet here's John Kerry -- Winter Soldier John Fucking Kerry -- going on about Munich and appeasement.

I'm happy to be able to break it to you John -- Assad is not going to conquer Europe, or even the part of Syria he's already lost. And nobody is proposing to give him Czechoslovakia, or even a parking spot. What we are proposing is not to blow up some Syrians on top of the ones who are already being blown up for the purpose of "sending a message" that he should stick to blowing people up rather than gassing them. This is idiotic. And by the way if you're worried about chemical weapons falling into the hands of people who might use them against U.S. interests, or otherwise beyond the current conflict in Syria, the best way to make that happen is to make the Assad regime collapse. Somebody should probably explain that to president John McCain.

What is most bizarre about this is how counterproductive it is when Obama should be using all his bandwidth to promote the Affordable Care Act and explain it to people as it rolls out just three weeks from now. He's stepping all over his own lines with this insanity and meanwhile destroying the credibility with the world community that he has won back after the disasters of the predecessor regime. And oh yeah, he's just compounding the political damage from the Snowden revelations.

And why? What exactly is the affirmative goal? He claims it's to defend the "international norm" against use of chemical weapons but a) the U.S. hasn't been bothering to defend said international norm for the past 50 years or so -- in fact the U.S. used chemical weapons in Vietnam, assisted Saddam Hussein in using chemical weapons, used white phosphorus in Fallujah (yep) and held massive stockpiles of nerve gas until recently.

Syria is not a party to the international convention against chemical weapons use, and the Geneva convention is silent on use within sovereign borders. In other words, the Assad regime did not in fact violate any treaties or international law by this action. You might like it less than you like shooting people and blowing them up, for some reason, but personally, I don't think it matters.

If Obama hadn't been threatening military action, he probably could have gotten a Security Council resolution of condemnation, or at least statements from the European Community and the Arab League. He would have had leverage to get the Russians to temper their support for Assad, but now he's just pissed them off and destroyed any hope of organizing a negotiated solution to the Syrian tragedy. He's made the Iraqi government more hostile and he's greeted the new Iranian government's very obvious and likely sincere diplomatic overtures with a punch in the mouth.

If he goes ahead and does this without congressional authorization, there will be a resolution of impeachment in the House and it might even pass. Then we'll be screwing around with that for the next six months while we hit the debt limit and the continuing resolution for government spending authority expires. It's time to lay in the canned goods, folks.

If it's not a brain tumor, what is it? Somebody please explain. 

Update: Juan Cole has a hypothesis, although it's not very convincing to me. Basically, the U.S. strategy in Syria has been to try to build up a secular fighting force that can beat out the Islamists on the battlefield. That will take a loooonnnnnggg time. The attack in Ghouta, according to Cole, was a response to this incipient force (which is being trained in Jordan) making advances in the Damascus suburbs. The idea is that Obama wants to make Assad fight "fair," (whatever that means) so the strategy has time to develop. Maybe so but is there any reason not to explain that publicly? Then we could have a meaningful discussion.

Just thought folks might like to see these

A pair of fawns came into my front yard a couple of weeks back. They've been hanging around the area together, but I haven't seen their mother, which is a bit odd. Anyway they seem to be doing okay. Some of these behaviors were a bit surprising to me - a lot of self-grooming. Most people live in cities now, so this sort of thing probably seems special if you do. It's nothing out here.

Incentives

A multitude of cogitators, writing in JAMA Internal Medicine, have computed the annual cost of hospital-acquired infections in the U.S. They use the term "healthcare associated infections" but they actually limit the analysis to certain of the most important infections caused by hospital care. They come up with an annual cost of $9.8 billion per year, not counting the pain, suffering and death of the victims.

Okay, that's a bummer. But here's what is, to me, the interesting part. As the authors point out, we've been making some progress on reducing this problem, but it's been slow. Here's the rather dry money quote:

However, despite the availability of solutions, the strong ethical case for improvement, and the intuitive argument that saving lives ought to save money, large-scale progress against HAIs has been slow. Only recently have health care organizations begun to achieve successes and overcome doubts about the scalability of pilot studies and vanguard institutions. Along with leadership of patient safety professionals, an important driver of progress is the move by payers to deny reimbursement for health care related to preventable harm.^10- 11 By placing the costs of HAIs with hospitals, this shift has accentuated the fiscal case for prevention.

Let me translate this into lay language. Until very recently, hospitals made money  by making people sick. That average $45,814 cost of a central line bloodstream infection? That's what the hospitals were paid when one of them happened. The more central line infections, the more revenue. This is a particularly meaningful issue for me because a major teaching hospital of Harvard University (as my surgeon's card bragged) botched what should have been minor surgery on yours truly, and then tried sending me a bill for $25,000 back in 1991. That's on top of what my insurance had paid them. I refused to pay it, they sicked a collection agency on me, I told the collection agency what happened, and the collection agency guy actually called me up to apologize and said they would drop the matter. Most people, however, pay up, plus they probably had already made a profit off of the insurance.

If you think this is insane, you're sane. However, the new reimbursement policies are by no means universal. And they don't go far enough. If your auto mechanic screws up, he is responsible. So should your doctor.

It's an epidemic!

OMG! The incidence of thyroid cancer has tripled in the U.S. in the past 30 years, from 3.6 cases/100,000 to 11.6. Is it radioactive fallout? Pesticides? Vaccination? Fluoridation?

Nope. It's CT scans. And you can relax. They aren't causing thyroid cancer, they're finding abnormal cells which in the past, nobody would have detected. But, as Brito, Morris and Montori tell us at the linked article (which I don't think you can read but that's okay, I'll tell you what's in it), they aren't actually cancer after all.

There are four different kinds of thyroid "cancer," the most common of which is called papillary carcinoma. Guess what? 99% of people with papillary nodules less than 20 mm in diameter will be alive after 20 years. It turns out that at least 1/3 of people who die of other causes have these lesions, which were never detected.

It used to be that thyroid cancer would be diagnosed when a person presented with symptoms or palpable nodules. Now, when people get CT or MRI scans to investigate coughing or neck pain, 16% of the time they find nodules in the thyroid, most of which are less than 15 mm in size.

Then what do you think happens? The doctor says, "You have thyroid cancer," and the person has surgery to remove part or all of the thyroid, which cost $416 million in 2006. They have to take thyroid replacement pills for the rest of their lives, and it's difficult to adjust the dose properly. Some have more severe complications. And, contrary to recommendations, 2/5 of people get radioactive iodine which makes it easier to do follow-up imaging but, er, causes cancer.

Well, at least we're saving lives, right? You already guessed the answer. The death rate from thyroid cancer in the past 30 years has stayed exactly the same. Rarely, people have opted not to have surgery and to just be followed carefully. In an observational study, of 340 people who made this choice, none died. That would be zero. In 31 patients, the nodules did enlarge, and 18 of them ultimately chose surgery. Thirteen did not, and in 7 of them, the tumors subsequently shrank.

Draw your own conclusions.

Facts are Stupid Things

Those are the immortal words of Ronald Reagan. (He meant to say stubborn, not stupid.) Anyway . . .

Many people have been noting lately that people know they're supposed to hate Obamacare, but they don't know why. The popular prediction now is that as the Affordable Care Act is actually implemented, and people find that either a) nothing happens, because the insurance they already have just goes on as before or b) they couldn't get insurance before, but now they can, and they can afford it; and there aren't any death panels and their Medicare benefits don't get cut and they can keep their doctor or pick one they want (assuming the doctor will take them, of course), and there aren't any government bureaucrats telling their doctor what to do, and everything is just fine, well then, they'll like it after all.

I am very reluctant to get into the prediction game, but that seems a reasonable expectation. However, we do have some problems. People in the Massively Resistant red states won't get the Medicaid expansion, and the federally run exchanges are likely to be kludgy and buggy. It is also essential that lots of young healthy people sign up, and I can't 100% guarantee that will happen in states with massive disinformation campaigns. Whether the wildly misinformed citizens of those states will correctly figure out who to blame for their problems is unclear.

There are also many technical defects in the Act which will need fixing, which an uncooperative congress won't do. And, in the long run, it will need more major surgery to achieve cost containment, which will be politically very difficult because your wasted money is profit for Merck and Hospital Corporation of America.

