American Exceptionalism, yet again

The UN Special Rapporteur on the promotion and protection of human rights and fundamental freedoms while counter-terrorism, Mr. Ben Emmerson, had this to say today:

The summary of the Feinstein report which was released this afternoon confirms what the international community has long believed - that there was a clear policy orchestrated at a high level within the Bush administration, which allowed to commit systematic crimes and gross violations of international human rights law. The identities of the perpetrators, and many other details, have been redacted in the published summary report but are known to the Select Committee and to those who provided the Committee with information on the programme.

It is now time to take action. The individuals responsible for the criminal conspiracy revealed in today’s report must be brought to justice, and must face criminal penalties commensurate with the gravity of their crimes. The fact that the policies revealed in this report were authorised at a high level within the US Government provides no excuse whatsoever. Indeed, it reinforces the need for criminal accountability.

International law prohibits the granting of immunities to public officials who have engaged in acts of torture. This applies not only to the actual perpetrators but also to those senior officials within the US Government who devised, planned and authorised these crimes.

As a matter of international law, the US is legally obliged to bring those responsible to justice. The UN Convention Against Torture and the UN Convention on Enforced Disappearances require States to prosecute acts of torture and enforced disappearance where there is sufficient evidence to provide a reasonable prospect of conviction. States are not free to maintain or permit impunity for these grave crimes.

It is no defence for a public official to claim that they were acting on superior orders. CIA officers who physically committed acts of torture therefore bear individual criminal responsibility for their conduct, and cannot hide behind the authorisation they were given by their superiors.

However, the heaviest penalties should be reserved for those most seriously implicated in the planning and purported authorisation of these crimes. Former Bush Administration officials who have admitted their involvement in the programme should also face criminal prosecution for their acts.

President Obama made it clear more than five years ago that the US Government recognises the use of waterboarding as torture. There is therefore no excuse for shielding the perpetrators from justice any longer. The US Attorney General is under a legal duty to bring criminal charges against those responsible.

Torture is a crime of universal jurisdiction. The perpetrators may be prosecuted by any other country they may travel to. However, the primary responsibility for bringing them to justice rests with the US Department of Justice and the Attorney General.”

Is that clear?  The acts described in the report are depraved beyond measure. The United States has lost all moral authority, and the only way to restore it is to prosecute the sadistic psychopaths who perpetrated these atrocities. That includes Richard B. Cheney.
 

The summary of the Feinstein report which was released this afternoon confirms what the international community has long believed - that there was a clear policy orchestrated at a high level within the Bush administration, which allowed to commit systematic crimes and gross violations of international human rights law.
The identities of the perpetrators, and many other details, have been redacted in the published summary report but are known to the Select Committee and to those who provided the Committee with information on the programme.
It is now time to take action. The individuals responsible for the criminal conspiracy revealed in today’s report must be brought to justice, and must face criminal penalties commensurate with the gravity of their crimes.
The fact that the policies revealed in this report were authorised at a high level within the US Government provides no excuse whatsoever. Indeed, it reinforces the need for criminal accountability.
International law prohibits the granting of immunities to public officials who have engaged in acts of torture. This applies not only to the actual perpetrators but also to those senior officials within the US Government who devised, planned and authorised these crimes.
As a matter of international law, the US is legally obliged to bring those responsible to justice. The UN Convention Against Torture and the UN Convention on Enforced Disappearances require States to prosecute acts of torture and enforced disappearance where there is sufficient evidence to provide a reasonable prospect of conviction. States are not free to maintain or permit impunity for these grave crimes.
It is no defence for a public official to claim that they were acting on superior orders. CIA officers who physically committed acts of torture therefore bear individual criminal responsibility for their conduct, and cannot hide behind the authorisation they were given by their superiors.
However, the heaviest penalties should be reserved for those most seriously implicated in the planning and purported authorisation of these crimes. Former Bush Administration officials who have admitted their involvement in the programme should also face criminal prosecution for their acts.
President Obama made it clear more than five years ago that the US Government recognises the use of waterboarding as torture. There is therefore no excuse for shielding the perpetrators from justice any longer. The US Attorney General is under a legal duty to bring criminal charges against those responsible.

Torture is a crime of universal jurisdiction. The perpetrators may be prosecuted by any other country they may travel to. However, the primary responsibility for bringing them to justice rests with the US Department of Justice and the Attorney General.”
- See more at: http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=15397&LangID=E#sthash.8YgrwEKt.dpuf

The summary of the Feinstein report which was released this afternoon confirms what the international community has long believed - that there was a clear policy orchestrated at a high level within the Bush administration, which allowed to commit systematic crimes and gross violations of international human rights law.
The identities of the perpetrators, and many other details, have been redacted in the published summary report but are known to the Select Committee and to those who provided the Committee with information on the programme.
It is now time to take action. The individuals responsible for the criminal conspiracy revealed in today’s report must be brought to justice, and must face criminal penalties commensurate with the gravity of their crimes.
The fact that the policies revealed in this report were authorised at a high level within the US Government provides no excuse whatsoever. Indeed, it reinforces the need for criminal accountability.
International law prohibits the granting of immunities to public officials who have engaged in acts of torture. This applies not only to the actual perpetrators but also to those senior officials within the US Government who devised, planned and authorised these crimes.
As a matter of international law, the US is legally obliged to bring those responsible to justice. The UN Convention Against Torture and the UN Convention on Enforced Disappearances require States to prosecute acts of torture and enforced disappearance where there is sufficient evidence to provide a reasonable prospect of conviction. States are not free to maintain or permit impunity for these grave crimes.
It is no defence for a public official to claim that they were acting on superior orders. CIA officers who physically committed acts of torture therefore bear individual criminal responsibility for their conduct, and cannot hide behind the authorisation they were given by their superiors.
However, the heaviest penalties should be reserved for those most seriously implicated in the planning and purported authorisation of these crimes. Former Bush Administration officials who have admitted their involvement in the programme should also face criminal prosecution for their acts.
President Obama made it clear more than five years ago that the US Government recognises the use of waterboarding as torture. There is therefore no excuse for shielding the perpetrators from justice any longer. The US Attorney General is under a legal duty to bring criminal charges against those responsible.

Torture is a crime of universal jurisdiction. The perpetrators may be prosecuted by any other country they may travel to. However, the primary responsibility for bringing them to justice rests with the US Department of Justice and the Attorney General.”
- See more at: http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=15397&LangID=E#sthash.8YgrwEKt.dpuf

From the weirdness file

I should probably dig up my weirdness file and post a few bits from it. For now, here's a new one.

I am doing some minor research on workflows in primary care clinics. One of the sites we're looking at is affiliated with a hospital, which has various draconian policies regarding people who are going to be on site and potentially having patient contact. I was required to get a badge, which meant answering a ridiculous quiz, getting a TB test, and antibody titers for measles, mumps and chicken pox. Also passing a criminal background check. I finally got my badge, which has a photo on the front. Then the security guard responsible for embadgement assembled it with two attached cards. One listed the emergency codes. (This is standard hospital speak. For example, Code Amber is child abduction, Code Blue a medical emergency, and so on.)

The weirdness was the card in back. It's titled "Off-Sites Bomb threat Checklist." It's a little form you're supposed to fill out if you answer the phone. (Not sure what "off-sites" means, sorry.) At the top you fill in call-taker's name, date, time, and phone # where the call was received. Then it lists questions to ask and has little spaces for the answers ("Exact words if possible.")

Where is it located? Building? Area?
When will it go off?
Time________ Time remaining
What kind of bomb is it?
What does it look like?
Is there more than one bomb?
What will cause it to explode?
Did you place the bomb?
Why?
Where are you calling from?
What is your address?
What is your name?

Okaaaay. I'm sure most bomb threateners are more than happy to have that conversation and answer all your questions . . . 

Journamalism

Most of you are probably too young to remember the Duke lacrosse team brouhaha, and if you do, you probably don't remember that I steered clear of it here, but I did. It didn't smell right to me and I figured I'd wait and see what happened rather than seize upon it as a parable of all that is wrong with society. The sad part is that frat boys often are racist and sexist and rapes do happen in frat houses. That's why it's always dangerous to seize on a cause celebre to make a wider point about society. Viz also Tawana Brawley.

