I was about to say this is the craziest ^*(%# thing I ever heard of . . .

. . . but that's become a very high bar. On August 1, it will become the law in Texas that carrying of concealed firearms is permitted on campuses of all four-year public colleges. That includes classrooms, dining halls, you name it. So the faculty senate president at the University of Houston has been advising professors:

• Be careful when discussing certain topics
• Drop certain topics from your curriculum
• Not "go there" if you sense anger
• Limit student access [i.e. to your presence] off hours

Indeed. There have been a few instances of students murdering professors over grades and theses. James Holmes, the Aurora Colorado theater shooter, was a graduate student when he had his psychotic break, and that's the typical age for it. Young men in Texas include a whole lot of politically radical gun and violence fetishists who aren't having any truck with evolution, cosmology, climate change, or most of what I teach in public health for that matter.

It doesn't bother me a bit if Texas wants to secede.

I'm of two minds

About the likely Republican nominee for president. In fact, ovewhelmingly likely. It's horrific and appalling that such a morally monstrous ignoramus could be on the verge of claiming leadership of one of our two major political parties. On the other hand, the people who are cheering for him and voting for him already existed, and they were already the constituency of that party. Republican politicians just kept the racism, mindless militarism, xenophobia and blood curdling threats of violence against all enemies real and imagined more obtusely stated.

So you could argue that it's salutary, even essential, to expose the rotten heart of American conservatism. He's opening up the canker and exposing the pus to the sunlight. And we all expect that in the general election, he'd be utterly wiped out along with the Republican Senate and even a good chunk of the House. Abrcadabra, Republican party destroyed, Hillary appoints Barack Obama to the Supreme Court (highly doubtful but wouldn't that frost their pumpkin?), and we get massive infrastructure spending, a carbon tax, immigration reform, and a multilateral foreign policy based on humanitarian objectives.

Or, the Trump candidacy legitimizes revolting rhetoric, extremism, and lunatic conspiracy theories. The world comes to view the United States with contempt and fear. (Maybe surprising they don't already.)

And then there's this. Could he possibly be elected? In a Clinton (or even more so Sanders) vs. Trump election, there's only one place the Koch brothers' billions could go. And the corporate media will be scrupulously fair and balanced. So who really knows? I wouldn't have thought the present situation was possible.

Speaking Ill of the Dead

Like me, Corey Robin has taken note of the hagiographic responses to the death of Antonin Scalia, often from surprising sources, and like me, he is not inclined to agree.

Scalia did not create and champion an important theory of constitutional interpretation, or really any theory at all. He just used whatever sophistry he could come up with to justify the conclusions he wanted to reach.

Those conclusions were to favor the powerful over the powerless, the oppressor over the oppressed. He was a raging bigot who actively promoted discrimination. He was a sadistic psychopathic who reveled in the execution of innocent people.

He was a vile and repulsive person. His death is the best news this country has had for quite a while. There, I said it.

Update:  In case you don't think I'm qualified to say that Scalia did not, in fact apply any consistent theory of constitutional interpretation, but did whatever it took to reach the conclusion that favored his political allies, take it from Judge Posner, who is a real conservative.

Pie in the Sky?

Sandro Galea and George Annas, in the new JAMA, repeat the familiar lament that we invest proportionally far too much in curing people with medical intervention and far too little in keeping the population healthy through public health measures. They see health as a fundamental right and they want to adopt the Universal Declaration of Human Rights as the ethical basis for public health.

Actually they seem to fall a bit short in their understanding of what public health means. For example, they say "Public health is not alone, sharing funding and infrastructure deficiencies with transportation, education and even public safety." In fact, all of these are part of public health. Education probably the single most powerful contributor to population health, particularly education of women and girls. Mass transit, cleaner and safer motor vehicles, fire and crime prevention -- these are all public health.

The problem in the U.S. right now is that public health is all about social justice, and fixing the problems that the mythical "free market" cannot. Therefore it is unpopular with the plutocrats who run things, who would have to pay taxes to make the planet better for the rest of us.

That's why the UN's new sustainable development goals, which were formally promulgated at the beginning of this year, seem unrealistic. If the wealthiest country on earth isn't interested in investing, it won't happen. The goals include ending poverty, ending hunger, quality education for all, gender equality, affordable clean energy, climate action -- you know, all that commie stuff. Unfortunately, we have an entire major political party, that controls most of the levers of power, that doesn't want any of that to happen. So let's tell it like it is.

Darwin Day

Yes, it so happens to be his birthday, following the announcement yesterday of yet one more (kind of unnecessary) vindication of general relativity. It's worth noting here that it was general relativity, and the subsequent discovery of the expanding cosmos, that led straight to the modern understanding of cosmology and the horribly named "big bang" theory. I prefer to call it the Initial Singularity, or IS theory, because there was no bang.

Anyway, the have a deep philosophical connection, not in a positive sense -- they don't need each other to be true -- but in a negative sense, which is only important to humans right now. Between them, they dispose of God. They don't exactly make God impossible (especially since the concept is not consistently defined) but they make he/she/it completely unnecessary.

The trouble is, the more we learn about the universe the more pointless it seems, from our point of view. Which indeed it is. It isn't about us at all, we just happen to find ourselves here. I'm not sure why that's so difficult for so many people to accept. It doesn't bother me at all, we still are what we are and what is meaningful to us still matters -- but only to us. That's good news! We don't have to worry about how a merciful God could give us earthquakes and evildoers, or what we're supposed to put on the altar. We can go about explaining earthquakes and evildoers without any bother about that nonsense. And we don't have to ask "Why me?" when something bad happens to us. No particular reason other than the reasons you can observe.

So let's celebrate.

A long time ago, in a galaxy far, far away . . .

. . . two orbiting black holes spun closer and closer and finally merged, sending ripples in space-time across the universe which were observed on Sept. 14, 2015 by some talking apes inhabiting a coating of slime on a speck of dust. By a long time ago I mean about 1.3 billion years ago, which is just another way of saying how far, far away it was.

The physicists who made this observation are saying it's a very big deal. Welllll . .. .kinda. It doesn't change anything at all about our understanding of the universe, it just confirms what has been understood for (coincidentally) just about 100 years before the observation, when Einstein published the theory of general relativity. In the years since, it has been confirmed by every test, including one that indirectly confirmed the existence of gravitational waves. Einstein himself didn't even think they would ever be detected because they are too subtle. So in that sense it's not a discovery at all. It is for sure an astonishing feat of technology. And it should lead to future detection of cataclysmic events, including some of much smaller magnitude that occur closer by.

But the real implications are philosophical. Again, nothing that many people -- but not most -- don't already understand. The scale of the universe is completely beyond the intuitive grasp of humans. This event happened, according to counting logarithms on my fingers, on the order of 10^20 kilometers away. According to the investigators, each of the black holes weighed about 30 times the mass of the sun; the event momentarily generated more energy than the entire light output of the universe, an impossibly tiny fraction of which humans just detected. You would not have wanted to be up close and personal. That tiny fraction represented a displacement smaller than the charge diameter of a single proton.