We may get this Rube Goldberg contraption to work for a while, and maybe that means a Democratically controlled congress sometime soon. But there's still only one way to have a sustainable health care system that can continue to cover everybody into the future, and that's universal, comprehensive, single payer national health care. There's no other way.

Weapons of Mass Distraction

No, sorry, but nerve gas is not a Weapon of Mass Destruction™. It is a battlefield weapon, which is not inherently any more massively destructive than bullets or bombs. It kills people over a limited area for a short time, then it blows away. The people are no more or less dead than people who get blown up by bombs or shot with bullets.

Now, it so happens that there are international conventions against use of chemical weapons, but there are also international conventions against bombing and shooting civilians. Something like 100,000 people have already died in the Syrian conflict, an accomplishment credited entirely to guns and bombs. The United States has not seen any need to blow up stuff and people in Syria throughout this carnage.

So now, apparently, for reasons that admittedly are a bit hard to see, the Syrian military has used organophosphate gas to kill a lot of people in a Damascus suburb. If they had just dropped bombs on the people, that would have been fine. But, since the people were poisoned rather than pulverized, the U.S. is compelled to do some bombing of its own.

The amount of bombing proposed is insufficient to change the course of the conflict, which we don't want to do anyway because we would probably like the new Syrian regime no more, and quite possibly rather less, than we like Bashar Assad. It might discourage Assad from further chemical attacks, but it won't discourage him from blowing people up because the message is precisely that blowing people up is perfectly okay. Cruise missiles cost $1 million each, which goes to Raytheon, so I'm sure they're happy.

Oh yeah. This will really piss off the Russians, who are just as capable of blowing up stuff and people as the U.S. This is not smart.

Oh yeah, the conference

Since I had my Baselian adventure at the expense of the U.S. taxpayers, I suppose I owe y'all something in return. To remind you, I was there to attend the annual international meeting sponsored by the International Society for Environmental Epidemiology and the International Society of Exposure Science. The latter is not about exhibitionism but what happens to your body when you swallow, inhale or have contact with various chemicals, mostly, and some other stuff like really hot weather or obnoxious noise or whatever.

So. On the one hand the environmental movement has had some great successes over the decades. They finally managed to convince political leaders to get the lead out of gasoline and paint, for one very good example. We've also reduced other nasty tailpipe emissions, banned many pesticides and restricted others, improved our drinking water, and reduced workers' exposure to many harmful agents, thanks to the scientists who attend these meetings. Environmental epidemiology is really the discipline that first established the link between tobacco smoking and all the nasty stuff it does, although lots of people still smoke.

Now that we're not dying so much of infectious diseases and us folks from the rich countries, at least, are well nourished and otherwise healthier and longer lived than ever, the relatively subtle effects of remaining hazards -- many of them created by ourselves -- loom larger. The overwhelming challenges of climate change and resource depletion may seem to relegate endocrine disruptors and ultrafine particles to minor league status, but that's really missing the point. It's all one fabric.

The problem of endocrine disruptors is increasingly recognized by scientists, but barely on the public radar. Innumerable pervasive chemicals, notably constituents of plastics, have chemical structures similar to hormones. A common effect is to raise estrogen levels. Fish and amphibians are very sensitive to these effects in their developmental phases, and the presence of these chemicals in water is likely contributing to the catastrophic decline in amphibian populations and also affecting many aquatic fish. So this has a great deal to do with the stability of ecosystems and the mass extinction now underway.

These exposures also seem to affect human children. Children now endure a very complex suite of low-level exposures. Yes, plenty of hazardous chemicals occur in nature but we're getting most of our exposures nowadays from manufactured goods and processed food. We just don't have adequate information on the safety of the vast majority of substances to which we heedlessly expose ourselves every day. They are affecting long-term cancer risk, neuro-development, sexual maturation, and many other biological processes, in ways we little understand.

The problem is, the good folks I met in Basel are largely talking to each other. The vast majority of folks, had they been able to come up with $250 for a conference badge, would barely have understood a word that was said. The societies worry about how to communicate with policymakers, but not with the public in general. They seem to think that these "policymakers" will do what is wise and good if only they are made to understand the science.

That's not how it works, obviously. Reason and truth have little to do with the making of public policy, until and unless the people rise up and make it happen.

I came away more convinced than ever that the democratization of science is our greatest imperative. We are the only species capable of understanding that we are destroying the planet even as we go ahead and keep doing it. There is a contradiction there that we must resolve, and fast.

Thought experiment

You might have noticed that the response of the U.S. and U.K. governments to the antics (is that the right word?) of Edward Snowden has been astonishingly clumsy and has only gone to reinforce the narrative he wanted to tell -- of governments out of control, undemocratic, and arrogating power. Forcing down the plane of the democratically elected president of a member state of the Organization of American States, with which we are and always have been at peace, based on a completely false assumption, was really, really stupid. Detaining a Brazilian subject who is merely transiting through your airport, for nine hours, on no relevant suspicion, aggressively interrogating him and stealing all his electronic gear, knowing that whatever information it contains already exists in multiple copies all over the world, is totally idiotic.

There's actually more but you get the idea. Why are they doing this? The spookmasters, including Msrs. Obama and Cameron and their underlings, are red in the face with frustration. The whole point of the secret "national security" apparatus is the unaccountable exercise of power. Here are a couple of nobodies who are openly taunting them and laughing in their faces, and they can do nothing about it. Gen. Clapper lies awake at night dreaming of droning Snowden, Assange and Greenwald.

But he can't. They are citizens of anglophone countries, and of European descent. Well okay, Greenwald is a homosexual Jew, but that's not the same thing as an Arab, you can't just murder him at will.

Try this. Change Snowden's name from Edward to Mohammed, put a beard on him, and move him from Russia to Yemen.

3-2-1 Blam! Am I wrong?

A bit more about Basel

As I said, the bikes are more prevalent than cars. People park their bikes everywhere. Most people put a bike lock on so you can't just ride off on it, but they don't bother to secure them to anything. Some people don't lock them at all. You'll see big patches of parked bikes and scooters in all sorts of nooks and crannies. The drivers -- those relatively few that there are -- are surprised if a pedestrian waves them on. They expect to stop. The trams go by constantly. It's completely unlike a U.S. city where people pile up in large groups for 15 or 20 minutes waiting for a bus or a trolley. You're supposed to buy a ticket or a pass, but it's on the honor system. People board by the back door and the driver never checks.

All of the cafes -- and as I say, there are three or four on every block -- have outdoor seating, and hardly anybody sits indoors. Of course the weather is paradisical right now, I can't say if that's always the case. And there are people there all day, often with beer or wine, but maybe coffee, a plate of cheese or cured meets, talking and laughing and interacting with passersby, half of whom, it seems, are their friends. That's where they live, on the street, in the cafes. Everybody seems relaxed and friendly and trusting. Yes, the service is slow and the construction workers are taking it easy, but there isn't a single piece of litter on the street, anywhere. I haven't seen a single cigarette butt or paper cup. Not one.

I was walking around in the early evening and I came to one block, just like all the others with the people out on the sidewalks having their beer and wurst, three hairdressers on the block (mysteriously, as always), and this happened to be where the ladies of easy virtue were. They were all young and lively and bantering with the cafe sitters but their reason for being there was obvious, and of course they all walked up to me and made what were evidently very friendly remarks in German. I just said Hi how yah doin' and walked on and everybody laughed. As I left the block a police car (they're Mercedes!) came around the corner but I expect they were just making sure everything was peaceful, it didn't seem like they were going to broom the young ladies. But don't hold me to that.

Update:  I looked it up. Prostitution is legal in licensed brothels. Street prostitution is confined to designated areas only. I am guessing that the young ladies I saw were actually the equivalent of carnival barkers for one or more indoor establishments on the block. They were there to advertise the business and invite customers inside, which is why everybody took them for granted. Maybe somebody who knows the city can confirm whether this is a plausible interpretation.

I asked somebody why there are so many hairdressers and he was nonplussed. It had never occurred to him that this is abnormal. I've mentioned it to my fellow American visitors and they confirm, I'm not crazy, they noticed it too. I should probably get a haircut before I leave, just to check it out, but . .. see below.

So yes, this is definitely a nice place to visit but save up for it. In case you think the Yankee dollar has clout, get over it. Swiss francs are very dear in dollars. A haircut would set me back 40 bucks. I just blew seventy bucks on two drinks and a cheese plate. But the cheese was good. And yes, it had holes in it.