So, I steered clear of Jackie and UVA, for the same reason. There was nothing entirely implausible about the Rolling Stone story, but quite a bit about it was odd and the lack of corroboration or any journalistic enterprise was unsettling. Where things stand now, we know that some details were wrong -- the date and which frat house it was we can excuse, could be misremembered. However, specifically identifying a real individual as the ringleader who could not have been is really troubling. Something bad evidently happened to Jackie but whatever it was, it was not the story she told.

However, that is basically irrelevant to anyone but the people directly involved. Rapes do happen on college campuses, they do happen in frat houses, and colleges have tended to sweep it under the rug. This was true before the Rolling Stone story, and it is just as true afterwards. For some reason the zeitgeist needed a specific, particularly horrific individual story before it could wake up to this. That should not have been necessary in the first place, and I sincerely hope this debacle won't set back the momentum that was already building.

In case you need your bubble burst

Ed Brayton, at FreeThought Blogs, constantly trawls both the near shores and farthest reaches of Wingnutistan, and his daily catch is unfailingly appalling. Our nation is fifty percent lunatic, it seems. Check it out if you dare.

It's not a bookmark for me because I just can't take it regularly, but if your blood pressure should ever drop too low it's a useful remedy.

The difference between men and women

Should you be among the lost souls who watch television, you will have seen advertisements for Wendy's grease pits fine dining restaurants.

If you are with me so far, you will recall that founder Dave Thomas used to be the commercial spokesperson. He'd appear in an apron avuncularly purveying his ground lips and anuses of played out milk cows, or whatever is in those gray squares. (I make no actual claims, having no actual knowledge.)

To put it kindly, Dave was no poster boy for the healthful properties of his no-doubt yummy products. He was one of those guys who makes you wonder how a belt that goes around the equator can keep his pants up. (And it is a mystery.)

So, tragically, Dave died in at age 69. For a while, recently, his daughter Wendy, after whom the business was named (it's actually a nickname, her real name is Melinda) took Dave's place as spokesperson. Alas, she takes after her father. Apparently the marketing geniuses behind the campaign decided that just wouldn't work. In Wendy's place they hired a cute, anorexic young woman and put a scarlet wig on her.

Connect your own dots.  

Nor all your piety and wit . . .

 . . . can call it back to cancel out one line,
nor all your tears wash out one word of it.

There seems to be a bit of a blogostorm going on right now over whether it was a good idea to pass the Affordable Care Act or not, either because a) we should have passed single payer instead (viz Scott Lemieux) or the president should have "focused" on the economy instead (viz. Krugzilla.)

Yeah single payer would have been nice, but the fact is, the ACA is working better than expected. The Urban Institute tells us that from the beginning of 2013 through September of this year, the number of people in the U.S. without health insurance went down by 10.6 million, and the percentage uninsured went down from 17.7% to 12.3% -- almost 1/3. Of course the improvement was bigger in the states that accepted the Medicaid expansion. And CMS is about to announce (at 4:00 pm today) that the growth in health care spending remains low, and was in fact lower last year than in 2012.

So continued Republican efforts to demonize the bill and take health insurance away from people are just evil. However, the corporate media are going along with the gag, and the bill remains unpopular, even though people are overwhelmingly in favor of everything that's in it. What a world.

Update: Here's the link to the CMS report on health care costs, no longer growing faster than GDP. This, for now, means the crisis people in the health care policy field have been panicking over for 15 years isn't happening after all. (Ditto for the "out of control" federal budget deficit, these two facts being more or less the same.)

The end of HIV?

I don't know why we need to have single days when we're supposed to think about stuff we probably should be thinking about regularly (e.g., why do we have National Pickle Week when pickles matter all the time?) but for what it's worth, today is World AIDS Day.

The One Campaign (Bono's charity) says there's good news: we're at a "tipping point" in that the number of people newly receiving HIV treatment now exceeds the number of new infections. Furthermore, the global incidence of HIV has fallen by 40% since 2001. This is no doubt for a combination of reasons, including better awareness and changes in people's behavior, but one reason is that more people are in treatment. People who take their medications regularly and have suppressed viral loads are much less infectious, maybe even not at all.

But, I don't think this is really a tipping point. There are several problems with that rather glib assertion. The first is that just because people are enrolled in treatment and have a prescription doesn't necessarily mean that they are going to remain in treatment, and remain adherent to their medications. It is definitely not the case that the number of people with unsuppressed HIV viral loads is decreasing. The number of people enrolled in treatment would need to greatly exceed new infections, and adherence to treatment would need to be better, in order for that to happen.

The second problem is that the expansion of treatment may not be sustainable. The wealthy countries are reducing their financing for HIV treatment in poor countries, and the poor countries still can't afford it. Where there is civil conflict, as in some of the areas of Africa most afflicted, treatment rates may well decline. And, since there are more and more HIV infected people alive, the number of people we need to treat is still growing, even as resources are more constrained.

Finally, we are never going to eradicate HIV by treating people. Some people are always going to be out there undiagnosed for a while, and infecting others. The only likely way to eradicate the disease is to have a highly effective vaccine, and that still isn't in sight. Possibly a cure could do it eventually, in principle, but we can cure syphilis and  gonorrhea and they're still with us.

Alas, HIV is just part of our world now. It isn't going away.

What Joe Romm says . . .

I'll have a real post of my own anon, but meanwhile you are required to read this essay by Joe Romm.

Collectively, we are in deep, deep denial. But the hard truth is that this civilization that we built on fossil fuel is terminal. It won't exist much longer. We can plan for what comes after and maybe make it okay, or we can just go on blindly sailing toward disaster. The time to choose is now.

Take your @#$%^ pills!

In case you don't know what the Cochrane Collaborative is, it's an organization that compiles systematic reviews of medical interventions, conducted according to rigorous standards. There's a new one on interventions to improve medication adherence, and it isn't pretty.

A commonly bandied about round number is that about half of prescribed medication doses aren't taken. Of course the number varies according to the kind of medication and the circumstances, but there's no denying that people often don't take their pills as prescribed. Sometimes this matters a lot, sometimes a little, but even people with a lot to lose -- such as people with HIV, or glaucoma -- don't all take their medications regularly.

Well, the Cochrane reviewers looked at 182 randomized controlled trials and found only 7 high quality trials that showed any beneficial effect on medical outcomes and even those were pretty small. And the interventions were complex and expensive, pretty close to having a nurse move in with you. I've spent years trying to figure out why this is. There are a lot of different reasons but here are a few of the most important.

1) If I take the pills, that means I have the disease. And I don't want to have the disease. This would seem to reverse cause and effect but it doesn't really. There are two meanings of "having the disease": The doctor's meaning, which is a biological construct; and the patient's meaning, which is a psychosocial construct.

2) There are other things in life that are higher priorities. Swallowing pills isn't particularly hard, but constantly dealing with refills can be a hassle, co-pays matter to many people, and it's easier just to convince yourself that it isn't really necessary.

3) The person doesn't believe the doctor's theory about what's good for him or her. Not extremely common but totally dispositive when it happens. The many well-publicized instances of drug company malfeasance make this actually not entirely ridiculous. Sometimes it's even true.

4) People just don't like taking pills, they can't even say why.

Any other reasons of your own?

The new me

No, the post is not about YT. I'll get to it in a moment. In passing, I don't really have anything to add about current events except that it is obviously the case that cops in the U.S. have a license to murder Black men. No possible circumstance would seem to result in prosecution.

That out of the way, I'm working on a paper now about people living with HIV. I intended to find out how much biomedical understanding they had of the virus, its pathophysiology, and treatment, but all that turned out not to matter very much to them. When I asked people, "If you had to explain to somebody what HIV is, what did you say," I'd get a lot of answers about how it is transmitted. Other responses included "It means I made a mistake," "It's not a death sentence," "It's a disease like any other, you can learn to live with it," and so on.

For most people, it took a while after they got the diagnosis for them to incorporate the new reality into their self-concept. A few people never did. Some had very negative reactions at first: attempting suicide, drinking heavily. But eventually, they sorted into people who turned it into group A -- People who responded posivitely; they felt good because they were taking care of themselves, being a role model for young people, had grown in wisdom and goodness through the contemplation of their mortality: and Group B: they remained in guilt, or anger, or despair. And it was the latter group who were less likely to be taking the pills on regularly and on schedule.

It isn't very deep wisdom that we need to make lemonade out of life's lemons, I suppose. But I wonder how well aware physicians are of this very basic truth about illness and self-care. What we need is the magic pixie dust we can throw on the people and transform them into the overcomers.