The very weird thing is that it only took 3 pounds of mush inside the heads of some of those talking apes to figure out how to look for these waves, and to find them. We pack about 86 billion neurons into that mush, which is all it takes to operate the body, eat fuck and fart, and discover a universe in which we are absolutely nothing. It's really no wonder that lots of people just don't want to believe it.

Facts are stupid things

One of the many spiritual costs of spending a lot of time behind the wheel is having to read the bumper stickers on the battered vehicles of my struggling neighbors. Yesterday's soul-rotting annoyance was

Keep Working. Millions of welfare recipients are depending on you.

It was a rusty truck belonging to a tradesman of some kind. Then there was the National Pubic Radio interview with a couple of enthusiastic Trumpistas in New Hampshire who said that they were tired of illegal immigrants getting free cell phones and free health care. Of course NPR didn't bother to point out that illegal immigrants get absolutely no government benefits whatsoever. As always, they just let the falsehood sit there. (As Cokie articulates the policy, it doesn't matter if it's true, it's out there.)

As for the millions of welfare recipients, basically there aren't any, at last as my guy with the bumper sticker understands the concept. From Center for Budget and Policy Priorities more than 90% of government benefits (not counting tax breaks and subsidies for the rich, obviously) go to people who are elderly, disabled, or live in working households where the Walmart wages won't pay for the groceries. Almost all the rest goes to unemployment benefits, survivor benefits (you know, widows and orphans), and medical care (as opposed to paying for it some other way, as we have always done rather than let people expire in the hospital parking lot). In other words, the bumper sticker guy's mother, and himself if he's out of work (which he probably has been). 

But Republicans get away with making people think there's a super secret kind of welfare that all the dark people are getting that they don't have access to. And the corporate media aren't going to set them straight on it because of Cokie's rule. That's where things stand.

Trying to locate the evil

Anna Marie Barry-Jester at 538 tries to tell us what went wrong in Flint. She doesn't get very far, it seems to me. Yes, she chronicles how responsible officials ignored and belittled citizen complaints, and cooked the books on testing the water. But she doesn't explain why they did this, and she doesn't go more than two links up the chain, either, pretty much sticking to the actions of flunkies.

I'm not going to speculate about where the true responsibility lies here -- apparently the FBI is on the case and maybe they'll make some headway through the zone of plausible deniability. But the fact is, this is a crime so vast, and so horrific, it's difficult for the mind to encompass. People get 20 years for armed robbery and life in prison or the needle for murdering one person. But I will be very surprised if anybody even pays a fine for poisoning an entire city, damaging the brains of thousands of children, diminishing their prospects, and shortening their lives.

Our conception of justice is horribly distorted.

Expect an epidemic of exploding heads in Wingnutistan

I believe I have commented here previously about CRISPR, which is a recently developed method for precise editing of genes borrowed from prokaryotic cells. (If you aren't up to speed on the technical background, that's not really the point of this post. But I will be kind enough to say that prokaryotes are bacteria and archaea, single celled organisms without a nucleus. We are eukaryotes.) It enables scientists to make specific changes at exact sites in a gene, not without some rate of error although they are continually improving the technique.

You don't have to think very hard to see where this could lead. Although we don't yet know enough about the genetic basis of human traits such as intelligence or ability to play basketball, while we're figuring that out we could correct genetic diseases caused by single mutations. If you edit genes in a zygote, the changes will end up in all the cells of the resulting embryo, and so be heritable by the genetically enhanced persons offspring. Yep, supermanperson.

So, this being problematic for many people it is not currently allowed in the U.S. Now the UK has given permission for a single scientist to edit genes in human embryos within 7 days of fertilization, just to check out the methods. Then she is required to discard the embryos.

As you might imagine, I don't have a problem with this. These are surplus embryos from in vitro fertilization, of which thousands are routinely discarded anyway. The anti-abortionists for the most part don't seem to have a problem with that, oddly, even though according to their ideology these are morally indistinguishable from babies. But I expect this will get their attention, not because it's any different by any rationally defensible criteria but because it creates an intuitive offense to moral sensibility, i.e. the embryos are a means to an end.

Since they aren't people, that shouldn't matter. But if you think they are, it must, no?

What will probably trouble many more people is not these particular experiments, but where we might end up in the future. If it's possible to create genetically enhanced humans, it's hard to see how it will never happen.

A couple of thoughts about Zika virus

Epidemics are scary, and often the fear is exaggerated and leads to all sorts of irrational behavior. All we need is to recall the lunacy over Ebola virus in 2014, which was never a significant threat to the United States. (Of course it was awful where it was epidemic, and the lack of sympathy here in the U.S. for people in the affected regions was at least as appalling as the misguided panic.) The flu pandemic hoax of 2010 was another excellent example.

However, the WHO's alarm over Zika virus does seem proportionate. But this is a complicated story. The virus, which is related to Dengue, has never particularly concerned anyone until now. It is indigenous to tropical Africa and southeast Asia, and was known only to produce mild symptoms. So why is it suddenly thought to be causing catastrophic birth defects in the Americas?

I don't know the answer, but I can offer a pretty good hypothesis. In areas where it has long been endemic, chances are excellent that a woman will have been infected at some time before she ever becomes pregnant, and therefore likely has long-term, perhaps lifetime, immunity. Assuming it is really true that infection during pregnancy causes microcephaly and other serious damage to the fetus, it didn't happen often enough that anybody noticed. Now, a note of caution: we are seeing a coincidence in time of the arrival of Zika in the Americas and an apparent spike in these birth defects. It's only a strong suspicion that they are related, it might be something else we don't yet know about.

In any event, if this is what is really happening, it's a variation on a classic theme. The indigenous people of the Americas were decimated by contact with Europeans because Europeans had all sorts of endemic diseases to which they had evolved relative immunity. But a population naive to an infectious disease is the formula for disaster.

In this case, it shouldn't be a long-term disaster because even as the epidemic of birth defects is raging, girls below reproductive age are getting infected, and presumably their babies will not be at risk. Of course that sanguine analysis depends on the probability of their getting infected before they ever get pregnant, and of a previously uninfected woman becoming infected while she is pregnant. Based on the African experience, we have to presume that the math works out pretty well.

But even an occasional instance of microcephaly is a terrible event. These babies will have very limited existence. So I do hope the vaccine comes soon. Meanwhile, this is a reminder that the prospect of disaster from emerging infectious disease always looms in the modern, densely populated, densely connected world. We need a World Health Organization that is well funded, highly competent, and gets full cooperation from the governments of the planet. We're short of that now.

Consciousness

A blog I occasionally visit, which you might enjoy, is Conscious Entities. The proprietor, who appears to be largely self-educated on the subject, but has done it well, it preoccupied with the so-called "hard problem" -- explaining our conscious experience, our self-awareness, within the modern naturalistic world view.