Swiss movement

Well, it's been a bit difficult getting this post out. First of all, it's in italics because for some mysterious reason blogger in Helvetia insists on displaying postss this way. (Atrios looks like this here as well.) (Okay, it's only in italics in the editing pane.) The hotel wifi doesn't work with my computer so I'm using the hotel guest computer which has a German keyboard. They don't use the letter Y, or the apostrophe, so they''re in weird places, along with some other peculiarities. It was a real struggle signing into this account as well, because blogger doesn't like me being in such a weird location. Among other problems, including terminal jet lag.

Anyway -- more about the conference later. But, a bit about Basel. There is far less automobile traffic here than any large U.S. city. The streets are not congested at all. Pedestrians can pretty much cross at will, there's unlikely to be a car coming and there are hardly any stoplights. Why is this? First, the city is completely knitted together by a dense network of street cars -- electric trolleys similar to Boson's Green Line, if you happen to be familiar with that, but going absolutely everywhere. At just about any block, you can get on anywhere from 2 to 5 different trolleys, that come every 2 to 6 minutes, going just about anywhere.

Second, there are more bicycles on the streets than there are cars, and at least as many scooters as cars. Such cars as there are are small. I have yet to see an SUV, a pickup truck, or a hummer. There are bicycle racks everywhere. Why can't Americans be half this smart?

Yes, the city is older than American cities and it has a lot of very old buildings. That doesn't always mean charming, some of the old stuff is drab and even run down -- the city isn't richer than New York, but on the other hand it's more egalitarian, as far as I can tell. The charming and elegant are all mixed together with the ordinary, but on the whole, it's pleasant to contemplate. There are two or three bars on every block downtown here near the Rhine, and also, for some bizarre reason, two or three hairdressers. The people don't seem particularly well coiffed, but they definitely have the opportunity. I can't explain that. They don't eat vegetables here, as far as I can tell. Cured meats, potatoes, a bit of fish, and pizza. That seems to be the diet. Also beer.,

Contrary to what you have been told, they don't all speak English. In fact, even the waiters in the hotel restaurants don't necessarily speak more than a few words. The language here is German, but the look is multi-ethnic. There are lots of black people and women in hijabs yacking away in Deutsch. So that may upset some of your mental pictures. On the other hand, everybody '-- well, not everybody, but a lot of the young men, smoke. They recently banned smoking in restaurants and bars, but a lot of the bars have banded together into a kind of civil disobedience association. We'll see how that plays out.

The river is of course long-since canalized, but it very much has that old world charm. It is lined solidly with lovekly old restaurants and hotels, taking advantage of the setting for outdoor dining and cafe sitting. The weather this time of year is paradisical. Generally, there's no AC, which is not a problem right now but I have to wonder about the future.

If I spoke the language, I could get a much less superficial view, but that,s about what I can see as an ignorant tourist. Something about the conference will come later.

A new peril for travelers

I'm off to Switzerland in a short while. (I just hope the constant yodeling and playing of giant wooden trumpets doesn't keep me up at night.)

The bad news is I have to change planes at Heathrow, and it turns out the British police, if they are so inclined, can at a whim, for no stated reason and indeed for no reason at all, hold me incommunicado for 9 hours and confiscate all my electronic equipment.

Back at the height of the Iraq war, when I was writing the Today in Iraq blog, I was marked for extra security screening. (True!) Every time I flew they'd take me aside and hand search my luggage. That seems to have stopped now but I haven't been abroad for a few years. Last time, coming back from Mexico, I got the full shakedown. So we'll see.

It turns out that once you're on the list, it's very hard to get off. Unfortunately, Harper's hasn't made the article available to non-subscribers, but there is a chilling tale this month by the writer William T. Vollman (link leads to the paywall, sorry), who discovered via FOIA that he has been on a watch list for decades in large part because he was suspected of being the Unabomber. The reason for the suspicion is that some of his novels seem to take the part of native peoples against the European invasion. True! Once the Unabomber was captured, he obviously was no longer under suspicion of that, but it didn't matter! He got detained and grilled for hours every time he crossed an international border.

The really ugly secret about the immense, secret national security establishment is that it is utterly inept. They're spending hundreds of billions of dollars of your money to pay idiots to violate your civil rights and your privacy for no good purpose whatsoever. The point of keeping it all a secret is that it gives them more secrets to keep, which is what they do. It's an end in itself.

Missing the obvious

A couple of nights back John Oliver had Rand Paul on the show. The good doctor seemed oh so calm and reasonable. He too, wants everybody to get health care and for it to be more affordable. But Obamacare isn't the way to achieve that.

No, the way to achieve universal, affordable health care is to make the patients pay for it. Dr. Paul has observed that procedures that aren't generally covered by insurance, such as laser vision correction, have come down in price. So if we just make everybody pay for everything, it will all get cheap, and we can all afford it!

Now, I could explain why this is complete bullshit, but I'm tired of doing that. The biggest challenge of blogging is that you keep writing the same post, over and over. So instead I'll just ask, WTF is wrong with John Oliver?

Having grown up in the land of the bowler and bumbershoot, Oliver presumably noticed some surprising facts about his surroundings:

1) Nobody has to pay one penny for health care, ever. (Some well-off people do pay for extra stuff they happen to want. That's allowed! Libertarian paradise!)

2) It costs half as much as it does in the U.S.

3) Everybody gets it, not a problem.

4) The people live longer, and they are healthier, than they are in the United States.

Now, one could go to the trouble of explaining this, but failing that, one could simply point it out. Nahh, not worth it. It's not a joke.

A reluctant, sad judgment on PZ Myers

As many people who may read this no doubt already know, there has lately been a raging controversy within the organized skeptical/atheist/secular humanist community -- whatever you want to call it -- about rampant sexism among leadership and misbehavior by loutish male conference-goers. I subscribe to Free Inquiry,  the publication of the Center for Inquiry which is among the accused institutions. I have long followed the Pharyngula blog of PZ Myers, who has championed the aggrieved women in this brouhaha.

That's as close as I get to the movement -- I'm a practitioner of rationalism and an avowed atheist, but I'm not an activist. So I don't have any firsthand knowledge about this. I must say however, that the torrents of crude, sexist and misogynist comments that appear on blog posts about this issue seem to powerfully vindicate the complainants.

Now, however, PZ has, in my view, screwed up. Rather than link to his original post, which may or may not stay up much longer anyway, I'll send you to this post by Jack Vance which summarizes the story and links out to further news and discussion. Briefly, PZ says he received communication from a woman who wishes to remain anonymous claiming that celebrity skeptic Michael Shermer got her drunk and raped her at a conference. He reprinted some of her allegations along with her assertion that she knows other women who have had similar experiences.

The Pharyngula commenters overwhelming back Myers -- there really isn't much of a discussion going on over there. Shermer, not surprisingly, has had his lawyer write a sternly worded letter demanding the post be taken down and seeming to imply further legal action. PZ Myers has largely kept silent on the matter since his original post, other than some cryptic remarks. Not that anybody is likely to care, but here's my take on this matter.

First of all, PZ already doesn't much like Shermer, who has has made some unseemly remarks of his own about the "feminism in skepticism" cause. I haven't thought all that much of Shermer as a skeptic since he started making claims to the effect that science proves the ideology of economic libertarianism to be correct. But not liking somebody is an excellent reason not to make yourself the instrument of questionable vengeance. So when in doubt, that should give you a presumption.

In this particular case, I don't think there's much doubt. The problem is that the accuser is anonymous, and refuses to specify even the time or place. The remaining accusations are pure hearsay, coming from the same anonymous accuser. Therefore, it is impossible for Shermer to defend himself. Anybody, anywhere, anytime, could completely fabricate such an accusation and post it on the Internet. While I trust PZ Myers and he says he trusts the accuser, that's obviously not good enough, because you might not happen to agree. PZ should not have done it.

Off to the land of Holey Cheese

As I have mentioned before, next week I will be in Basel for the international environmental health conference, sponsored by the International Society of Environmental Epidemiology ISEE, International Society of Exposure Sciences ISES, and International Society of Indoor Air Quality ISIAQ.