Mired in the quag

Two more U.S. troops were killed today in Afghanistan, which I suppose we're supposed to care about more than we care about the dozens of Afghans who die in violence every day. It's costing us $10.17 million an hour, more than 3/4 of a trillion dollars so far. And now the Kenyan Muslim Socialist Atheist secret son of Malolm X in the White House has declared that the U.S. combat role in Afghanistan will continue in 2015.

Balance this against our actual interests in Afghanistan:

Zero

The only conceivable national interest the United States has in who governs Afghanistan is the illicit opium industry. And our $760 billion has not been well spent in that regard, since opium production in Afghanistan is now at an all time high. The last time opium production was effectively stopped in Afghanistan was when the Taliban ruled, before the U.S. invaded.

So what exactly the hell are we doing there? For $10.17 million an hour, I want more than zero.

Riiiiiiiiiiiiiggggghhhht . . .

Everybody is talking about Cosby, so what do I have to add? Not much, so here's 2 cents.

Maybe this is weird or maybe it's typical, but I don't recall ever hearing about these allegations until this week. Evidently they were reported earlier in a couple of places, but all of a sudden got major attention, purportedly due to a routine by a little-known comic that did the viral thing. Whether this heralds a New World Information Order seems to be one of the questions of the day.

I don't know about that, but I do think the zeitgeist is changing. Like the cultural landslide that is burying homophobia, we are suddenly seeing a massive change in prevailing norms about sexual assault. (Struggling mightily to keep my metaphor unmixed) the boulders started rolling in the military, rolled onto college campuses, and now are knocking down the privileges of the famous and iconic.

Is it a reach to say that we are finally seeing more payoff from the long, slow but very real expansion of the number of women in influential roles? Female senators had a lot of to do with the focus on the military, as do female faculty and administrators in universities, and now women in the news and entertainment industries. That's not all the credit obviously -- lots of men are on the right side. But it helped to get us to this tipping point.

As for the question of Cosby's innocence until proven guilty, come on. There will never be a trial but we're allowed to use our common sense to draw reasonable inferences. At the same time, this has no bearing on the soundness of his Booker T. Washington politics, which continue to stand or fall on the merits; nor on the value of his cultural contributions. Wagner's music is what it is, regardless of his antisemitism, and Pablo Picasso is widely thought to have been an asshole. (That's the technical term.)

Still, going forward, no-one will be able to suspend disbelief in the Cosby persona or find him amusing. (He was already pretty much anachronistic anyway, so small loss.) When the reality of the actor behind the mask is that overpowering, the act is bound to fail. So he is now gone from public life, and he'll just wither away.

What I'm about to say

I'm appearing on a panel tonight at our great university, entitled "Doctors reading race: how conceptions of race shape medical care." Since you probably can't attend, here's the sneak preview.

When I first began to study this issue, 15 or 20 years ago, there were quite a few influential studies that identified disparities in physicians' treatment decisions based on patients' race or ethnicity. For example, Latino patients with long bone fractures were less likely to be prescribed opioids in emergency departments. Doctors were less likely to take a sexual history from adolescent white adolescent girls presenting with abdominal pain than from Black and Latino girls. Black veterans in VA hospitals who'd had myocardial infarctions were less likely to undergo revascularization. (Interestingly, they were also less likely to die. This led the authors to propose that "process of care is a more specific indicator of quality than is outcome. Ha ha.) There were others.

Back then we had all sorts of calls for "cultural competence" in health care, and people sprang up who offered cultural competency training, generally for a fee. In its earliest incarnation this mostly consisted of people who would proffer interesting tidbits from medical anthropology about exotic health beliefs. They'd tell you that Puerto Ricans believe in the Evil Eye and rural African Americans are into rootwork and mojo, that sort of thing. Absolutely ridiculous. It's like teaching doctors that patients from California believe in the healing power of crystals. Maybe a few of them do but that's not what you need to be culturally competent.

So then we got a better class of cultural competency trainers who claimed, more plausibly, that the first step toward becoming culturally competent is to have insight into your own culture. What are your preconceptions and how do you understand the nature and meaning of health and illness, and medical care? The next step is to learn how to not make assumptions about the people you encounter, but rather to learn from them. Ask them! What do you want to know? What are you comfortable and not comfortable telling me about yourself? How do you understand your condition and treatment? How do you want us to relate to each other? Everybody is unique, your job is to understand each person.

This all sounds great but I haven't seen any evidence that this sort of intervention produces better results or more satisfied patients, though I don't suppose it can hurt. So what have I found in my own research?

First of all, using my structured methods for analyzing clinical encounters, we've noticed a couple of things. Black patients, on average, talk less than Latino or white non-Hispanic patients, but there doctors talk just as much. This has been observed by others, in a couple of different settings. The result is that the so-called verbal dominance ratio -- the proportion of doctor to patient talk -- is higher for Black patients. Of course I have no idea why. There are also some other indications of less rapport or patient engagement, including fewer so-called expressive utterances by Black patients -- those are expressions of desires, goals, feelings, intentions -- and less joking with Latino patients. But again, I don't know why this happens or what significance it has.

What I have observed is that where things tend to go wrong is doctors not understanding patients' lifeworlds. The fact is that most medical encounters are essentially cross-cultural. Physicians tend to start off as higher socio-economic status than most patients before they get to medical school. Being a physician is, in fact, often a hereditary condition in itself. Then they go through a socialization process in which they internalize a particular way of understanding human beings and the nature of health and disease. Then they ultimately go on to live in pleasant neighborhoods and have nice things.

This makes it hard enough to understand the experience, perceptions and needs of the typical patient who comes before them; But more social distance, be it of class, ethnicity, language and culture, just compounds the problem. The physician may make stereotypical assumptions about people, and may make other assumptions based on assuming that the patient or the patient's situation is more similar to the physicians than the reality. I have many fascinating examples but I'm only supposed to talk for 10 minutes so maybe I'll get to some of them in the Q&A.

So I'll just leave off with this. When I worked for the New England Coalition for Health Equity, I'd go around to various meetings and conferences where one way or another the idea of cultural competency was promoted. I can't tell you how many times I heard doctors say, "I don't need any training, I don't have any issue with cultural competency. I treat everybody the same." I'll leave it to you to ponder if that's a good answer.

Real Science

A commenter on my recent post on chronic pain calls attention to Dr. John Sarno. You can read a summary and a critique of Dr. Sarno's ideas here. Superficially, they resemble the current consensus that chronic pain with no corresponding physical lesion is generated in the brain. But there's a big difference.

Sarno has a psychodynamic explanation. He thinks that suppressed anger is translated into low back pain. The linked essay by Todd Hargrove offers good arguments why that doesn't make sense. But I want to use this example as a jumping off point for a broader discussion.

It is very common for someone to get an idea that perhaps seems plausible (sometimes it does not, even superficially, viz homeopathy), and then become very attached to it. Sometimes these people have strong scientific credentials. Nobelist Linus Pauling, with his supposed discovery that large doses of vitamin C are a panacea, is an excellent example. These people may gain large followings. But .. .

There is no credible scientific evidence for the idea. The originator and his (or less often her) followers are convinced that it works, but we never get past anecdotes and testimonials. Many precincts of the Internet devote substantial resources to debunking such claims. I recommend Quackwatch, which has a lot of fun stuff to read, and Science Based Medicine, a blog by rotating authors that reliably puts up a new essay every day.

I won't trouble to repeat here the extensive resources you can get to via those links to understand how to recognize pseudo-science, and the harm it does. But I do want to talk briefly about the whole problem of motivated reasoning.

The originators of quackery probably actually believe in it, most of the time. They aren't consciously lying. But they do, of course, have a lot at stake: their self-image as breakthrough thinkers, the gratitude and loyalty of their devotees, quite likely money, reputation and fame. So their thinking becomes dedicated to strengthening the belief, and the whole world is seen through the lens of confirmation bias.

Unfortunately the whole world largely works this way. Social psychologists have found that showing true believers evidence that contradicts their beliefs just strengthens them. Sen. Inhofe says he was at first convinced by the argument that burning fossil fuels is changing the climate but then he found out how much it would cost to do something about it. So he changed his belief. Creationists don't want to give up the myth of original sin and redemption through the sacrifice of Christ, which makes no sense to begin with but they make their living from the collection plate or the TV ministry. I could go on.

So why am I so sure my own beliefs are generally correct and rational? I suppose I can't be entirely, but I am aware of the problems of confirmation bias and motivated reasoning so I make a serious effort to continually re-examine my ideas and to insist on standards of evidence for my understanding of the world. The evidence that I do this is that I have frequently changed my opinion about matters large and small.