Of course, I may be the only entity in the universe which has the experience I call consciousness -- maybe the rest of you are zombies. That's one of the hard things about it. The only consciousness we can observe is our own. It seems a fair assumption that since humans are similar to each other in other fundamental ways, we all share the phenomenon of consciousness; and those of us who are not psychopaths are wired to believe it instinctively, through the capacity of empathy. It's less certain with other animals, but that very imponderability leads to all sorts of conflicts about ethics.

For those of who think that metaphysics is dead, the problem of consciousness is an irritant. It feels as though there is some realm outside of the material in which our selves exist. If that is not the case, then we are saying that consciousness is indeed a material phenomenon. Yet we can't detect it, and it seems unnecessary for the evolved functioning of the organism. You could presumably write a lot of instructions that process sensory inputs and generate behavioral outputs that look exactly like a conscious human, but without the consciousness part.

It's a puzzle, and since we can't detect consciousness in others directly, all we can do is talk about it.

People are all mixed up

Here is a thoughtful and eloquent essay about the humane practice of medicine from a physician. Dr. Newman, like me, thinks that the biological reductionism of medical practice is not good for patients. He espouses humility in medicine, and understanding the profession as both art and science.

It appears that he also occasionally drugs his patients and sexually assaults them, or so it is alleged, which would seem harmful to the cause. I find this quite mysterious -- certainly I can't see how it is gratifying or why anybody would do that. If you think about Bill Cosby's public persona and his (rather prissy) hectoring about rectitude and respectability, it seems these are kindred spirits.

The Jekyll and Hyde story is archetypal, I suppose. All people are a mixture of good and bad, but some people conceal more than others, and have more extreme polarity. I guess you never really know.

One thing that doesn't get said enough on MLK day

It is not just outrageous, but grotesque, that the FBI headquarters is still named for J. Edgar Hoover. The gay-hating homosexual racist far right blackmailer who, among other crimes against the people of the United States, tried to extort Martin Luther King into committing suicide. Read this and barf.

Members of Congress have tried to get legislation passed to take Hoover's name off the building, but it never goes anywhere. It seems he is still very popular with one of the two major political parties.

Long Term Problem

John Iglehart, in the new NEJM, does the Cassandra thing with Long Term Services and Supports, also called Long Term Care. (I'm not sure what the public access is to this piece.) The kicker is that right now, this problem is getting essentially no attention from politicians.

Most people who have chronic disabling conditions get most of their care from unpaid family members or friends -- some 40 million people currently in that role. Many of them end up leaving the workforce because they can't handle both jobs simultaneously. What many people don't seem to know is that their health insurance -- whether it's private insurance or Medicare -- won't pay for long term health care, in a nursing home or in the community, and won't pay for essential non-medical services such as housekeeping. It costs more than $90,000 a year to be in a nursing home, and $43,000 to be in an assisted living facility or to get full-time home health aide services. Very few people have that kind of money.

Right now about half the people who need LTSS are over 65 but that percentage, and the absolute number, will obviously increase as the population ages. Not everybody will ever need to pay for LTSS -- some of us are lucky enough to die before we develop severe disabilities -- and others won't ever have to pay for it because we'll be able to rely on family members. But 16% will spend more than $100,000 and few elderly people have that kind of money. I think you know what happens in that case -- you have to spend everything you have, then Medicaid takes over.

It is possible to buy long-term care insurance but it is very expensive and hardly anybody has it. While the Republicans are all promising to repeal the Affordable Care Act, neither they nor Hillary nor Bernie are saying anything about this problem. It's solvable the same way many of our other severe problems are -- tax the rich.

Diversionary Tactic

Rita Rubin, in the new JAMA, discusses the relationship between mental health treatment and gun violence. Since we can't seem to get any policies implemented that will actually reduce gun violence, it's fashionable for politicians to use the problem as an argument for improving accessibility of behavioral health services.

I am reluctant to be contrarian about this because I'm all for getting people the help they need. However, this is an excellent example of the way cognitive biases distort our politics. While it is true that mass shooters -- like the perpetrators of the attack on Gabby Giffords and the Aurora, Colorado movie theater massacre -- are disproportionately likely to be seriously mentally ill, such mass killings are a minuscule proportion of all gun violence.

And of course, the vast majority of people with mental illness are not dangerous -- they are far more likely to be victims of violence than perpetrators. And psychiatrists just have no way of predicting who is going to commit violence. So the argument that mental illness is a modifiable cause of gun violence just stigmatizes people who have enough problems already. The real point is to divert attention from what we can do effectively to limit gun violence -- much of which, by the way, is either suicide or what you might call accidental or might not.

After a mass murder in Australia in 1996, that country imposed much more restrictive gun laws. They banned some semi-automatic weapons altogether, and required people to get a firearms license and to show a good reason -- not just "self-defense" -- why they needed to own a gun. They bought back 700,000 weapons which were no longer legal. Since then, the incidence of gun violence in that country has fallen substantially, and there hasn't been a single mass killing. And the Australians do not live under tyranny.

So let's not surrender to this diversionary tactic. Yes, let's fix our mental health delivery and payment system. But don't pretend that will do anything to solve the gun violence problem.

But, the ACA does fall short

A New York Times survey finds that about 20% of people under 65 who have health insurance nevertheless have trouble paying out-of-pocket medical costs. The problem is that health care in the U.S. is still the most expensive in the world and many insurance plans have high deductibles and co-pays. People who sign up for health care on the ACA exchanges in particular tend to pick plans with high out-of-pocket costs because they are attracted by the lower premiums; but this doesn't necessarily turn out to be a good bet.

We still need universal, comprehensive, single payer national health care. Many of us supported the ACA because we thought it would be the camel's nose under the tent; but if anything it leaves the insurance companies more entrenched. Ultimately, we need a Democratic congress and president who are willing to take them on. I don't know if that's possible any time soon, but it's still the answer.

The Alternate Reality Care Act

As Paul Krugman does from time to time, he once again points out that the Affordable Care Act is working at least as well as hoped for, giving a helpful link to the latest Commonwealth Fund report that proves it. He also points out, as he does at the same time to times, that Republican politicians and they're allied scribblers and gibberers willfully refuse to embrace this reality and continue to predict the policy's imminent collapse, or even to claim that it is already happening.

Well he's right, but how can they get away with this? Part of the reason is that most people have been pretty much unaffected by it -- they still have the same employment based insurance or Medicare that they always did, so it doesn't really have anything to do with them directly, but if their congresscritter or favorite yacker is claiming it's a disaster for other people they aren't staring directly at the counterevidence. In fact, since premiums continue to go up, albeit more slowly than before, they can be persuaded to blame Obamacare for a situation that it has actually helped to ameliorate.

It is also true that people with relatively high incomes, who don't quality for big subsidies and chose not to buy insurance before, don't get the greatest deal. They might resent the mandate. There aren't many such people, and what is demanded of them is that they be socially responsible, but lots of people don't want to be. And yes, people who have benefited still have substantial out of pocket costs and their insurance will only turn out to be a good deal for them if they have major medical expenses. But that's true of the homeowners and car insurance too -- that's what insurance is for.