I will be presenting on Thursday, one of several presentations and posters coming out of the Community Assessment of Freeway Exposure and Health (CAFEH) study (Doug Brugge, PI). This is a "big science" community based participatory research project funded by the National Institute of Environmental Health Sciences. The study included detailed assessment of air quality near I-93 in Boston and Somerville, and in comparison urban areas, using a mobile laboratory, to create a detailed model of exposure for individual locations; a survey of residents in the study area; and collection of actual biological information including blood samples from a sub-set of survey respondents.

My piece is a social science sub-study of risk perception. We asked people how concerned they were about air pollution in their neighborhood, and about pollution specifically from the highway; and whether they supported more or less government action to control pollution. We gave them various psychological and attitudinal scales that have been though to be related to risk perception, and we have a lot of other information about them including demographics, education, and even how much physical activity they engage in, smoking history, and you name it.

I'm basically supposed to wait till the conference presentation before I spill the beans on the results, but I will say a couple of things about the context. First of all, in case you didn't know it, living near a major highway or otherwise spending time near one is very bad for you. The principal danger is ultra-fine particle pollution -- unburned hydrocarbons come out of the tail pipes and condense, essentially forming hydrocarbon steam. The most numerous particles are extremely small -- much smaller in diameter than a human hair. If you breathe these in, they go right through your lungs into your bloodstream, and they can enter cells. They cause general inflammation, seem to contribute to atherosclerosis, and are an acute risk factor for myocardial infarction as well as chronic vascular disease.

And guess who lives near the highway? Disproportionately, low income and non-white people. It's a favorite place to build public housing projects, as a matter of fact, but private housing is obviously cheap there too. And this basic fact has been underappreciated, I think, in previous studies of risk perception. More in due course.

Any friends in Helvetia who want to do lunch or something, you have my e-mail.

The ability to think is not a requirement

to enter the journalistic profession.

Headline: Near-death experiences aren't figment of imagination, study shows

Actual study: Rats' brains remain active after cardiac arrest.

This doesn't actually "show" anything about near death experiences, but it is consistent with what we already know: Near-death experiences are a figment of imagination.

Apparently there's an intelligence test, and if you pass it, they won't hire you at CBS news.

True Crime

The good people of Boston are experiencing a surfeit of big time crime stories, from the historical -- the Bulger trial and definitive identification of the Boston strangler -- to the immediate -- the Marathon bombing, the murderous Patriots tight end, and now a young woman who came to the city to make her fortune and was brutally murdered by a wacko who had been serially attacking women in South Boston over the recent week. The cops could have brought him in, too, but the detective assigned to the case dropped the ball. (The police commissioner, who says "lawr enfawcement," busted him back to flatfoot.)

Lurid crime stories pretty much dominate my memory of local news in my 25 years living in that town. One of the earliest was a 15 year old kid who murdered a neighbor woman, about his mother's age, for no particular reason. Back in 1989, a young woman was murdered after a birthing class at Brigham and Women's Hospital and her husband told the cops a drug-crazed negro did it. The police jacked up ever young black man in Mission Hill. They even arrested one of them and publicly announced that they had their man. Then it more or less accidentally came out that the husband did it himself. He jumped off the Tobin Bridge.

Then we had John Salvi, who shot up two abortion clinics in Brookline; a guy in the leafy suburb of Newton who murdered his wife and two children in the marital bed and then fled to England (not sure why that one got the OJ treatment from the media, but it did); a couple of young girls who were killed in gang crossfire, a couple of workplace mass murders, the sexually motivated murder of a ten year old boy that led, briefly, to restoration of the death penalty in Massachusetts until the boy's father changed his mind and came out against it (really, that one man's original wishes, followed by his change of heart, was dispositive in swaying the legislature); and of course the pedophile priests. I could go on and on. The point is that my memories of all this are more vivid, and detailed, than my memories of public policy disputes or elections, even though I was a political activist most of the time, and for a while a professional social policy analyst. They are even more vivid and detailed than my memories of my own life (such as it was).

My point is that the narrative of community life stitched together by the news media, and particularly television with its evocative and memorable images, is dominated by crime news. To be sure, although only a small percentage of people are directly affected by serious crime, it's a public responsibility of journalists to document it, and also to make the criminal justice system transparent. But they don't do either very well -- they are not consistent in their decisions about what to make into a big story, they do a terrible job of holding police and prosecutors accountable, and they don't put all this in its proper place or context.

I would prefer to have a somewhat different headful of memories from my years in that town.

The Olympics Problem

Sorry for not posting yesterday, insanely busy. (I don't know how academics like PZ Myers and Brad DeLong do it every day.) Anyhow . . .

I am going to speak about a current difficult issue from the sagacious perspective of advanced age. Yes, V. Putin's new anti-gay law is a putrid, stinking excrescence. It is deeply galling to think that the winter Olympics will happen in Russia in a few months and give Czar Vladimir a chance to strut around on the world stage. Equally galling has been the tepid response of the IOC and for that matter the USOC, and yes, we do have to worry about participating athletes who might run afoul of the law and also any gay athletes who may feel threatened or forced to deny who they are for the duration.

However, a boycott of the Sochi games would be, in my view, a really bad idea. Jimmy Carter boycotted the 1980 Moscow Olympics to protest the Soviet invasion of Afghanistan, and here's what happened. Only a few countries went along, so the games happened anyway. Athletes who had spent the entirety of their young lives preparing for their single chance lost it. Americans were deprived of a spectacle many people look forward to -- the boycott was unpopular with the public and cost Carter politically. The Russians stayed in Afghanistan, if anything they dug in deeper. And the Soviet bloc turned around and boycotted the next Olympic games in the U.S.

Positive accomplishments? Zero. And we'd have exactly the same result this time.

Obviously, the IOC, USOC, and U.S. State Department have to make it absolutely clear that the law will not be enforced in Sochi for the duration of the time that international visitors are there for the games -- and that's at least a week before and after the opening and closing ceremonies. If the Russians can't make, and keep, that commitment, we can specify diplomatic and economic consequences.

Next, the Obama administration has to move this higher on its list of beefs with Czar Vlad. They should stop giving a fecal bolus about Mr. Snowden, which I know is not going to happen, but at least they can elevate this to the same level. It's not about meddling in Russia's internal affairs -- we can't do business in Russia under the circumstances, just as if they discriminated against African American businesspeople or diplomats. Putin needs to understand that we can't have a normal relationship under the circumstances.

But the Olympics are not the right lever to pull. IMHO.

The Republican Party

I recently commented (elsewhere) that the Republican party is a Ménage à trois among racists, plutocrats and religious fanatics. On reflection, I left out an element, which is hard to define, or at least to name.

Let's call it ultra-nationalist anarchism. This overlaps to a considerable extent with the racists and religious fanatics, but it has a distinct -- and distinctly American -- flavor.

These are people who on the one hand consider themselves the only True Patriots, and who hold the idea of the United States in quasi-religious awe. They believe that the United States should dominate the planet and that it enjoys moral exceptionalism; that the U.S. is not bound by the norms and expectations of international behavior that apply to other nations, and that to criticize the U.S. for actions which U.S. officials routinely condemn in other nations is treasonous "moral relativism." They glorify the military and are cheerleaders for U.S. military action whenever some global actor annoys us.

On the other hand, they view government as inherently oppressive and the federal government in particular as fundamentally illegitimate. They have an unexamined assumption that government is the only entity that can constrain their freedom, apparently unaware of the ocean of private coercion in which they swim. The subculture of firearm worship is an essential component of this philosophy. With a gun, a man makes himself free, protects his own interest, without having to rely on the oppressive state.

I need hardly point out the multiple intersecting and cross-cutting contradictions in this world view. Its historical roots are evident in the bitter defeat of Southern slave culture and white racial resentment generally, the anarchistic conditions of the frontier and the continuing urban/rural divide, and Christian dominionism which delegitimizes the secular state. But it is a very dangerous combination because it includes all of the ingredients of fascism. 

The plutocrats, of course, merely exploit it to convince people to vote against their own interests. But that so many of them are willing to do so today is very worrisome.

A couple of drive-by insights from the Global Burden of Disease

The GBD is a project of the World Health Organization, started in 1991. It's a massive effort to put together comparable morbidity and mortality statistics for all the nations of the world. The numbers are more reliable in some places than in others, and have all sorts of conceptual and systematic weaknesses, but they're the best we've got and they do tell us quite a lot that's interesting and important.

http://www.nejm.org/doi/full/10.1056/NEJMra1201534, review the changes in the U.S. and the world from 1990 to 2010. It's a complicated story, which they perhaps could have made more clear than they do in some ways. Read it if you're interested in understanding what's going on with the good ole human population, but I'll pick out a couple of noteworthy points.