I grew up going to church and Sunday school and believing in a high church protestant version of Christianity. Once I was old enough to think for myself, I concluded it was bunk. I was never a Communist but as a youth I read romanticized accounts of the Chinese revolution and I thought that on balance it was a good thing. I had no appreciation of the depravity of Maoist tyranny but I do now. At first I wasn't at all convinced that the official version of the 9/11 attacks was accurate but I sorted through the evidence and the arguments and ultimately concluded that it is, essentially. (I think it likely that the government has deliberately covered up involvement by Saudi royalty, for reasons of geopolitics. I also find it plausible that the Bush administration security establishment expected something of the kind to happen, without having specific information, and had no interest in preventing it. But that's only a suspicion, I certainly can't assert it.)

In my professional work, I used to think that average people could be empowered to have a mechanistic understanding of their health and treatments that more or less corresponded to the ways their doctors think but now I believe that is unrealistic for most people. What I am striving for now is to understand the nature of the information people really do need and can use to make good decisions on behalf of their own health and well-being, but I think it has a small component of science and a bigger component of other kinds of meanings.

I may well cling to some ideas due to confirmation bias, but I do recommend this exercise to you. Try to take an inventory of important ways in which you have changed your mind over the years. If you can't come up with very many, maybe you should undertake a critical assessment of one or more of your cherished beliefs and see what happens. Can you find reason to doubt? Make a serious effort to talk yourself out of what you think now. Go down that road and see where it leads. You might well decide you were right in the first place, but at least you will have put it to the test.

Things that aren't true

Two worthwhile columns in the NYT today, one by  the always reliable PK, the other by Steven Rattner. Let me put two and two together.

Krugman points out that contrary to Republican freakout, the Administration responded competently and effectively to the ebola outbreak, the Affordable Care Act is working just fine, the Department of Energy loan program that lost money on the Solyndra investment has in fact made an overall profit of $5 billion, and the deficit has in fact fallen sharply. In other words, government can indeed do things well.

Rattner is despairing, as economic inequality in the U.S. grows worse, and the incomes of people near the bottom are actually falling. But, it's worse here than it is in Europe. We have the lowest tax rates of the OECD countries, and the least generous social programs. Republicans constant screaming that our taxes are too high is just nonsense. And in fact, higher taxes are not associated with lower rates of growth. That's pretty simple: government spends that tax money, creating demand directly, and by giving people salaries that they in turn spend; meanwhile, wealthy people spend a much smaller portion of their income than do poor people. And they don't create jobs either. They won't invest in job creation unless they can sell stuff, and they can't do that if people don't have the money to buy it. Also, government makes essential investments that the private sector never will, because of the problems of free riders and common goods.

But the corporate media, not to mention Democratic politicians, don't seem to understand any of this. Republican claims that tax cuts stimulate the economy go unchallenged. Yes, the wrong kinds of taxes at the wrong time slow down the economy, but right now taxing the rich to invest in the present and the future would be good for economic growth, and particularly sustainable growth. Mass transit, basic research into renewable energy and conservation, creating a smart power grid, educating the children who will make our future, guaranteeing affordable health care for all -- these are all things government can and must be doing.  And anybody who says otherwise is a lunatic. Of course, they can always move to Kansas.

Just Pain

I'm working up a couple of research proposals having to do with chronic pain. This subject is actually challenging clinically and philosophically, which means it also very challenging for physician-patient communication and relationships.

There used to be great controversy over the very existence of fibromyalgia, or the usefulness of the label. It just meant people with unexplained, widespread pain. People also would present with unexplained localized pain, such as low back pain or temporofacial pain. They'd get MRIs and what not and doctors could find no physiological explanation. Many people viewed these situations as having a psychodynamic origin, in other words the person was in fact obtaining some sort of reward from being sick or disabled, or acting out guilt or self-loathing, or just generally nuts.

Now we understand that people with otherwise unexplainable chronic pain are experiencing what's called Central Sensitization Syndrome (CSS). Pain signals (there's a fancy word for them, "nociceptive" which the blogger spell checker doesn't even recognize) do originate at the site where pain is perceived, but the sensation of pain is constructed in the brain, with maybe some intermediate processing in the spinal chord. The brain can also send signals back down to dampen nociception.

So what happens is that the systems in the brain that signal pain to your conscious awareness become hyperactive. If you close your eyes and just pay attention to your body right now, you will notice that you feel a bit of discomfort here and there. Maybe you have slightly achy joints, or your tuchy is a little uncomfortable on the chair, you have an itch, whatever. But it's minor and you weren't even paying attention to it. So, it shouldn't be hard to imagine that the circuits that process these sensations could get out of whack and continually scream "Pain!" at your frontal cortex.

Now that we have functional Magnetic Resonance Imaging, this has been confirmed. Researchers can see the circuits light up excessively in people with CSS. That doesn't help us know what to do about it, but at least we have an explanation. We also don't know why it happens. Often, people have a real injury that causes explainable acute pain, but after the injury heals, the pain persists. Somehow the circuit gets stuck in the open position, as it were. CSS also seems to be associated frequently with severe psychological trauma. But we don't have a good mechanistic explanation.

That said, if you tell people with CSS that there is in fact nothing wrong with the places where they feel pain, and the problem is in their brain, they generally don't like that answer. They hear you saying that the pain isn't real, that they are crazy, that they're faking it, that you aren't respecting their very real suffering which they perceive to be happening in their back and their joints or wherever.

Drugs don't usually help much. Long-term opioid therapy is generally a bad idea, I shouldn't have to tell you why. Anti-depressants and drugs that are used to treat seizures or neuropathy (pain caused by damage to peripheral nerves) are often prescribed, but only a small percentage of people really respond to them, and they have side effects. NSAIDs help only a little.

What people with CSS should do is basically not to let it get them down. Do what they call graded exercise -- a little bit more than is easy each day. Keep moving, keep up with your activities of daily living, have hope for the future, and really believe that there is nothing wrong with the parts of you that are hurting. It takes a long time, but often symptoms do ameliorate and even resolve. But if the pain beats you and you retreat from life and social contact, and stop moving, they won't.

So, how doctors and patients can communicate constructively in this situation, and form a therapeutic alliance that really works, is a big problem. Hopefully I'll be able to contribute.

The American Nation

An interesting essay by Michael Konczal in Boston Review discussing three books, by Nicholas Parillo, Dana Goldstein and Radley Balko, and tying them all together.

Per Parillo, I never learned in my American history courses -- and I did take quite a bit -- that until the 19th Century, judges and government clerks and prosecutors and so on did not receive salaries. If you wanted your case heard, you had to pay the judge -- they worked on commission. Prosecutors were paid by the conviction. And if you wanted your homestead application or your deed processed, you had to pay the clerk, and he (always) could set his price. Really. Seems bizarre, but there was no idea of public service as a right of citizenship -- it was, by and large, for sale.

Per Goldstein, of course we didn't have universal public education for most of the country's history either, but as it began to come in, teachers had very low status. They gained more eventually, but now they are losing it again.

Balko discusses the militarization of the police, and the increasingly adversarial relationship between police and public, in recent decades. This kind of gets wedged into Knoczal's argument, because what he is really looking for are the civil forfeiture programs whereby police get to grab all kinds of cool stuff when they bust people, and the privatization of jails. We are also returning to the privatization of education, and of course rich people are buying judges and politicians.

The grand picture is that we are losing the consensus belief in national community that grew up in the 20th Century -- that all citizens have a stake in government and that government exists for the good of the people. Instead, whatever benefits government may offer are for sale to those who can afford them, while many services we used to depend on government to provide are no longer public goods at all. You get what you can pay for.

One would think this can only go so far before the civil order disintegrates. We shall see.

On denialism

It's a very frustrating problem. As the old saying goes, "Don't confuse me with the facts, my mind's made up," and that is indeed how most people work most of the time.

If you don't already know about it, and you're into deep thoughts, you might want to bookmark Massimo Pigliucci's webzine Scientia Salon. He discusses a recent conference on denialism at Clark University here. We are currently in a very dangerous historical moment (my point, not his) in which a basic membership requirement for one of the two major parties in the world's most powerful nation is to believe a whole lot of important stuff that is not true.

The trap is that facts, reason, critical thinking -- none of these are of any use. In fact, research shows that when confronted with contrary facts, true believers just did in deeper.. An endless parade of experts can testify in front of James Inhofe's committee presenting every possible proof that humans are changing the planet's climate and that the consequences will be catastrophic, and the denial will just grow deeper.