Still, the biggest problem is the corporate media, who won't sort out the truth for people -- not necessarily because of their philosophy of not refereeing fact and falsehood, but because they don't actually understand health care policy -- and the chickenshit Democrats who should have mounted a full-throated defense of the ACA from the beginning, and instead hid under their desks, where most of the remain.

Better Democrats, please.

The Golden Age of American Politics

Actually, there wasn't one. The present may seem particularly horrifying but it really isn't. Before 1860, obviously, we had slavery and we were busy exterminating the natives and stealing their land. Then right after the Civil War the freed slaves wound up back in bondage as sharecroppers and terrorists roamed free in the land to assure they didn't assert any political or cultural rights. There was scarcely any objection.

We had the Gilded Age in the 1920s and then yes, we got some progressive measures through in the 1930s but that was only because the circumstances were desperate and that was the only way to save capitalism. The post-war years felt a little better but then we got Vietnam, Nixon, and Ronald Reagan, followed by the triangulating Bill Clinton and He Who Shall Not be Named. Barack Obama had 2 years before racist, reactionary lunatics took over the congress, not to mention most of the states, and now we have the Age of F.F. von Clownstick.

So really, the struggle is never ending. It isn't about fixing our foul stew of plutocracy and racism, it's about keeping up the fight. I intend to do so.

The River in Egypt

Reading this piece by Elizabeth Kolbert on the coming innundation of much of Florida, specifically focusing on the imminent uninhabitabity of Miami Beach, I found myself profoundly baffled.

The governor of the state and one of its senators, along with the entirety of their political party, maintain that this is not happening, and that the claim it is happening is not just a mistake, but a deliberate hoax by thousands of scientists and allied politicians who are conspiring to rob us of our freedom because of some reason they don't quite get to specifying.

Presumably the politicians who say this know it is completely insane. I don't know about James Inhofe, he is an idiot who might actually believe it, but the delusion cannot possibly be widespread. Rick Scott and Marco Rubio are liars. And what are they planning to say when all of that very expensive real estate disappears? I mean, this isn't happening fifty years from now, after they are dead. It is happening today.

I really do not get it.

Missing the point when it's the size of the moral universe

Here is a very strange essay by physician Vyjeyanthi S. Periyakoil about his interaction with a dying patient, a Vietnam veteran who had never spoken to people about his combat experience. The man finally confesses to the doctor the reason for his long-concealed distress. The essay is all about the terrible burdens carried by veterans.

However, what the good doctor fails to observe is that the soldier's burden is that he murdered a pregnant teenage girl in cold blood, a peasant who just happened to be in the wrong place at the wrong time, because she had seen him and might have given away the presence of U.S. troops in the area. This is the doctor's take on it:

What would I have done if I had been in his shoes, I wondered. I could have let the girl go, but maybe the mission would have been compromised and my entire platoon would have been killed or taken prisoner of war.

Er, no. Evidently this was the policy of the United States army the time, but this was in fact a war crime. I remember during the war reading an outraged essay by a conservative writer about how Viet Cong propaganda was claiming that U.S. troops murdered young women with knives. What do you know, it was true. And how weird that the New England Journal of Medicine would publish this essay in this form. These sorts of personal musings are actually peer reviewed (I have done it myself), so this was read by at least three people in addition to the editors.

And the Terrorists Have Won

Now all you have to do is send an e-mail, and the second largest school system in the country will close, keeping 650,000 children home. If you think that's ridiculous, you have forgotten about the world's second most ridiculous human, Chris Christie, who said this in the "debate."

"The second largest school district in America in Los Angeles closed based on a threat. Think about the effect that that is going to have on those children," Christie said during his opening statement at the fifth Republican presidential debate in Las Vegas. "When they go back to school tomorrow wondering, filled with anxiety about whether they're really going to be safe. Think about the mothers who will take those children tomorrow morning to the bus stop, wondering whether their children will arrive back on that bus safe and sound." The governor then suggested the Obama administration was to blame for failing to address the threat.

Uh, governor, it was a hoax, by somebody who doesn't even know how to make a convincing impression of a Muslim. But basic logic and obvious facts are irrelevant to Republican voters, so he'll probably get a bounce in the polls.

The Paris climate agreement

Joe Romm actually has a positive view of the Paris accord, which surprises me a bit. If you haven't had a chance to get familiar with it, the 186 participating nations each have pledged what's called an "intended nationally determined contribution" toward a goal of limiting the global mean temperature rise to 2 degrees Celsius. However, the existing intended contributions aren't enough to get there -- they will need to be reviewed and ratcheted up going forward.

That sounds great but there is no enforcement mechanism. It is meaningful that essentially all of the world's nations agree that yes, there is a problem, and yes, we need to do something about it. The symbolism is powerful and it may help politicians in some countries establish more effective policies. To my mind, however, that is speculative. The agreement is purely rhetorical. It doesn't actually do anything. The economic forces driving fossil fuel consumption are unchanged.

The only really effective measure, which happens to accord with brown shoe economic theory, is a tax on CO2 emissions equal to their social cost -- which means enough to drive them to zero within a few years. In other words, we need to make investments in essential technology and infrastructure pay off. That includes energy storage, and  a "smart" electric power grid, which are necessary to make renewable energy viable. A carbon tax can also provide subsidies to low-income people so that they are not economically harmed in the short run, and subsidize energy conservation and adoption of renewable energy sources.

And yes, it will have to be global.

If the nations of the world can't come together to do that, or something very much like it, the agreement is just so much hot air. And given that one of the two major parties in the nation with the world's largest economy denies reality, we're a long way from doing anything meaningful.

Here's Bill McKibben's less enthusiastic take on the accord.

On becoming a physician

JAMA this week is a semi-theme issue on the evils of medical education. Most of it is behind the paywall but they are letting you read this on the high rate of depressive symptoms among physicians in training.

It isn't really surprising. I've had a couple of friends go through it and, first of all, the all consuming demands on medical students and residents lead to a lot of breakups with spouses and partners. Second, there are those all consuming demands themselves. And, perhaps most important, there is the unprecedented encounter with suffering and loss. All day and night you're working with sick and dying people, and watching them die, and telling them they will die, and seeing their loved ones suffer, and sometimes you think you screwed up and it's your fault and sometimes you really did screw up.

On top of that, as the issue also recounts, there is still a tendency for preceptors to be abusive and to humiliate trainees. It's just very hard to root that out of the culture.

The huge challenge for physicians is to compartmentalize -- to really be compassionate and empathic when dealing with patients and families, to really care, and then to leave it behind, at least enough to live with yourself and have a happy life. Not everyone can do this. Physicians sometimes burn out, and in addition to depression, they are at risk for addiction (the drugs are right there) and suicide. Yeah, they make the big bucks, or at least bigger than most. (Less so primary care doctors, who also work very hard.) And its no excuse for misbehavior or mistreatment of patients.

But it's not an easy job. Never forget that.

More on the peer review process

So applicants for NIH funding send in proposals in response to one of the announcements I described previously. These are very complicated documents that take dozens of person-hours to create. I don't know exactly what they are estimated to cost, but I'm sure people have figured that out and it must be many thousands of dollars. Right now, however, due to gradual budgetary strangulation by the congress, NIH is funding something like 10% of all applications.