They use a metric called Disability Adjusted Life Years, which is an attempt to measure loss of functionality and death in a common currency. You may or may not think that's morally correct, or even possible, but people who study public health think that something like it is necessary in order to compare the harm caused by various diseases or risk factors, and the value of competing investments in treatment or prevention. (I have covered this concept in the past.)  They make it a bit confusing by using the term DALY to mean its opposite, that is DALYs lost -- the sum of premature deaths and years spent living with disability. As far as I know this is not conventional, and they don't explain it. That seems to be an editorial oversight. But anyway . . .

Ranked by DALYs, the most costly disease in the U.S. is ischemic heart disease, which also happens to be the leading cause of death. The second leading cause of death, stroke, is number 7 on the DALY list. Since these are in considerable part manifestations of the same underlying disease, atherosclerosis, that's pretty impressive. Cancer of the respiratory tract is number 4 on the DALY list and number 3 on causes of death. That is mostly caused by smoking, which also contributes heavily to heart disease and stroke. So the major fact that we could have an enormous public health impact by getting tobacco out of our lives hasn't changed.

Something new is that dementia is now listed as the 4th leading cause of death, and its 12 on the DALY list. That's not exactly because we're having an epidemic of dementia, obviously, it's because we're living longer. Right now, there's exactly nothing we can do about it.

Globally, ischemic heart disease is now number 1 on the DALY list, and that's a measure of how deaths from infectious disease have fallen globally while life spans have increased, even in the poor countries. (Lower respiratory tract infections were number 1 in 1990, and heart disease was number 4.) This is true in spite of the HIV epidemic, and it's largely due to a decline in deaths of children from diarrhea. That's actually something of a global success story.

Compared to the rest of the world, we're much more likely to die from dementia -- because we live a long time and don't die from other stuff -- but also from lung cancer, because the tobacco epidemic started here. (Don't worry, the world is catching up.) So, obesity and physical activity are indeed major challenges, but tobacco is still with us. Now is not the time to stop fighting it.

What's in a name?

If the name is "cancer," plenty. When people are told they have cancer, they ordinarily are terrified. And they and their doctors feel compelled to do something about it. Doing something about cancer normally means surgery, chemotherapy, radiation -- all extremely expensive, unpleasant, and in fact damaging to your health.

It turns out, however, that since we've undertaken massive programs to screen the general population for what is generally called cancer, we've been detecting a lot of phenomena which, if untreated, would never hurt anyone. But the doctor tells the person "You have cancer," and  off we go.

The National Cancer Institute convened a working group to, well, work on this problem, and a summary of their group working is posted on the JAMA web site. They'll even let you read it!

They give a careful explanation of issues I have often discussed here, and I think it would be good for lots of people to read this and understand it. The mass hysterical freakout we've experienced every time the Preventive Services Task Force recommends less cancer screening is proof that people just don't get it.

The key ideas are:

Some abnormal cells that look like cells that sometimes become cancerous never in fact do so. In many cases, we really can't tell the difference.

The importance of early detection of cancer, or what might become cancer, has been exaggerated. The American Cancer Society is as guilty of this as anyone. Yes, five year survival is higher with lesions detected by screening than lesions that are detected because they are symptomatic; but that's largely because a) some of them were completely harmless to begin with and b) others would eventually become harmful, but they would not have killed you within five years even if untreated. What we really need to look at is whether, over the long term, the death rate from a form of cancer goes down in a screened compared to an unscreened population. This is difficult because you can't really do a controlled experiment, but the best evidence shows that general mammographic and prostate specific antigen screening have very small effects on population mortality. (In fact, the evidence is somewhat mixed. Some people aren't convinced it does significant good at all.)

The benefits of screening are offset by the costs, which include "overdiagnosis" -- finding those lesions that aren't going to hurt you and scaring you, treating them with all the attendant harm, and spending tens or hundreds of thousands of dollars. So yes, we need to strike an appropriate balance.

Good ideas include focusing tests on higher risk people, screening less frequently where indicated (and this has to do with parameters such as how fast a cancer tends to grow), and maybe abandoning screening entirely, as many people recommend with respect to PSA.

The working group has one more good idea: don't call it cancer when it isn't. For example, so-called ductal carcinoma in situ is not carcinoma. (Carcinoma is cancer arising from epithelial cells of ectodermic origin. That's fancy anatomy, look it up if you care.) Similarly with some prostate lesions. Instead of calling these "cancer," they want to call them Indolent Lesions of Epithelial Origin, or IDLE conditions. (Yes, the correct acronym would be ILEO, but evidently IDLE sends the right message.) If you're told you have an IDLE condition, rather than cancer, you won't freak out, and you'll be more likely to say okay, what the heck, let's not do anything and just keep an eye on it.

Seems like a good idea, but will doctors do it? We'll see.

Apparently "Being in Florida while Black" . . .

. . . is now a crime worthy of summary execution.

The Bulger Trial

The good people of Boston have had more than their share of True Crime stories of late, from the marathon bombing to the murderous tight end to, of course, the Bulger trial. Having spent 25 years in Scrodtown before moving out to the country and painting my mailbox blue, I am most interested. I'm pretty sure most of the country doesn't really know what's going on in the courtroom, so let me fill you in. People who already know the story, or think they know it, might appreciate a quick review as well.

Let me first state that the news media just love gangster nicknames. They can't say, or write, "James Bulger." They have a form of Tourette's such that they must always render it "James 'Whitey' Bulger." In fact his associates called him Jimmie. And I'm pretty much 100% certain that nobody ever addressed Stephen Flemmi as "Rifleman," but you'll never see his name in print or pronounced on air without that middle name.

Anyway . . .

In Bulger's day South Boston, which was and is indeed known as Southie, was an insular Irish enclave, virulently racist and paranoid about the maintenance of its ethnic homogeneity and dysfunctional folkways. When South Boston High was integrated by a court order, the people lined the streets to throw rocks at the school buses. Southie even had it's mini-Faubus in the person of city councillor Louise Day Hicks, who famously compared black people to a spreading stain on the fabric of the city.

During Jimmie's murderous reign over Southie, his brother William was the president of the state senate and Dictator of the Commonwealth. The Democrats had veto-proof majorities in both houses, so they would nominate weak candidates for governor and not give them any support in the general election, thereby insuring there would not be a competing powerbase in the corner office. Mitt Romney was one of the Republican figurehead governors during this era. Legislators never actually voted. Billie would stand at the podium and intone, "Comes now the question pertaining to the bill to be engrossed the clerk will read the amendment." The clerk would get out three words then Billie would say "Without objection the clerk will dispense with the reading of the amendment do I hear the ayes do I hear the nays the nays have it the amendment is not adopted." Then he would bang his gavel. There might be a few senators milling about the chamber talking with each other, but nobody ever actually said "aye" or "nay."

There was an odor of corruption around Billie but he was never caught, or at least he was never prosecuted. When he got tired of politics he got one of those figurehead Republican governors to appoint him Chancellor of the University of Massachusetts, to the violent retching of the faculty. He was forced to resign when Jimmie went on the lam, and Billie was apparently in contact with him. Billie was suspected of withholding information about Jimmie's whereabouts, which if I remember correctly he never explicitly denied. Instead he made remarks to the effect that blood is thicker than water. Anyway . . .

Jimmie knows that there is no possibility he will die anywhere but in prison. In fact, his lawyers stipulated to enough facts in opening arguments to get him life. He's an old man so the Angel of Death will probably parole him in no more than five years anyway, so what's this trial all about? Why not just plead out and get it over with? Gather 'round and I shall tell ye.

Whitey Bulger (and he was known by that name to the general public) was a folk hero in Southie. They saw him as a sort of embodiment of Irish machismo and the community's transgressive identity. For one thing, he was credited with keeping drugs out of Southie.

Hah! South Boston had the worst heroin problem in the city, much worse than the black ghetto of Roxbury. This was not a secret. You could see the junkies nodding in the doorways, everybody knew enough not to park where they could break your window and steal your radio, and the ambulances were continually hauling the ODs off to Boston City Hospital. Jimmie didn't try to stop the drug trade, he controlled it. He didn't operate it, but he decided who could sell dope in Southie, he parceled out the territory, and of course he taxed it, just like he shook down the legitimate businesses. So the first thing he told his lawyers was that they had to attack the accusation that he was the local drug kingpin. In that, they have, from what I have read of the trial, failed spectacularly.