So what is to be done? Obviously if I had the magic bullet we wouldn't be in this mess, but I will say that the key to the problem is more cultural than it is intellectual. We have to make saving the planet something the cool kids do, in essence. I largely credit the entertainment industry with the astonishing cultural transformation regarding attitudes toward homosexuality. The only people who are really going to establish the truths of evolution, environmental threats, macroeconomics (no, cutting rich people's taxes does not create jobs), and the fallacy of "free markets" are movie and TV producers, fiction writers, comedians, celebrity chefs, and such. Scientists should keep saying what they believe and keep answering questions, but the only ones who are going to accomplish very much are also entertainers -- Neil DeGrasse Tyson and his ilk. He pays as much attention to his costumes and his hairdo as he does to his words, and well he should.

 

What happens if the Supreme Court loses legitimacy?

It appears well within the realm of plausibility that five justices of the Supreme Court have already decided to trash the Affordable Care Act by means of a preposterous legal maneuver. Paul Krugman discusses it here, and attorney Neil Seigel says pretty much the same thing here. So you have the perspectives of an economist, and a lawyer.

They, and many other sober observers, find the reasoning of the DC Circuit panel in Halbig v. King absurd. It will be reversed by the full court, and it has been resoundingly rejected by all other federal courts. The Supreme Court does not need to hear the case. Why have they chosen to do so?

As all our readers presumably know, the ACA has three main components, all of which are essential for it to work. It requires insurance companies to cover everybody for the same price, with an adjustment for age, regardless of their current or former state of health. In other words, you can't be denied coverage or charged a fortune because of pre-existing conditions. (That's called guaranteed issue and community rating, BTW.) However, if you do that, there's a danger that people won't bother buying insurance until they get sick. You need those healthy people in the pool to keep it affordable for everybody. Hence the individual mandate. Again, however, not everybody can afford insurance, so you have subsidies for moderate income people. (We'll leave the Medicaid expansion aside for now.)

The literal language of the ACA says the subsidies are available to people who buy insurance through "exchanges established by the state." But Republican governors refused to establish exchanges in many states, so the federal government stepped in on their behalf. Elsewhere in the ACA this is clearly intended and the federally run exchanges are fully the equivalent of state-run exchanges. It's just slightly ambiguous language, but the intent of the statute is clear. Yet Halbig claims that people who get insurance through federally-run exchanges aren't eligible for the subsidies.

Krugman and Seigel both state, quite boldly, in their own ways, that if the court buys this absurdity it will prove that conservative jurisprudence is not about upholding the law, or any theory of law; it is purely political, adopting any form of sophistry in order to further the conservative political movement and the interests of the Republican party. That millions of people will lose their access to health care, and many of them will die, would apparently mean nothing to Scalia and Alito.

But what happens to the American polity if half of us are forced to conclude that the Supreme Court is a fundamentally illegitimate institution? I hope John Roberts is thinking about that.

Less, in this case, is a whole lot more

This study in NEJM has actually gotten a lot of attention, which I actually didn't expect when I decided to blog about it. (I believe it's behind the paywall but at least you can read the abstract.)

In a nutshell, the incidence of thyroid cancer in South Korea has increased 15 times since the 1990s. Is it radiation? Water or air pollution? A plot by the north? Nope. It's an epidemic of overdiagnosis. The death rate from thyroid cancer hasn't gone up even a tiny little tick. What's happening is that the country offers free screening for other cancers -- cervical, colon, breast, liver -- and they'll throw in thyroid for 35 bucks. So people go for it. They find these tiny little tumors that were never going to cause trouble, remove the thyroid, and the people have to go on pills for the rest of their lives. They may suffer other complications. It turns out that about 1/3 of people die with these "cancers" without even knowing it. All of the increase -- 100% -- is overdiagnosis resulting in iatrogenic harm and wasted money.

This is appalling but it's happening in the U.S. too, to a lesser extent. We don't do screening but people sometimes happen to have ultrasounds or CT scans that include the neck and these meaningless phenomena are discovered. So you're told you have "cancer" and it's all bad from there on. As I have discussed before, something very similar happens with prostate "cancer" but the appallingness is less extreme because prostate cancers are somewhat more likely to cause trouble.

I do have one new point to make based on this atrocity. Doctors are always discovering non-existent diseases that need treatment. Sometimes the people have actual symptoms but the putative cause is not really there. Chronic low back pain is an example. A couple of decades ago the Agency for Healthcare Policy and Research reported that surgery commonly performed for chronic low back pain was useless. Orthopedic surgeons persuaded congress to eliminate the agency. (It has since been restored as the Agency for Healthcare Research and Quality.) This surgery is still performed, though less often than before.

There are many other examples but I won't belabor the point. When the doctors went on strike in Saskatchewan to protest single payer health care in 1962, the death rate went down. Just keep that in mind.

Democracy

What can be very hard to see from the perch of someone with graduate training in public policy and a steady diet of journals of politics and public policy is that the great majority of people have a very limited grasp of public policy, and really for the most part don't understand how government affects their lives at all. Most Americans believe that the greatest share of the federal budget goes to foreign aid and "welfare," in which they do not include Medicare of Social Security. They think their taxes are too high even though their government services aren't good enough. They rationalize that because they think most of the money is either wasted or given to moochers. They are possessed of irrational fears while living in deep denial of real risks and problems.

These are the people who the Koch brothers are wooing with their billions in advertising. It's not that people actually want what Republicans want to give them. But if we are to do anything about this, we need more politicians who will tell the truth. The strategy of running away from president Obama instead of defending the achievements of the past six years was idiotic. If you pretend to be a Republican, there is no reason why people won't just vote for the real thing.

A BIG idea

So, we have a problem: technology is increasingly replacing labor. George Dvorsky has a wide-ranging discussion of the problem, just so you know I'm not just making this up. As he writes,

Another prominent thinker who has given this considerable thought is James Hughes, a sociologist from Trinity College in Connecticut. "We are now entering the beginning of an era in which technology has started to destroy employment faster than it creates it," he told io9. "The advance of information technology, artificial intelligence and robotics will eventually reduce the demand for all forms of human labor, including those dependent on 'human skills' like empathy and creativity."

He offers the example of Expedia. The online program may not be as creative at travel planning as an experienced travel agent, but it still displaces travel agents because it's considerably cheaper and more accessible. It's also an example of another impact of information technology, that of cutting out the middle man. 

"Eventually 3D printing and desktop manufacturing will cut out most of the work between inventors and consumers," says Hughes. "Alongside growing technological unemployment, we will also be living much longer, and will need to figure out an equitable solution to the growing ratio of retirees to workers and tax-payers.

At the same time, and probably related, is the much-discussed growing concentration of income and wealth among a smaller and smaller elite. If most people can't find work, two things will happen: a) nobody will be able to sell anything because consumers will mostly be broke and b) civilization will collapse. Otherwise, it won't be a problem.

The only solution -- an outcome Dvorsky thinks is inevitable -- is a Basic Income Guarantee. Everybody gets a check from the government, every month, that is enough to live on. Whether or not they choose to work, assuming they possibly can.

Hoo boy. Tell that to the Tea Party.

A thought experiment

Suppose my greatest fantasy is realized, and I invent teleportation. Several versions exist in sci-fi but let's say it's the kind where there are two capsules or chambers, and when you press the button the contents are swapped.

Distance doesn't matter, so I start by opening a service between Manhattan and LA. Ten people at a time, plus their luggage, can get into the machine at each end and badabing badaboom they're on opposite sides of the continent. Assuming they get on and off expeditiously, I can run it every sixty seconds. And it doesn't take a lot of energy. I can make an excellent profit charging 50 bucks a ticket. That's $1,000 a pop, 60 times an hour. I quickly have enough money to expand the service and create a dense network throughout the U.S., then go international, first to Mexico and Canada and then the whole world.

Apart from my own enrichment (not to be sneezed at), what are the consequences for humanity? It seems a great boon, not only because we save time and energy, and the world becomes more accessible and we all get to know each other and it ushers in a new era of peace and planetary cooperation (maybe, you can argue about that); but also because it creates an economic renaissance and stimulates a fabulous enlargement of prosperity.