At NIH, an official called a Scientific Review Officer (SRO) assembles a panel of reviewers. Some are standing panels that meet regularly and rotate members only every two years or so. These review the R01s, R03s, R21s and other investigator initiated proposals, but they have specialties. Investigators can request assignment to a particular review panel, or NIH can decide where to send it. One-time announcements often have what are called "special emphasis panels" that only meet once, to review those specific applications. That was the kind of panel I was on.

The SRO then assigns each proposal to 3 reviewers. Each reviewer, in turn, has about 8 proposals to review. The reviewers get access to their assigned proposals through an Internet site before the meeting. They have to read them all, including the budgets, protection of human subjects, personnel, and other material in addition to the research plan. It's quite a chore. Each reviewer then writes a critique, scores the proposal for Significance, Innovation, Investigators, and Environment (the latter is usually fine, it's a reputable research institution), and then gives an overall "impact" score. Scores range from 1 to 9 and it's like golf, lower numbers are better.

NIH than computes the average score of the 3 reviewers and tosses out, without further ado, all proposals in the lower half. (The applicants will get to see the reviewers' comments, but they are now dead.) At the meeting, everybody sits around a big table with their computers plugged in and off we go. The first reviewer of each  proposal makes a verbal presentation and critique, followed by the other two reviewers, then the whole gang is free to ask questions and make comments. Often the scores of the three reviewers are quite different. They may converge after discussion, but occasionally people dig in their heels, and they don't.

Then the entire panel gets to score the proposal. Since only the three assigned reviewers have been able to read it carefully (the rest just skim it while it's being discussed), most go along with the average of the assigned reviewers, or they maybe lean toward the high or low depending on whose arguments they find convincing. And that's pretty mu6ch it.

You need to be in the top 10% or maybe a little lower to have a chance at funding. NIH staff can put their thumbs on the scale where there is a close call, and the National Council ultimately has to approve all awards, but the peer review process goes 95% of the way toward the final result.

There are a lot of reasons why decisions aren't close to perfect. Reviewers often don't have quite the right expertise, they may have their own axes to grind about scientific controversies, and they may even try to spike the competition although I'm sure most are doing their best to be honest and fair. If the competition wasn't so horrifically intense, a little bit of slop would be more tolerable, but right now it's just torturous. People complain about the peer review process all the time but nobody seems to have a better idea.

Science marches on

This is not funny and I am not playing it for humor. It is however quite thought provoking. The VA has approved experimental penis transplant surgery for veterans whose genitals have been destroyed in the war. This will use deceased donor organs.

You may have read the Earnest Hemingway novel The Sun Also Rises, about a veteran with this injury. There are serious downsides, including the need to take immunosupressive drugs which may result in opportunistic infections, and of course organ rejection. Whether the donor penis will ever be capable of intromission or produce the desired neurological effects seems highly uncertain. It is also just plain  weird concept to contemplate.

I won't say more about it because I'm not sure what to say.

Where I've been

I spent most of the past week in Bethesda as a member of a proposal review panel for the National Institute of Minority Health and Health Disparities. I'm not allowed to say anything about the proposals, but the fact that the meeting happened, and my participation, are a public record, as is the announcement for the proposals we reviewed.

I thought people might be interested in how the various components of the National Institutes of Health (NIH) go about spending your money. It's too complicated to go into all of the details, but I'll hit the highlights. NIH consists of several different so-called Institutes and Centers (I/C), of which NIMHD is one. Other examples are the National Cancer Institute; National Heart, Lung and Blood Institute; and the Fogarty International Center. Congress allocates money to the various components, and may establish some priority issues for them, but beyond that they have considerable discretion.

Each I/C has a national advisory council which sets general priorities and has final approval power over funding awards (a general term which includes grants, cooperative agreements, and contracts, each of which work a bit differently). Awards to external researchers -- mostly in universities -- are called "extramural" funding. In addition, most of them have some intramural funding in which they run their own labs and employ their own scientists,  but most NIH-funded research is extramural.

Based on congressional mandates, national council guidance, and staff decisions (with occasional requests for additional public input), the I/Cs issue so-called "Parent Announcements" which invite ideas for research projects from investigators and are completely open; and so-called "Program Announcements" and "Requests for Applications," which have increasing degrees of specificity. (They also make awards for training and career development, which I'll only mention here.)

The main kinds of research awards with "parent announcements" are called R03s, which are small awards for preliminary work, usual using already available data, to figure out what it would take to do a study and to generate hypotheses. It isn't necessarily expected to result in scientific findings, other than perhaps a paper on methodology or suggestive observations. The R21 is an "exploratory and developmental" award. It is enough money to do some real science, but isn't necessarily expected to have enough statistical power to draw definitive conclusions. Rather, it is preparatory to an R01 which is a full-scale research project. The R21 might yield methods and measurement instruments, or demonstrate the feasibility and safety of an intervention. In terms of clinical drug trials, it is equivalent to a Phase 2 study.

Investigators who win these awards are given the money and they just run with it. NIH doesn't get involved except to require annual progress reports. However, if you don't end up with publications they aren't likely to fund you again.

The proposals we reviewed this week were for so-called U01 awards, which are cooperative agreements, That means NIH staff will work with the investigators to implement the projects. That makes our job as reviewers slightly different because it means we don't have to assume that the project will be implemented exactly as proposed. If there are "addressable" weaknesses, which could be fixed in cooperation with NIH staff, but we like the project otherwise, we can still give it a good score.

Next, I'll explain the review process and exactly what the heck I did.

The A Word

The moral logic is impeccable. If you truly believe that a fetus has the same moral status as a baby, and that, as Republican politicians have said, Planned Parenthood is akin to Auschwitz, abortion is a holocaust, and abortion providers are murderers, then you have a moral imperative to stop them, by any means necessary.

Funny thing. Nobody, including the Pope, believed that until the late 19th Century. Abortion (and for that matter infanticide) were commonplace in the Biblical world, and that was just fine with the Bible. Here is the Skeptic's Annotated Bible on abortion. A couple of good 'uns:

God sometimes approves of killing fetuses.

And Moses said unto them, Have ye saved all the women alive? ... Now therefore kill every male among the little ones, and kill every woman that hath known man by lying with him. -- Numbers 31:15-17
(Some of the non-virgin women must have been pregnant. They would have been killed along with their unborn fetuses.)

Give them, O LORD: what wilt thou give? give them a miscarrying womb and dry breasts. -- Hosea 9:14

Yea, though they bring forth, yet will I slay even the beloved fruit of their womb. -- Hosea 9:16

Samaria shall become desolate; for she hath rebelled against her God: they shall fall by the sword: their infants shall be dashed in pieces, and their women with child shall be ripped up. -- Hosea 13:16

God sometimes kills newborn babies to punish their parents.

Because by this deed thou hast given great occasion to the enemies of the LORD to blaspheme, the child also that is born unto thee shall surely die. -- 2 Samuel 12:14

God sometimes causes abortions by cursing unfaithful wives.