One true fact that might have further enhanced Jimmie's reputation was that he sold weapons to the Irish Republican Army. He did it for the money, of course. But this brings us to the second reason for the trial, that he wants his lawyers to trash the claim that he was an FBI informant. That has also been an epic fail. This story has long been well known and told from every angle in many books and long-form newspaper pieces. The FBI was intent on breaking up the Italian mafia, so they recruited Bulger to rat. But he wound up turning the tables and put his FBI handler on his payroll.

Bulger oversaw an operation to run machine guns, ammo and plastic explosives out to an Irish trawler on the high seas via a Gloucester swordfishing boat. (The weapons never made it to the IRA because of an informant on the receiving end.) A crewmen on the fishing boat later got drunk and spilled the beans on the operation. Unfortunately, he ended up being interrogated by Bulger's pet FBI agent, John Connolly (now in federal prison for racketeering and murder), who of course tipped off Bulger, who (of course) tortured the man to death. Connolly later tipped of Bulger that he had been indicted, leading to Jimmie Bulger's 19 years as a fugitive and Billie's fall from grace.

The last claim Bulger wants his lawyers to refute is that he murdered women. His lieutenant Flemmi testified that Bulger personally strangled Flemmi's girlfriend and stepdaughter when they became inconvenient. Flemmi could be lying about who did the actual strangling, but there can be no doubt that Bulger knew and approved.

So the trial isn't about guilt or innocence, in general. It's about Bulger's legend. And he's already lost.

What they really believe

Jonathan Chait tells you what you already know, but does it eloquently. The Republicans in congress are threatening to destroy the credit of the U.S. government and crash the global economy in order to prevent people with pre-existing conditions and low income workers from getting health care; and low-wage workers from having enough to eat.

In case you think it's a mystery why they would do this, let me clue you in. It is and always has been bedrock of the conservative psyche that my possessions and my enjoyments are worth much less to me if everybody else has them too. After all, privilege depends on the deprivation of others. What good is abundance if the undeserving -- be it the dark complexioned, the foreigner, the servant class -- get to share in it.

In the U.S. today, as has been classically true throughout history, the economically privilege have allied with the religious establishment to mutually preserve their prerogatives. Here again is the famous essay by Philipe E. Agre:

From the pharaohs of ancient Egypt to the self-regarding thugs of ancient Rome to the glorified warlords of medieval and absolutist Europe, in nearly every urbanized society throughout human history, there have been people who have tried to constitute themselves as an aristocracy. These people and their allies are the conservatives.

The tactics of conservatism vary widely by place and time. But the most central feature of conservatism is deference: a psychologically internalized attitude on the part of the common people that the aristocracy are better people than they are. Modern-day liberals often theorize that conservatives use "social issues" as a way to mask economic objectives, but this is almost backward: the true goal of conservatism is to establish an aristocracy, which is a social and psychological condition of inequality. Economic inequality and regressive taxation, while certainly welcomed by the aristocracy, are best understood as a means to their actual goal, which is simply to be aristocrats. More generally, it is crucial to conservatism that the people must literally love the order that dominates them. Of course this notion sounds bizarre to modern ears, but it is perfectly overt in the writings of leading conservative theorists such as Burke. Democracy, for them, is not about the mechanisms of voting and office-holding. In fact conservatives hold a wide variety of opinions about such secondary formal matters. For conservatives, rather, democracy is a psychological condition. People who believe that the aristocracy rightfully dominates society because of its intrinsic superiority are conservatives; democrats, by contrast, believe that they are of equal social worth. Conservatism is the antithesis of democracy. This has been true for thousands of years.

Obviously I couldn't give a FFOARD . .

what they name the baby, but what I don't understand is why anybody cares, much less why this is the screaming headline leading every news platform on the earth.

People are weird.

Something that really matters

I can't tell whether Americans really are completely obsessed with the birth of an heir to a useless, anachronistic institution in a faraway land, or if the corporate media just assume we will be or would rather manufacture a meaningless frenzy over nothing than actually, you know, report the news.

So here's a thing, via Brad DeLong (he alas does not provide a link to the original source):

Median household income in the U.S. today is about what it was in 1989, and has continued to decline throughout the recent "recovery." This of course as per capita GDP has increased, meaning, via simple arithmetic, that the rich have gotten richer while the middle class has gotten poorer. In other words, the recovery isn't actually happening for most people. So why is this?

It's partly because of an ongoing substitution of capital for labor, because of the continual decline of union power, because of continuing declines in public sector payrolls, because multinational corporations continue to pursue the lowest possible wages around the earth.

And yet, in the aggregate, the country is wealthier than ever. We can provide people with a better standard of living, but capitalism isn't doing it. Ergo, we need to try something else. Let's have that conversation.

The worst (corporate) persons on earth

If corporations are people, they're all psychopaths, but drug companies seem to be more psychopathic than others. Graduate student Jeppe Schroll, in BMJ, finds numerous instances in which Novo Nordisk, in published results of clinical trials, completely omitted important adverse events including deaths. I won't get too deep into the weeds here, which would just confuse the issues. I'll make it simple.

For background, a commonly used marker for diabetes control is called glycated hemoglobin, often called hemoglobin A1c and written as HbA1c. Basically, if you have high levels of glucose in your blood, higher levels of this variation of hemoglobin form. So doctors can use it to estimate what your average blood sugar level has been recently. Keeping it low is therefore a goal of diabetes management.

Lately there has been recognition, accompanied by considerable controversy and false balance in both the public reporting and the FDA response, that some drugs which have been found to reduce HbA1c in clinical trials are nevertheless associated with a higher rate of cardiovascular disease and adverse events. This is one more indication that it's probably not a good idea to rely on surrogate endpoints in approving new drugs. After all, the most important complication of diabetes is death from heart disease. We also want to prevent other adverse outcomes but it doesn't matter if you're dead.

So, investigations sponsored by the company found that some of their products lowered HbA1c, and on this basis the drugs were approved and widely prescribed. What they didn't bother to tell us in the published reports was that some of the people in the studies died, and that they couldn't rule out that this was linked to the drug. They failed to report other adverse outcomes as well.

Now, there are all sorts of lies, and for some reason we don't generally view omission of important facts as negatively as we do affirmative false assertions. But in this case we should, because clinical trials investigators are under a prior obligation to report on adverse events. These are lies of omission which can kill people, and the motive is greed. That's evil.

Required Reading

Tom Streithorst, in the LA Review of Books (and isn't LARB much easier to pronounce than NYRB?) offers an economic history of the past couple of centuries and tells us where we are today. I do think it's best for you to read it, but I will hit a couple of high points.

Not so much in rural Bangladesh or Burkina Fasso, perhaps, but all around the the global north and more and more of the south, "we live like Gods," as Streithorst says. Not long ago at all, the average American or European worked from dawn till dusk, lived in what we would today consider a hovel, and spent more than 50% of income on food. People in most of the world (think Irish famine) were continually one bout of bad weather or a plant disease away from starvation. Most people could scarcely read, and had never been a few miles from the place they were born.

It's nearly unimaginable how different this world is. Middle class people spend maybe 2 or 3% of their income on food. We have closets full of clothes and most people refill them every year. Less than a room and a half per person is considered residential overcrowding. Just about every family that wants to owns a machine that can transport them 500 miles away in a day.

And yet, and yet . . .

People feel financially insecure, they are struggling to get by day to day, and hardly anyone can achieve security for their old age. The economy can't supply gainful employment to everyone who wants it and much of what is available won't support a decent standard of living. Conservatives think the answer is to cut taxes and let wages fall further, so that capitalists can make more on investments and will find it worthwhile to hire more of those cheap workers.

Wrong, and completely upside down. Capitalists will hire workers when somebody wants to buy the stuff they have to sell. They'd rather make a profit that gets taxed than none at all, but again, they won't invest if they can't sell their crap. And right now, they can't. The reason is that not enough people have enough money to buy it.