Sadly, no. It will put the airlines, airports and aircraft manufacturers pretty much out of business, along with the intercity trains and buses. It will substantially reduce automobile sales. You still need them to get around town, but there will be many fewer long distance trips. All of this means massive unemployment. Instead of two or three pilots, six flight attendants, and time of baggage handlers, ticket sellers, air traffic controllers, airplane mechanics and what not, I employ a ticket seller, two schmoes to push the buttons, plus security and administrative resources, but again much less than it takes for air travel.

So what I have actually created is massive unemployment and the worst depression in history. With no evident way out for a long, long time. And this is a real problem we face today, without the fantasy. Technology that removes inefficiencies from the economy, and replaces human labor with technology, puts people out of work. So far, other forms of economic activity have come along so we haven't had massive, long-term structural unemployment, but there is no law of nature that says that has to happen. And maybe it won't this time.

There is plenty of argument going on right now about this question, but I think it's a real danger. And it has many possibly terrible consequences I won't take time to specify now. There is a solution -- income redistribution -- but our politics is dead set against that. I'll have further musings on these issues anon.

"We have gone terribly astray in the last 30 years. What went wrong?"

The title of this post is from Jan Bellamy, noting that 30 years ago Claude Pepper's subcommittee on health and long-term care published a report trashing the then-$30 billion a year health quackery industry. That's everything from naturopathy to acupuncture to homeopathy -- all fraudulent, then as now. And yet, instead of getting itself stamped out, this fraudulent enterprise has only grown, not only in size but also in acceptance. Quackery has wormed its way into medical schools and prominent clinics, from Harvard to the Cleveland Clinic. It even has its own institute within NIH.

But it isn't just health care fraud. The prestige of science has been demolished in this country. One of our two major political parties has denial of climate science as a central plank in its platform. Measles cases in the U.S. are now at the highest rate in 20 years because parents refuse to vaccinate their children. Creationism is an open and influential political movement. And now we have this outrageous and moronic behavior by politicians from Maine to New Jersey, plus the loathesome Andrew Cuomo in between, over ebola virus.

Let me give you the 4-1-1. Upon initially infecting people, the ebola virus is at such a low level in the blood that it is undetectable. Rather, it infects internal organs. It produces no symptoms, and it is not shed in urine, feces, sweat, saliva or for that matter in blood. People without symptoms are not infectious -- we aren't just talking low risk, we are talking zero, as in zip, zilch, nada, nothing, not happening. Note that Tim Duncan's family lived with him for days, while he was symptomatic, in fact, and not one of them became infected.

The infectious stage of ebola disease happens when the person is very sick. That's when the virus appears in the blood stream and in bodily secretions in sufficient quantities to be transmissible. Ergo, a person who has potentially been exposed need only keep track of his or her temperature and note any possible symptoms of the disease, and present to a hospital as soon as they appear, and we'll all be safe. If you don't trust people to do that, you can have a public health worker visit them a couple of times a day. I can see justification for travel restrictions since you don't want to lose track of the person or have them come down with symptoms in a situation where an appropriate response is not close to hand, plus which a certain amount of irrational fear is inevitable and you don't want to burden authorities elsewhere with it.

But Chris Christie and Paul LePage are both claiming that they know better than Anthony Fauci, and the public doesn't believe him either. Listen up folks: scientists don't know everything, and indeed they are often wrong. But there are some things we do know. We know this.

Odds and Ends

Research Ethics: Poli-Sci profs at Dartmouth and Stanford sent mailers to voters in Montana, bearing the state seal, claiming to rate candidates in non-partisan judicial elections according to their ideological affinity Barack Obama and Mitt Romney. This is purportedly a research project to determine whether providing this information increases voter turnout.

Of course, leaving off the state seal, anybody is free to do this, but if the purpose is research you have a whole different kettle of ethics. First of all, while it might seem unobjectionable to increase voter turnout, we don't actually know ahead of time whether this will increase it or decrease it; we also don't know whether it will influence the results of the elections, and reasonable people can disagree about either the accuracy of the ideological ratings, or their relevance to fitness for judicial office. (The ratings were evidently based on the candidates' previous political contributions, and unspecified other publicly available information.) One would expect that in Montana, being linked to president Obama would be a disadvantage.

Research on human subjects must not predictably do harm, and there are lots of ways this can do harm. Toss in the state seal and dudes, what were you thinking? The Dartmouth Institutional Review Board is said to have approved this. Eww.

Elon Musk is only half smart: Apparently he fears the revenge of our robot overlords. Me, not so much. Here's the thing about artificial intelligence: actions require motivation. There is no reason why a computer program would desire, or for any reason strive for power or any action harmful to humanity. Computer programs carry out instructions. In order to interact with humans, they must be programmed to respond in particular ways to particular inputs. That is all. And, you can always just turn them off.

That said, we're nowhere near artificial intelligence. Watson is completely idiotic, it doesn't understand anything, it just makes predictions based on statistical associations with semantic content. I do work in computational linguistics and believe me, the way computers label speech acts and identify topics has nothing to do with understanding anything and they won't do anything with those labels other than print them out or create some sort of response to the human interlocutor which hopefully will be appropriate, such as listing the nearby pizza restaurants (when you actually wanted to know how to make a pizza). I am not afraid.

Chris Christie and Andrew Cuomo, however, are afraid, or more likely pandering to the irrational fears of voters as whipped up by Faux News. This crap just makes me plotz. Christie confined this heroic nurse in an unheated tent, with a porta pottie and no shower, having take-out food delivered by workers in moon suits. There is absolutely zero danger of her infecting anybody. Absolutely outrageous. The man is a clown.

Bizarre Obsessions

It's becoming something of a theme here that the obsessions of the forum are largely insane. For example, is Renée Zellweger really the first performer ever to have plastic surgery? So it would seem.

On to more serious matters, comes now the case of the son of a senior Canadian federal official, with a lengthy history of substance abuse and criminal offending, who was likely mentally ill if we can believe the reports that fellow residents of the homeless shelter where he was living that he was talking about the end of the world. This pathetic individual, acting entirely on his own, killed one person and was then killed by a security guard. He apparently claimed to have converted to Islam although I doubt he knew anything about Islam or had gone through any conversion process or ceremony. But this is the single most important thing that happened all week -- after all the other nothings that were even more important the day before.

Get over it folks.  

Yes, we Americans are weird

An essay in the new JAMA by health economist Uwe Reinhardt, which alas is for subscribers only so you pitiful rabble can't read it. He discusses the movement (much beloved by conservatives) to make people may more of their medical costs out of pocket, which Republicans call ""consumer-directed health care." Ha!

As Uwe informs, and as everybody should already know but hardly anyone does, in the civilized world health care providers - doctors, hospitals, nursing homes, pharmacies - are all paid the same amount for a given product or service based on published fee schedules. In countries where there are multiple insurers, they all pay the same price.

Here in nutso land, every private insurer negotiates with every provider, which means that different providers receive different fees from the same insurer, while simultaneously the same insurer pays different fees to various providers (or none at all if they can't come to an agreement in which case the provider is "out of the network.) If you don't have insurance, and couldn't get in on the negotiations, of course, you will be charged an outrageous amount. Also, too, Medicare and Medicaid don't pay enough to cover the full cost, which means costs get shifted onto private payers.

As wacky as this is, making people pay out of pocket just makes matters worse because a) many people can't afford their medical costs at all. If you have a high cost-share policy, you could end up spending more than $10,000 a year, which lots of people don't have. Second, telling people to shop for their own health care is ridiculous. There can be thousands of separate items on a hospital's or physician's menu of good and services, most of which are completely uninterpretable to almost everyone. And the only way we really know, or think we know, what we need or how much we'll benefit from a medical procedure is because our doctors tell us so. We can't meaningfully make our own choices as we can in markets for say, cheese. We know what we like and what we're willing to pay for it. In the case of medical care, not a chance.

There is no such thing as a "free market" in health care, and pretending that is like other goods and services is transparent nonsense.

We need universal, comprehensive, single payer national health care. Oh, have I said that before?

On the other hand, who cares about this?

Last month was the hottest September, globally, since record keeping began 135 years ago. 2014 will almost certainly be the warmest year on record. And next year will very likely be even warmer, with the developing El Niño.

But, Ebola. Migrant children. Benghazi! Are we all going to die? Yes.

Stupid Question

Now that the Ebola virus is extinguished in North America somewhere well short of the collapse of civilization, and there is even progress in Africa, will the wingnut politicians and pundits who took to Faux News and far right hate radio to fan hysteria and even accuse president Obama of trying to create an Ebola epidemic lose any credibility?