The priest shall say unto the woman, The LORD make thee a curse and an oath among thy people, when the LORD doth make thy thigh to rot, and thy belly to swell. And this water that causeth the curse shall go into thy bowels, to make thy belly to swell, and thy thigh to rot: And the woman shall say, Amen, amen. ...
And when he hath made her to drink the water, then it shall come to pass, that, if she be defiled, and have done trespass against her husband, that the water that causeth the curse shall enter into her, and become bitter, and her belly shall swell, and her thigh shall rot: and the woman shall be a curse among her people. And if the woman be not defiled, but be clean; then she shall be free, and shall conceive seed. -- Numbers 5:21-21, 27-28

The reason the Catholic Church, and later protestant sects, suddenly got all life begins at conception in the 19th Century was because of the women's movement. They were afraid of independent women and sexual liberation. It's about sex and gender, not babies. Never forget that.

The first thanksgiving

It's not the story you learned in school. This is an excellent piece of historiography by Charles C. Mann, much of which I am ashamed to say I did not know. But the main point that's most relevant to this blog is that the reason the Pilgrims were able to establish a settlement on the Massachusetts shore where no Europeans had done so before was that the area had been depopulated by a terrible plague. In fact it killed 90% of the Wampanoag who until then had a sophisticated, densely populated and prosperous kingdom. They knew from experience not to tolerate European settlers, but after the catastrophe their chief Massasoit was persuaded to form an alliance with the English at Patuxet (now Plymouth). Even more fascinating was the person who did the persuading, Tisquantum (who is usually today called Squanto). So read it.

The plague was apparently a viral hepatitis imported from England. (The depopulation of natives by smallpox came later.) As Mann concludes, referring to King Phillip's war, in which one of Massasoit's son's tried unsuccessfully to expel the invaders:

The Europeans won. Historians attribute part of the victory to Indian unwillingness to match the European tactic of massacring whole villages. Another reason was manpower—by then the colonists outnumbered the Natives. Groups like the Narragansett, which had been spared by the epidemic of 1616, had been crushed by a smallpox epidemic in 1633. A third to half of the remaining Indians in New England died of European diseases. The People of the First Light could avoid or adapt to European technology but not to European germs. Their societies were destroyed by weapons their opponents could not control and did not even know they possessed.

Can something like this happen again? Yes.

Sorry, it's been a while

Partly just that the zeitgeist is too depressing to even comment on. First, I'll cross-post this from Today in Afghanistan.

The U.S. military has released its explanation for the assault on the MSF hospital in Kunduz. Of course it was all just a big mistake. To summarize:

• Afghan forces requested an airstrike, saying they were under fire. However, they did not provide map coordinates of the building they wanted to be attacked, they just "described its location."
• U.S. special forces passed on the description to the crew of the AC-130.
• The plane had been diverted from another mission and its crew was not familiar with Kunduz, and had not been briefed on the location of the hospital.
• The location description was apparently vague or inaccurate (it referred to an open field), so the crew decided to attack the hospital building.
• U.S. ground forces were not within visual range of the attack.
• An on-board targeting computer that might have stored the coordinate of the hospital as off-limits wasn't working.

Okaaay.

• No explanation as to why the AC-130 attacked even though there was no evidence of a firefight. (They would have seen it with infrared surveillance if it was happening.)
• No explanation of why the crew did not confirm the identity of the target when the information they had turned out to be incorrect.
• No explanation of why the attack continued for an hour despite frantic calls by hospital personnel to U.S., Afghan, United Nations and Red Cross officials. 

Gen. Campbell says some individuals have been "suspended" from their duties.  I have no further comment on this right now. Oh shoot, I will. If this is true (and that's a far reach) it shows utterly depraved indifference to the people the U.S. is supposedly trying to protect. You don't spend an hour blowing up a building and massacring the people who flee from it without actually knowing what it is you are attacking, unless you are a maniac.

More on other subjects soon.

Proud to be an American

I've never understood those bumper stickers. Is this something you achieved? Did you toil and sacrifice to accomplish the lofty goal of being an American? I really don't think so. In fact,  I think you were born here, in your shiny white skin.

Now suppose murderous maniacs were to take over the country you are so proud to be of, and you were forced to flee with your family for your lives. Would you think people who turned you away and sent you back to your doom should be proud?

But however proud you are, you apparently think that you aren't as proud as you want to be because we need to Make America Great Again, meaning, obviously, that it isn't Great right now.

And it's not just Republican primary voters who feel like you. The man with the dead muskrat on his head is tied in recent national polling in a hypothetical general election with the likely Democratic nominee, who will apparently not Make America Great Again. But muskrat man will, just like that German guy with the funny mustache, who used to shout pretty much the same way.

I am not proud.

Stigma

That Charlie Sheen is HIV+ is not a huge shocker, given his well-known history of drug abuse and patronization of prostitutes. Fortunately he is taking his meds and his doctor says his viral load is undetectable (a term that seems exotic to the reporter, who oddly puts it in quotation marks).

The most interesting moral of this story is not to avoid doing the stuff that can get you HIV infected. I believe we already knew that. It's the decision he finally made to go public, after paying millions in blackmail to keep it a secret. (Assuming this is entirely true. Sheen is crazy so it might be a bit askew.)

Whether or not you think a person should be ashamed for shooting dope (if he did) or paying prostitutes, being HIV+ is not anything to be ashamed of. I have interviewed a lot of people with HIV, and here's what I can tell you. Initially, a lot of people are ashamed, maybe because they regret making a mistake, or because they have internalized the stigma of being gay and/or having a lot of casual sex, or being a drug addict. People often can't incorporate the fact of being HIV+ into their identity so they pretend to themselves it isn't true. They don't see a doctor or take meds because if they take meds, that means they have the thing, and they don't want to have it.

Maybe they do finally start on meds but they don't take them consistently because it reminds them of what they don't want to be reminded of.

But lots of people -- at least the ones who are still around to talk to me -- sooner or later get okay with it. They might see it as a kind of blessing, because the news finally got them to stop doing things they didn't really want to be doing. Many people even take pride in having made changes, and taking care of themselves, and being an example for others. They talk to the young people, they volunteer, they get on track with a career and they don't mind telling anybody. Those are the people who take their meds and do just fine.

I don't know why Sheen thought he needed to pay millions in blackmail to keep the secret. Now that he's come out, I guarantee you nothing bad will happen to him. In fact, he might just overcome his depression and his anger problems and his weird behavior and get back to work and once again fulfill his tremendous talent. And believe me, nobody will hold it against him. What I don't know is how to throw the magic dust on people and make that happen. If anybody has the formula, please let me know.

Update on Death Rates

I noted in an earlier post the surprising discovery that death rates for "middle aged" (i.e. age 45-54 year old) non-Hispanic white people in the U.S. have been rising, against a background of overall decreasing death rates in all other demographic categories.