Productivity defined as output per hour of work has climbed steadily throughout the past 2 centuries, but since 1970 or so, average wages in the U.S. have been stagnant. This is because capital has displaced labor. But if people don't have money to spend, they can't buy stuff and put each other to work. So, they economy was sustained by a series of asset bubbles and rising debt. This put money in people's pockets until the bubbles burst and they couldn't borrow any more. Now we're stuck.

The answer is that we need a totally new kind of economy in which wealth is, yep, redistributed. Government needs to spend money by putting people to work doing good stuff -- Streithorst favors high culture, arts and the life of the mind, others might favor more subways and replacing all those water mains that keep breaking, but there's no reason we can't do it all.

But this has to be a permanent state of affairs. Once you have too much stuff, your problem is not supply, it's demand. And no, John Galt and the Koch brothers can't create that. 

What terrifies Republicans . . .

. . . is of course that the Affordable Care Act will be successful. That's why they keep trying, impotently, to tear it down like a dog gnawing on granite. While I am constitutionally loath to peer into the crystal ball, it certainly seems that the early signs are favorable. Premiums in California turn out to be generally affordable, and now New York has generated an even better headline: the price of health insurance on the individual market will fall by about half.

This may seem like sorta, kinda the opposite of what you may have heard about the effect of the ACA in general -- that it will actually make health insurance more expensive for young, healthy people -- but the explanation is what's so great about this for prospects of getting through to people who are unclear on the concept (which is 90% of the population).

New York State is unusual in that it already has guaranteed issue, but, obviously, without the individual mandate. That makes it a perfect experiment that shows why the individual mandate is necessary and good. Right now, New York state has 2.8 million people with no health insurance, and only 17,000 (that's right, only 3 zeroes) who have purchased policies on the individual market. The reason is they're much too expensive for almost everybody, because of adverse selection, i.e. the only people who buy them are people who are sick enough that it's worth their while paying the exorbitant premium. Insurance companies, expecting an influx of new customers who are less expensive to insure, therefore are cutting their prices. Lots of people will be eligible for federal subsidies to buy those cheaper products, so it will be well worth their while even if they are on the young and healthy side.

That's the whole idea, folks. Yes, you may feel you'd rather not buy health insurance right now because you're invulnerable, but by making people like you buy it now, we make sure you'll be able to afford it when you need it. That's the point of insurance -- to spread risk, and make everybody more secure. Sure, there will be glitches, especially in the states whose governments aren't cooperating, and the corporate media will blow them way out of proportion. But if people's actual experience is good (and for most people, nothing will change), maybe the 2014 mid-terms will turn out differently from what people are expecting.

Physicians and dying

Before I get to the question of this post's title, let me make the obligatory George Zimmerman statement. No, I have nothing unusually insightful or unique to add, but neither does anybody else. If you can strap on a gun, see a kid simply walking through your neighborhood, stalk him, and shoot him dead, and have no legal accountability or responsibility whatsoever -- in fact you get your gun  back and you are free to do it again -- we are not living in a civilized country. (Yes yes, the sole, only and single reason Trayvon Martin was suspicious was because he was black. But everything I say here is true regardless.) It seems that according to Florida law, if you claim self defense, it is the burden of the prosecution to prove beyond a reasonable doubt that your actions were not in self defense. I don't think that losing  a fist fight is grounds for murder even if you are, in some sense, defending yourself, but even so: if you live in Florida, and you want to murder somebody, just get them alone, kill them, and claim they attacked you. That's all you have to do.


Okay, now on to business. Bill Noble, a British palliative care specialist, doesn't like a proposal in the land of the bowler and bumbershoot to legalize physician assisted suicide. It might surprise you -- and it did surprise some folks the last time I wrote about this question -- but I'm quite leery of this idea myself. Nothing terrible seems to have happened so far in Oregon, which did legalize it a few years back, but it still raises some distressing problems.

All of these proposals, like the Oregon law, have safeguards. The people must be terminally ill, you can't help a patient die just because the person is suffering. Also, they can't be diagnosed with depression or other major mental illness. But, if you've been reading this blog, you already know that neither of those criteria has the status of a "fact." Doctors are notoriously inept at predicting how long people have to live, and the diagnosis of depression is largely arbitrary. Obviously, if you're very ill, suffering, and don't have long to live, you're probably unhappy. Calling you "depressed" or not is pretty ridiculous either way.


In another vein, it seems to me quite disingenuous to claim that this choice can reliably be assessed as non-coerced. People's opportunity to die a natural death with dignity depends very much on their material and social resources. People are inevitably going to consider, at some level, the burden that their care puts on others -- both personally and financially, no matter what they say or how you talk with them. Palliative care specialists claim that often, not enough is done to relieve suffering and that people will often change their minds about wanting to die if they are given better care.

Noble thinks that even if you do conclude that there are meaningful criteria to distinguish those deserving of help in killing themselves and those who are not deserving, it should not be the job of physicians to make these decisions. He suggests a team of social workers, but I think his real point is that these proposals radically redefine medical ethics and the role of the profession, and a lot of doctors are just very uncomfortable with it.

I'm the first to concede that one of our greatest cultural pathologies is the denial of mortality. Death is not necessarily a tragedy, or I should say that any given individual death does not necessarily add to the overall tragedy of the human condition. Our time will come, and our refusal to accept that is at the root of a good deal of disordered thinking and bad public policy. (Weirdly, it's religious people who believe in an afterlife who seem to suffer from this delusion the most.) But it has traditionally been the job of doctors to delay that time, if possible and worthwhile, not to hasten it. This idea has many implications which people seem to stop short of thinking through. So no, I'm not yet convinced this is a good idea, although I'm willing to listen.

Cross posted from Today in Afghanistan . . .

UK newspaper the Mail reports that Prince Harry witnessed a war crime by U.S. soldiers in Afghanistan. Really. Excerpt:

Prince Harry was no more  than 220 yards away when a US trooper standing aboard an armoured vehicle cocked a .50 calibre machine gun and fired successive bursts at Afghan shepherds tending their goats, The Mail on Sunday can reveal. The shocking incident, which  was confirmed last night by the Ministry of Defence, triggered a war crimes investigation by US military police. It took place on Harry’s first frontline tour of Afghanistan, which, until today, has been shrouded  in secrecy. . . .

According to a British eye- witness the three shepherds were peacefully minding their own business when they were engaged. Given the force of the heavy machine gun rounds it is likely  they suffered serious or fatal  injuries, though their bodies were never recovered.

This would have happened in 2007. Note that although the story says the M.P.s investigated,  I am unaware that anyone has been prosecuted for this murder, nor that any investigation has been publicly acknowledged. I wonder if the U.S. corporate media will bother to report this? So far I haven't seen any mention of it.

We'll never know how many atrocities U.S. forces committed in Afghanistan, with total impunity. But the Afghans have a pretty good idea.

If you're interested in public health, this is kind of cool

If also a bit depressing. The Institute for Health Metrics and Evaluation at the University of Washington has released a report on the state of health in the U.S., based on the Global Burden of Disease data from the World Health Organization. The depressing part is that, as we already know, the U.S. population is in worse health than all the other wealthy countries. We don't live as long, we're sicker, and we're more depressed. That isn't news so I won't dwell on it.

However, the cool part is all of their data visualization tools. You can quickly see trends in all the causes of death, by age category and sex; compare countries; see how leading causes of death have changed places over time -- all sorts of enlightening interactive graphics are at your command!

One of the most interesting is an interactive map of the U.S. in which you can see various health status indicators by county. Funny thing -- they've made longer life expectancy bluish and shorter life expectancy reddish. I don't know what they were thinking, but with the exception of Utah (Mormons don't smoke or drink, doncha know) the map ends up looking a whole lot like another map you may have seen. (Push the slider all the way to the right to get the most recent year, and click on female rather than male to get the strongest picture.) Yep: the redder the state, the sicker the people. Why do you think that might be?

Why is the corporate media obsessed . . . .

with this plane crash in San Francisco? I was watching the ball game on Saturday and idly switched to CNN during a commercial when I first saw the completely static video of the tailless plane sitting on the runway -- a shot that seemed to stay up about 80% of the time while CNN went totally wall to wall with this for two whole days. MSNBC also dusted off Ed Schulz to go wall to wall with this in place of their usual weekend lineup of tabloid psycho-porn. The local and network newscasts on both weekends were devoted almost entirely to this story -- in which nothing was happening and there were no significant developments -- as were all of the major news websites pretty much right through Monday, and it's still just barely tapering off.