Why did I even ask.

Now this is truly getting ridiculous

A teacher in Maine has been placed on leave because she attended an educational conference in Dallas, 10 miles from Presbyterian hospital. Really. Bring on the killer asteroid, is all I can say.

Time to set some heads a-rollin'

I still maintain that ebola virus is a very minor public health concern in the United States, it is a very big public health concern in west Africa and possibly eventually elsewhere; and it is a very big threat to the global economy and to U.S. politics. But . . .

We will never persuade the American people or the ignoramuses in the corporate media that our attention and our resources should be focused on west Africa, not Kennedy Airport, if it does not appear absolutely and transparently true that our medical and public health infrastructure is fully competent to protect us. And no, it doesn't look like that. The medical director of Texas Health Presbyterian Hospital should be escorted to the door and banned from the premises, along with the director of emergency medicine and the director of infectious disease. Not only was Mr. Duncan sent home despite telling the nurse that just arrived from Liberia and having a fever of 103, we now learn that after he was admitted to the hospital upon returning, his care team did not wear full protective gear for two days.

Nurses all over the U.S. are now coming forward to say that they do not feel prepared, have not been adequately trained, do not have adequate equipment, that procedures and policies are not in place, and that they have not drilled. Again, the probability that any given hospital will encounter an ebola case is very small, but public perception of risk is what's at stake here.

Then there is whoever is head of the division at CDC responsible for telling nurses who have exposure liability that they can go ahead and use their round trip ticket to Cleveland. This is not a question of the actual risk to the public, although I must say that as this story has played out it is not in fact zero. But even if it were zero, the consequences are inevitable and unacceptable: schools closed, hundreds of air travelers terrified, money spent to sterilize school buses and an airplane, public health workers spending their days following people around in two states who ought to be doing real work such as tracing partners of people with HIV and STIs, tracking down sources of food poisoning, getting kids vaccinated. In other words we will have some additional cases of infectious diseases because of this.

Now it turns out that a pathology technician who handled some of Mr. Duncan's specimens is on a Caribbean cruise in Belize. Let me repeat myself: it is irrelevant if she or he is actually at substantial risk. This is so utterly, gobsmackingly boneheaded that it makes me shriek. The risk is obviously not zero and what the hell will they do if this person starts vomiting blood in her cabin, on a cruise ship, in Belize? And even if the risk is zero, how do you expect the public to react to this?

The authorities seem to be doing everything in their power to fan the flames of fear and build them into panic. A display of competency and enough excess caution to convince people that it's really enough are absolutely essential if this is not to turn into a disaster -- an economic and political disaster, which will gravely damage the U.S. and meanwhile prevent us from doing what must be done in west Africa, which only the United States has the resources to do.

President Obama is saying the right things, but the CDC is doing its utmost to sabotage him.

Update: Stupid crap like this, for example:

Syracuse University on Thursday disinvited a Pulitzer Prize-winning photojournalist who was scheduled to participate in an upcoming journalism program because he was recently in Liberia covering the ongoing Ebola crisis.

The dean of Syracuse's S.I. Newhouse School of Public Communications, Lorraine Branham, spoke to News Photographer magazine about the decision to disinvite photojournalist Michel du Cille. "He was disinvited because of concerns that were generated by some students that led me to believe that it would lead to even more concerns," she said. "So it was in the best interest of the students for me to withdraw the invitation."

 He left Liberia more than 21 days ago, BTW.


 

The secret history of the world

By now, you have no doubt heard all about the New York Times report on the exposure of U.S. military personnel to discarded chemical weapons in Iraq. It is indeed a scandal that the Bush administration and its military kept these incidents a secret, failed to provide troops with the information and equipment they needed to stay safe, and failed to properly compensate or care for the injured. Yeah, that's bad, but it buries the lede.

Of course the wingnuts are already screaming that there were too Weapons of Mass Destruction™ in Iraq after all, but obviously that isn't true. The last thing W would have done is to keep that a secret. As the Times story says, "The discoveries of these chemical weapons did not support the government’s invasion rationale." These weapons were manufactured in the 1980s and mostly buried after Iraq abandoned its chemical weapons program. They were no longer usable, although the residues were dangerous. But . . .

The real story is that the U.S. and European nations supported Iraq in its war against Iran, so they made sure Saddam had these chemical weapons. German firms provided manufacturing plants, and U.S. firms sold Iraq the chemicals to make mustard gas. European companies provided the shell casings and rockets. The U.S. was well aware that Iraq was using these weapons against Iran, weapons which the U.S. and its European allies were supplying. In case you don't remember, the president of the United States was St. Ronald Reagan.

But the false accusation that Iraq had a current Weapons of Mass Destruction™ program provided the rational for an illegal war of aggression by the U.S. The use of chemical weapons by Bashar al-Assad was a "red line" that would have triggered a U.S. air assault if Vladimir Putin hadn't arranged a way out. The point is, all of our political discourse is hypocrisy and lies. The Times occasionally does a service like this and reveals the truth, but it pretty much sinks without a trace in the public consciousness.

Another goodie from the Times today, the not always reliable Frank Bruni. Like I said.

Proportionality

Sorry for my absence, I needed a few days to clear my head and the muse just didn't inspire, not for this blog at least . . .

Anyway, it's something of a repeating theme for me that we humans just aren't very good at deciding what is important, or what we ought to be worried about more than something else. So, of course the ebola virus is worrisome. Lots of people have already suffered and died and many more will. But the attention it deserves is mostly because the incidence is increasing in the fairly restricted geographic region where the outbreak is occurring, and nobody can be sure how it's going to play out.

Here, Andrew Ross Sorkin reports on calculations by the world bank that the economic cost of the outbreak will be $32.6 billion by the end of 2015 if the virus spreads to neighboring west African countries, which they consider to be a worst case scenario. That's a lot of money no? Well yes, it's probably about five times as much as the U.S. will spend bombing Syria and Iraq during that period. On the other hand it's about 1/300 of the trillion dollars we spent on the previous Iraq war. (Of course the U.S. will bear little of the cost of ebola.)

Yes, people are dying. Many fewer than died in the Iraq war of course, but it is also true that more Africans are dying right now of malaria, TB, HIV, and diarrheal diseases than of ebola, by orders of magnitude. Even in the worst case scenario, that will still be true.

As Sorkin's story tells us, the biggest economic risks are from overreaction, not the epidemic itself. Impediments to international travel and trade, useless spending, fearful declines in investment -- those are likely to cost more than $32.6 billion.

So why the wall-to-wall media coverage? Well, for one thing it's novel. That's what the word news means, after all. But this is a cognitive bias that's costly. Buried on page A-14, and nowhere to be found on the web home page, the NYT tells us of a new Pentagon report detailing the national security risks of climate change:

The Pentagon on Monday released a report asserting decisively that climate change poses an immediate threat to national security, with increased risks from terrorism, infectious disease, global poverty and food shortages. It also predicted rising demand for military disaster responses as extreme weather creates more global humanitarian crises. . . .

Defense Secretary Chuck Hagel, speaking Monday at a meeting of defense ministers in Peru, highlighted the report’s findings and the global security threats of climate change.“The loss of glaciers will strain water supplies in several areas of our hemisphere,” Mr. Hagel said. “Destruction and devastation from hurricanes can sow the seeds for instability. Droughts and crop failures can leave millions of people without any lifeline, and trigger waves of mass migration.”

On the front page, however, we do have the story of the single person who was infected within the U.S., a nurse who cared for Thomas Duncan in Dallas. A single, identifiable person is much more likely to get our attention than the probability that even thousands of people who aren't identified, who are mere abstractions, will suffer or die. That's another dangerous cognitive bias. It's what led to the counterproductive reaction of the U.S. and Britain to the grotesque beheading of hostages by the self-styled Islamic State. Yes, we need to seek justice for those individuals but we need to keep the threat posed by IS in proportion and respond in a way that isn't going to make matters worse. Until those identifiable individuals were killed, that seemed likely to happen. Of course, that's why they did it.

That river in Egypt . . .

Is it really this deep? Remember Jahi McMath, who died last December but whose parents think she's alive because she's hooked to machines that keep her flesh from rotting? (Yeah, yuck, I know.) They're still at it, petitioning a court to have her declared un-dead. Her body is apparently now in a house somewhere in New Jersey, where somebody has paid to have the necessary machinery installed and for personnel to keep it running and keep most of her cells alive.