As it turns out, subsequent analysis by other researchers has modified this conclusion. Here Andrew Gelman explains that in fact, this is true only for women. The death rate for men increased until 2005, then started back down. The reason for the mistake is interesting for those of you who care about ways to lie -- or just make a mistake -- with statistics. It turns out that during the period of analysis, the age composition of white non-Hispanic people within the 45-54 year old cohort increased. In other words, more of them were near 54 at the end than at the beginning. The death rate doesn't go up a lot from 45-54, but it goes up enough to wipe out the apparent effect for men.

This is a version of what is called an error of aggregation. In any case, the result is even more puzzling than the original analysis. How would you explain it.

Confronting Evil

First, a crosspost from Today in Afghanistan.

I expect that most people contemplating the massacre in Paris last night are puzzled by the motive. The Islamic State can hardly expect to strengthen its grip on territory, or to expand, by provoking a militarily powerful nation to counterattack, as France almost surely will. I commend to your attention this article in the Atlantic by Graeme Wood. It's fairly long, but go ahead and read the whole thing.

He actually makes a mistake at one point by predicting that IS won't carry out attacks on foreign soil (the Charlie Hebdo attack was sponsored by al Qaeda). But the events last night actually do make sense in terms of his analysis. The most important thing we need to understand is IS adherents really do believe that they are fulfilling apocalyptic prophecies, which in fact include their near-destruction at the hands of "Rome," which today mean essentially what we all the West, the European Christendom as it has expanded to North America and elsewhere. They want to provoke conflict, in other words. Here is a key pull from Wood's essay:

In December, The New York Times published confidential comments by Major General Michael K. Nagata, the Special Operations commander for the United States in the Middle East, admitting that he had hardly begun figuring out the Islamic State’s appeal. “We have not defeated the idea,” he said. “We do not even understand the idea.” . . .

Our ignorance of the Islamic State is in some ways understandable: It is a hermit kingdom; few have gone there and returned. Baghdadi has spoken on camera only once. But his address, and the Islamic State’s countless other propaganda videos and encyclicals, are online, and the caliphate’s supporters have toiled mightily to make their project knowable. We can gather that their state rejects peace as a matter of principle; that it hungers for genocide; that its religious views make it constitutionally incapable of certain types of change, even if that change might ensure its survival; and that it considers itself a harbinger of—and headline player in—the imminent end of the world.

 So do read it. This is not an enemy that behaves according to the logic of others.  Its actions make no sense in most people's terms. It is essential to understand its internal logic.

Now, expanding on this, it was a bit odd to hear Francoise Hollande decry the attack as "an act of war." France is obviously already at war with IS, and committing its own acts of war, specifically bombing them from the air, every day. Now, Hollande will make the entirely respectable claim that France (like the U.S. and its other partners in bombing) tries not to blow up non-combatants. Obviously they don't always succeed, but they are engaged in a military campaign, not indiscriminate massacre.

I am also not in the least contrarian about the moral inequivalence of France and IS.  The self-styled Islamic State is a cancer upon humanity, and its existence is intolerable. Principal objectives of the war on IS are to liberate people it enslaves, prevent it from continuing atrocities, and to allow people it has driven from their homes to return. France, in contrast, is a legitimate state with acceptable concern for the rights and welfare of its citizens, and of guests. France does not take visitors hostage and behead them, for example, nor does it crucify religious minorities. France does restrict the religious practice of Muslims, notably by prohibiting the hijab. This may be a legitimate grievance, but a proportionate response would be protest or civil disobedience.

All that said, what is to be done? This is a real quandary. The front line troops against IS, unfortunately, as presently constituted, cannot do the job. The Kurdish peshmerga is capable, courageous and disciplined, and has shown that it can defeat IS on the battlefield with U.S. air support. However, the peshmerga cannot legitimately take on the task of liberating the Sunni Arab heartland from IS, nor do they have any interest in doing so. In fact the reconquest of Sinjar is an irritant to the Baghdad government, as Sinjar is outside of the previously acknowledged Kurdish autonomous region, and the Kurds have announced that they intend to keep it.

The Baghdad government, despite some recent attempts at reform, remains Shiite dominated, has no legitimacy with Sunni Arabs, and has a corrupt and incompetent army. Its most effective elements are Iranian-led Shiite militias, and they would have even less legitimacy than the Kurds moving into Sunni Arab cities. In fact the Kurds and Shiite militias recently clashed in Tuz Kharmato, and the Baghdad government has interdicted arms shipments to Kurdistan. So our allies in this fight are on the brink of war with each other. (Turks and Kurds are also at war, although it's a Kurdish faction which does not have the support of the Kurdistan regional government. Nevertheless it makes the situation very awkward and makes Turkey of little help against IS.)

What IS wants, and what they hoped to get from the Paris massacre, is for Christian troops to come and fight them. This may not make sense to you, but to them it is the point of their existence. They believe they are fulfilling prophecy, and that the battle they are trying to provoke is essential to the fulfillment of God's plan. No, God won't give them the victory, but the spectacle of European and North American armies marching into the Arab heartland is not going to advance the cause of global harmony. That is what Barack Obama has so far done his best to avoid.

Knowledge is Evil

Certainly it is evil to contemporary U.S. conservatives. This is a particularly offensive example. It seems the Missouri state senate has, get this a "Committee on the Sanctity of Life." The chair of said committee wants the University of Missouri to prohibit a graduate student from continuing her dissertation work, which is studying the effect of the state's 72-hour waiting period for abortions. It's research -- it doesn't have a pre-determined outcome. And, as grad student Lindsay Ruhr says, "The whole point of my research is to understand how this policy affects women. Whether this policy is having a harmful or beneficial effect, we don’t know."

But, of course, the Committee on the Sanctity of Life doesn't want us to know. Just as the Republicans in the U.S. congress don't want NASA to study the earth because they might find out that it's getting warmer, or other bad news about the Free Market. Just like the church fathers who refused to look through Galileo's telescope. But that didn't stop the earth from going around the sun.

A brief history of the world

Here Brad DeLong discusses the history of technology. His particular emphasis is on the past 250 years or so with the sharply accelerating pace of change, but he ranges back to the invention of the spear and the domestication of the horse. His central concern here is on whether machines, having replaced much of the work of our bodies, will shortly replace the work of our brains, and how the economy would then work.

That's a fair enough question, but I will take this opportunity to step back and reflect on the human created world in which most of us humans now live. This is the 50th anniversary of the great northeastern blackout, an even I remember although I was in the fifth grade. We lived in the country so nobody was stuck in an elevator, but we had to go out to the car to listen to the radio in order to find out what was going on. The power came on by morning and apparently people in New York City generally refrained from antisocial behavior, but it was still an impressive event.

Since then I have endured much longer, but more localized power failures -- about a week seems to be the limit for our tropical storms and major winter weather. And they get the hospitals and gas stations and supermarkets back in business first, so it's really just the showers and hot meals that we miss, and maybe TV if you're into it, except for people who do lose work for the period. But that's still pretty miserable.