As plane crashes go, this was as minimal as it gets -- two people dead. The basics of what had happened were immediately obvious -- the plane landed short and its tail hit the seawall at the edge of the airport and broke off. We knew that five minutes after it happened. That's still what we know.

Meanwhile, they had another perfectly good, far more consequential and even more photogenic industrial disaster available to obsess over, the train derailment in Quebec that destroyed an entire downtown, was still very attractively on fire, killed dozens of people, and has important public policy significance. But it didn't interest them in the slightest. The turmoil in Egypt, abortion controversy in Texas, imminent implementation of the Affordable Care Act and associated difficulties, you name it, they ignored it. For three whole days. Instead, they sat there and talked about the absolutely nothing that was happening in connection with a minor event that was long over.

I suppose it's the weird media magnetism of plane crashes that has made Al Qaeda so obsessed with causing them. And yeah, TV talking heads make a lot of money and fly a lot so that probably makes them care about it. But I don't really get it. To most of the audience, this must be just as boring and pointless as it is to me.

Baffling.

More of Less is More

Some folks at BU review evidence about a diagnostic test, called CT pulmonary angiograms. (I think you can only read the abstract, but I shall summarize well.)

A pulmonary embolism is a blockage in an artery in the lung. Sounds bad, right? And indeed it can be: symptoms can include respiratory distress, chest pain, and rapid heart beat and it can be fatal. The treatment is to take anticoagulant drugs, normally warfarin. This present a risk of bleeding but it beats dying. So we want to diagnose them all and make sure we don't miss any, right?

That's what doctors thought to and they were accordingly delighted when CT scanning came along. It is now possible to inject iodine into the blood stream and create very high quality images of the arterial network in the lungs, which means they can find even tiny embolisms. This has largely replaced an older method called ventilation-perfusion scanning, in which the patient inhales a radioactive gas and has a radioactive material injected, and a gamma ray camera can then image where air and blood are getting to within the lungs. Although that sounds scary, it actually subjects the person to a lower radiation dose than does CT scanning. However, it is less sensitive.

Doctors love the CT pulmonary angiography scan because they don't want to miss any of those "silent killers." But, what the BU researchers find is that since CTPA was introduced, the diagnosis of pulmonary embolism has increased by 80%, but deaths from pulmonary embolism have barely changed. It turns out that the procedure can detect tiny (isolated sub-segmental, referring to a small branch artery) embolisms, but apparently, these are harmless. In fact the body can reabsorb them, and it may well be that evolution has actually favored the lungs performing the function of filtering out tiny blood clots originating elsewhere. In one study, of 65 patients found to have these tiny embolisms who did not receive anticoagulants, none had any adverse effects.

As the authors summarize, anticoagulation is actually a leading cause of medication-related death. In one case series of patients given anticoagulants for isolated sub-segmental embolisms, 5.3% had major bleeding. Being told you have a condition that could kill you, and having to take a dangerous medication, is obviously unpleasant for people. And the cost? In 2006, hospital admission for a pulmonary embolism cost $44,000.

But the drug companies and medical device companies push these procedures hard. Hospitals need to have the latest scanners so they can appear cutting edge and high tech, but in order to justify paying for them, they have to use them. We're getting far too many of these scans, which increase the risk for cancer as well as costing money and finding all sorts of incidental abnormalities which aren't actually dangerous but have to be investigated, at great expense and angst. We should knock it off.

Too much news

You hardly know where to begin. Anyway --

Obama has decided to delay the insurance mandate in the ACA by one year. This is actually wise. In this respect, the law was horribly crafted. The first thing you learn in Public Policy 101 is not to create a "cliff," meaning in this case that there was no employer mandate at all with 49 full time employees, then it kicked in for all a company's employees when they hire the 50th. You don't need to take the course to see why that doesn't work.

The right way to do this is to impose a penalty on the 50th employee and subsequent employees only; therefore no cliff and if you need a 50th employee, the added cost is small so you'll probably go ahead and do it anyway. Once you get up to 60 or 70 or so, you'll say what the heck, might as well start offering insurance for everybody -- as most companies that size already do. Meanwhile you've paid a bit to help the subsidies for people buying individual insurance. Congress could fix that, of course, but they won't -- unless the Democrats take both chambers in 2014. The fate of humanity depends on that happening, so start working now.

Oh yeah, the fate of humanity. I'm sweltering as I write this, taking the day off from work and no AC at home. I wonder what will happen when all those folks who've fled the northern winters for the sunny paradise of the Southwest find the place uninhabitable?

Cure Schmure

No doubt you have encountered the hype about a purported cure for HIV infection. That would indeed be great news, but sadly, no. Here's an example of the selective and misleading coverage this is getting.

Two men who happened to develop some form of cancer (not specified in the public story) while also being HIV+ received the treatment called "bone marrow" transplant, continued to take antiretroviral medications throughout the procedure and recovery, and now appear to be free of HIV. They seem to have turned great misfortune into good fortune, but in reality, this is a big, fat, so what?

Here's the real deal. The procedure they underwent is more properly called an allogeneic hematopoeitic stem cell transplant (HSCT). Nowadays they don't actually transplant bone marrow, but rather the cells that reside in bone marrow which are the progenitors of blood cells. Doctors do this for a few different reasons. The most common is that the person has some form of leukemia -- abnormal proliferation of white blood cells, which is a kind of cancer. In this case, if chemotherapy doesn't work, the alternative is to destroy the person's HSCs with radiation or chemicals, and replace them with cells from a donor. Other reasons are lethal abnormalities of red blood cells -- aplastic anemia, and the procedure is increasingly being done for severe sickle cell disease.

The reason this appears to cure HIV is that the virus lives in white blood cells. Replace them all, and you eliminate it. It may also lurk in other reservoirs, but if so the new immune system gets to work on a very low presence of HIV infection, and is able to wipe it out.

That's all well and good but it does not mean that everybody living with HIV should now go and get one of these procedures. Alas, the cure risks being worse than the disease, because HIV can be controlled with drugs, but allogeneic HSCT creates a risk of what is called graft vs. host disease (GVHD). The new immune system was originally somebody else's, and it is likely to recognize the recipient as foreign, whereupon it starts destroying the person's tissues and organs. This is basically incurable and causes severe symptoms and a short life. In order to prevent it, you have to take immunosuppresive drugs which means that you have -- wait for it -- immunodeficiency. Which was your problem in the first place. In spite of this, some people get GVHD anyway. (And, I should have added originally, you might die while you're waiting for your new immune system to reconstitute. In fact you have about a 25% chance of that happening. It's a desperation move, not an ordinary treatment for anything.)

So whether a feasible cure for HIV/AIDS might somehow follow from this observation is unclear, but personally I don't see it. If there is a path from here to there, it's a long one. The bad news is that lots of people will see this overhyped story and get false hope, or believe that a cure exists which is being withheld, or offered only to the wealthy. I wish the hope were real, but not yet. Keep taking your pills.

Category Error

It seems there is a new conservative society trying to get established in graduate schools of "business, medicine and public policy," inspired by opposition to the affordable care act. They think the reason you don't read a lot about the wondrous powers of the Free Market™ to heal our health care system is because we're all socialist atheist commies.

No, actually the reason you don't read in Health Affairs all about the stuff they fervently believe in is not because academia is ruled by ideologues, it's because what they believe is not true, and the purpose of academic inquiry is to find the truth. Excerpt:

The Duke group’s guest speakers included Dr. Keith Smith, an Oklahoma City anesthesiologist whose surgical center lists the costs of its medical procedures online in a move toward price transparency. The practice only accepts private health insurance, not Medicaid or Medicare. . . .

The Benjamin Rush Society traces its roots to 2008, when Canadian activist Sally Pipes organized a Washington meeting with support from the Kansas City-based Ewing Marion Kauffman Foundation. Its credo: “the profession of medicine calls its practitioners to serve their patients rather than the government.” Conversely, they also support so-called “concierge medicine” in which those with more money pay for individualized care otherwise unavailable.

Now, personally, I have no problem with that. They can refuse to take insurance and only work for rich people if they want to. However, it does not follow that the Free Market™ therefor is the solution to our dysfunctional health care system because think about it Randroids: what happens to people who cannot afford to pay Dr. Keith Smith for an appendectomy when there isn't any Medicaid or Medicare?

Ridiculous.