It is not puzzling, of courses, that parents cling to hope despite the vast weight of reality, as did Terry Schiavo's parents. What is puzzling is that their understandable delusions are incorporated into an ideological crusade by people who think that keeping corpses with dead brains in a state of pseudo-animation using late 20th Century technology is mandated by God. I somehow missed that passage in the Bible.

I remember during the Schiavo brouhaha a priest organizing Catholic teenagers to demonstrate with tape across their mouths with the word "life" written on it. Sorry folks, but this is not life, and if it were, why would you want it? It is, of course, possible to do this with just about everybody who dies, as long as their circulatory system can hold blood. I don't need to point out the reductio ad absurdum. (Terry Schiavo was not technically dead when she was disconnected from life support, but that's a distinction based on the new definition of death that had to be invented in the light of new technology. She was in a state that I would be happy to call death, and she would have been dead in any and every possible sense of the word far earlier if the machinery had not been available.)

What seems even stranger is that the people who take this bizarre position don't even believe that death is real. They think it's the greatest thing that can happen to you, that you go off to Paradise to be with Jesus. Why don't Jahi's parents want that for her?

The times they are a'changin'?

I was reminded by Adam Liptak's report on the Supreme Court's historic punt on gay marriage that in 1967, interracial marriage was illegal in 24 states. Not only that, but a majority of Americans supported banning it. The SC took that case, and declared the bans unconstitutional -- you know, that pesky 14th Amendment -- but honestly folks, that wasn't very long ago.

This is a salutary reminder for me because I've lived in something of a bubble as a New Englander from a liberal, well-educated family. I entered high school in the same year that the court ruled on interracial marriage, and although I wouldn't call Andover (also attended by George W. Bush) a hotbed of pinkoism in those days overt racism was definitely out of bounds and I can't recall encountering it. The black kids even had a bit of cachet as the Civil Rights movement was broadly inspirational in that cultural milieu.

As a community organizer in Philadelphia's poor white Fishtown neighborhood I encountered profound, grotesque racism, pretty much for the first time. So yeah, I knew it existed but that was a brief phase as I went on to graduate school and spent most of my adult life traveling in progressive circles and working in multicultural environments. So the real world out there, full of racists and creationists and homophobes is exotic to me. It's really hard for me to appreciate how commonplace ignorance and bigotry really are.

Ergo, I always struggle to understand why people vote for lunatics who believe, or claim to believe, in crazy ideas and are fully and publicly committed to working against those voters' best interests. It's sobering. On the other hand, who would have thought just 5 years ago that there would be majority support for same sex marriage in the U.S.? Racism has been very slow to fade, if it's fading at all right now, but for whatever reason, this particular form of irrationality is dying fast. Maybe there's hope for the rest of the reality agenda.

Bobby Jindal is still an idiot

He wants the U.S. to ban all flights from nations where Ebola virus has been found and, he says:

[T]he Obama administration keeps saying they won’t shut down flights. They instead say we should listen to 'the experts.' In fact, they said it would be counterproductive to stop these flights. That statement defies logic. How exactly would stopping the entry of people potentially carrying the Ebola virus be counterproductive? This seems to be an obvious step to protect public health in the United States.

 Okay doofus, it's time for you to listen to an expert. In the first place, the Dallas patient arrived on a flight from Brussels. I don't even know if there are any direct flights from Liberia or Sierra Leone to the U.S., but even if there are, it's easy enough for people to take connecting flights, even to travel over land to Lagos or wherever. So it would be pointless. Furthermore . . .

In order to combat the epidemic in west Africa, it is necessary to bring in personnel and supplies. Airlines obviously can't fly in if they can't fly out. It is also important to limit the economic collapse in those countries, and to limit fear and civil unrest. Closing them off from the outside world is about the worst thing we can do. Furthermore . . .

As you presumably know if you are conscious, there have in fact been several people in the U.S. with Ebola. We bring our citizens here when they contract it. Not a problem. Mr. Duncan's contacts are being carefully monitored. It wouldn't be surprising if one or two of them do come down with the disease -- particularly his family members who he was living with -- but it will stop there. The screwup at the hospital that allowed him to go home will not be repeated.

So again, Ebola is a problem in poor countries that lack medical and public health infrastructure. It is not a threat to become an epidemic in the United States or any other country -- even a middle income country like Mexico or Brazil -- that has the resources to deal with it properly. So please stop pissing in your pants.

Oh yeah, about the conference . . .

I'm not going to bore you with any of the specific presentations (okay, except for mine) but I will try to give a sense of the overall state of research into communication in health care. Yes, this is a scientific field and we do empirical research, as rigorously as our usually quite limited funding will allow. But it's impossible to separate facts from values.

The goal of health care is to make money improve patients' well being. But that presumably means different things to different people. Do you want to live as long as possible or enjoy yourself more? Do you want to take a chance on surgery that will probably fix your arthritic hips and let you get back out on the golf course, but might just possibly go wrong and leave you worse off? And so on, including many even more complicated and stress inducing situations.

Furthermore, your doctor might think that you will unambiguously be better off if you take some course of action, but for various reasons of your own you don't do it, one possibility being that if you take pills you will have to think of yourself as sick but you don't want to be. Is it the doctor's job to use our research to manipulate you into doing what the doctor thinks is best? To take a more concrete example, I feel that my orthopedic surgeon somewhat downplayed the pain and disability I would endure after thumb arthroplasty, but I'm not mad at him. I now feel that it was worth it in the long run but I might not have gone through with it if he'd been totally honest. Of course he also had the ulterior motive that he gets paid to do surgery.

The fact is that most patients will never understand the biomedical reasoning behind treatment decisions, and even if you strip the decision down to relative probabilities of understandable outcomes, most people don't really grasp the concepts of mathematical probability and they have all sorts of cognitive biases. A 90% chance of a good outcome and a 10% chance of a bad outcome are evaluated very differently, even though they are of course identical.

So, the value now is "shared decision making," which even has a standard presentation as SDM. The doctor is supposed to be the expert the probabilities of various outcomes of various courses of action, and the patient is supposed to be the expert on what she values the most among that landscape of probabilities and so we decide. But that is merely aspirational, Nobody knows how to accomplish it consistently in the real world in a meaningful way.

It's only over the last 20 or 30 years that we have even had this aspiration as the standard in medicine. It used to be that doctor knew best and we were supposed to follow doctor's orders. As you can imagine, it is a very complex problem to establish the relationship between features of clinical communication and outcomes because, pretty much by definition, what constitutes a good outcome is undefined going in. We can arbitrarily say it's life expectancy, or quality adjusted life years, or some specific reduction in some pre-specified symptom. But if we don't get there because the patient chose a course that didn't maximize that outcome, is that a failure? And asking people to evaluate decisions retrospectively is not very helpful; we have powerful cognitive biases in doing that.

So, we have to start by trying to measure what people understand after a clinical encounter, whether they feel their questions were answered, and how confident they feel in their ability to make choices that affect their health. Then, if we can define a patient centered good outcome, we can eventually find out if it's achieved --but we might have to follow them for years, and that costs a lot of money, and they aren't giving it to us, yet, for this kind of research.

I'll tell you exactly what I'm doing anon.

I am sterdam

The headline of this post is the ridiculous slogan of the tourist board. Nobody even knows what it's supposed to mean. (No, it doesn't mean anything in Dutch.) But that's about the only thing I have to complain about.

The single most notable feature of Amsterdam is not, in fact, that it's Waterworld, which it is. It's that on dry land, everybody gets everywhere by bicycle. There are wide, perfectly maintained bike lanes everywhere, that interweave skillfully with the streets and wide sidewalks. The traffic lights are set up to safely direct bicycles, pedestrians and motor vehicles. The actual volume of traffic is in that order. There is a continual torrent of cyclists everywhere: school kids, blue collar workers, guys in business suits, old folks, families with their kids, every conceivable category of human getting to work, to school, around town on errands. The style is to sit up very straight, and nobody wears a helmet. Also, nobody is fat.

Such few cars as there are include plug-in electrics, and there are charging stations on the street. Yep, you can grab one of the regular parking spaces and plug in your car. There is also a fantastic network of street cars that goes everywhere, frequently, and knits together the whole city. So the air is clean, there is no traffic congestion, and it's easy and safe to cross the street. The stream of cyclists however is a bit scary.

I'll have more to say about the city, and the conference. For now, however, I'll say this. It seems the deepest fear of conservatives in the this country is that we'll end up like Europe. Check it out, folks: it's actually better.