So think about what would happen if we had another total northeast blackout that lasted, say, two weeks. We'd have a lot of short term fatalities, obviously -- people dependent on electrically powered devices, medications or oxygen that they could not obtain, ambulances running out of gas, people freezing if it's winter, and what not. Maybe some of those people in elevators would never be rescued. But then the power comes back on . . .

Lots of small businesses would go broke, from spoiled goods, or just lack of income leading to unpayable debts. Most people would have lost two weeks of wages but many of them wouldn't get back to work right away, or ever. All sorts of business processes would have been disrupted and it would take weeks to get things running again, with more losses and cascading bankruptcies. There could be widespread social disorder and political turmoil.

One can think of other possible disruptions of the impossibly complex social machinery we have constructed that would have devastating consequences and be very difficult to repair. Now, of course specific predictions such as we hear from Ron Paul and Glenn Beck are nonsense -- there is no reason to expect the economy to evaporate in an explosion of hyperinflation (and if it does, nobody will want your gold, by the way). But I can understand the free-floating unease that many people have that translates into political paranoia. The world is complicated and scary, it's changing much too fast, the conclusions of science are incomprehensible and bizarre. People want clear, simple answers and they want to feel secure.

And that's how we get the Republican presidential candidates.  

Odds and Odders

I've been extremely puzzled by the Ben Carson phenomenon -- not so much that he polls well with Republican primary voters. They love a fellow religious fanatic, and being a deranged ignoramus is just a bonus. Recent polls show him tied with HRC in the general election, and that is quite weird, but let's chalk it up to most people not really paying attention. No, what's puzzling is the man himself. How can you graduate from Harvard, presumably having studied the science pre-requisites for medical school, and be as ignorant and incapable of critical thinking as a slug? FYI, the Egyptian pyramids were built over a period of about 2,000 years, from c. 2.667 BC - 664 BC. I'll just stop there.

You'll just have to take my word for it that it was pretty obvious to me that GI Joe Gliniewicz had committed suicide pretty much from the beginning. Obviously I couldn't say anything until the official word came down, since he had a family and all that, but we knew right away that: a) This happened in a remote area where there was not particular crime to be committed, even if he did see some guys walking around; b) He was killed with his own gun which was found near his body; c) Even if those guys did have something to hide there was no reason to confront him and kill him since he was on foot a couple of hundred feet from his vehicle and all they needed to do was walk away; and d) There were no reported crimes and no known fugitives meeting the description anywhere in the area.

And just as obviously, the police knew this even before I did. And yet we had to put up with this two-month-long bullshitfest from Fox News and the police unions about how Obama murdered him. Disgusting.

I'll refer you to Erik Loomis commenting on the DoD paying for military tributes at sporting events. This sickens me for several reasons. First, the sports teams get credit with their fans for what appears to be (in their worldview) public spirited support for "our troops," whereas in fact they're just pocketing cash. Second, the glorification of the military is intended not only to lure young people into the ranks of cannon fodder, but also to promote the beauty and romance of war. Third, I have better things to do with the five or ten minutes before the game starts. Let's have some tributes to teachers or social workers instead.

Ha Ha. Study finds children from non-religious households are more generous than children from religious families.

Stayin' Alive

I almost wound up accidentally missing the tree for the forest by immediately posting on Ma et al's "Temporal Trends in Mortality in the United States, 1969-2013," in last week's JAMA. (You should be able to read the abstract here.) Fantastic news, it seems. During that slightly more than 4 decades, the age-adjusted death rate in the U.S. fell by 43%. Death rates were down for all major causes except for COPD, a remaining echo of the tobacco epidemic. The biggest killers, cancer and heart disease, showed big declines, although the decline for cancer has leveled off.

But, as it turns out, buried in all the good news is this rather surprising but previously overlooked nugget of ugliness, which is that the death rate for middle aged white Americans, particularly those with no more than a high school education, has been rising. Don't take this the wrong way -- African Americans are still at higher risk of death than white people. But it's quite unusual for any large demographic group in a wealthy country to have a rising death rate recently. (The collapse of the former Soviet Union resulted in elevated death rates, but it's hard to think of another example.)

What's perhaps most surprising is the reason -- suicide, alcohol and drug overdoses, and alcoholic liver disease. Part of this is that people have been reporting more chronic pain of late, and this group -- middle aged white people -- is more likely to get opioid prescriptions than are others. Apparently doctors don't think they are at risk for addiction. But opioid addiction can send people onto a profound downhill trajectory. The group seems also to be at risk for social isolation, economic deprivation, and mental distress. So yeah, it's bummer city out there for a lot of folks. Enough to kill them.

Muslim Atheist President Establishes Death Panels by Executive Order

Yep, he did. In the absence of legislation, the Centers for Medicare and Medicaid Services has promulgated a rule that will provide a billing code and reimbursement for physicians to discuss end of life plans with their patients.

In such conversations, patients could discuss whether and how they would want to be kept alive if they became too sick to speak for themselves. Doctors can advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

Under the rule, officials said, Medicare would pay $86 for the first 30 minutes of “advance care planning” in a doctor’s office and $80 for the service in a hospital. In both settings, they said, Medicare will pay up to $75 for 30 additional minutes of consultation. These standard amounts can be adjusted for differences in costs in different parts of the country.

What should astonish us all is that this has gone almost completely unnoticed. It turns out that the former half-term governor of Alaska did spew about death panels when she heard about the rule, but she was just about totally ignored. So progress is possible.

The late, unlamented

Willis Carto, of whom I had never heard -- not surprisingly, since he worked behind the scenes and didn't put his name on his publications or organizations. Carto was the insane wizard behind the curtain of the far right racist Liberty Lobby, it's publication The Spotlight, and its radio broadcasts; and the Institute for Historical Review, dedicated to proving that the Nazi holocaust was a lie.

Lest you think he lived beyond the fringe and had no impact on American politics, he was invited to testify before congressional committees numerous times, and, as the Times obit notes, he "helped bolster what became fairly conventional rightist causes: drastically slashing the income tax and blocking a constitutional amendment to guarantee women equal rights. His positions on immigration, globalization and multiculturalism — all of which he loathed — were influential."

We hear the echoes of the Liberty Lobby in the modern Republican party. Holocaust denial and overt anti-Semitism are largely out of fashion on the right, because of the alliance between right-wing evangelical Christians and right-wing Zionism, not to mention Sheldon Adelson's money. But the rest of the program is the essence of contemporary conservatism. While the historical association of these causes is not an argument about their substance, it does help to explain the psychological appeal of contemporary conservatism in terms of its cultural roots. The line we can trace from Carto to Donald Trump and Ted Cruz is very easy to see.

The flesh of tetrapods

There are many good reasons not to eat meat -- something I have not done for 40 years, by the way. (I do eat some seafood.) But I'm a little nonplussed, if that's the word, by the massive global flapdoodle over this new publication by the World Health Organization saying that eating procesed meats (and probably any red meat) is associated with an elevated risk of cancer.

My nonplussedness is because we have known this for decades. All they are doing is restating epidemiological evidence that has been emerging since the 1980s. This is not a "study" as most reporters have been calling, but a systematic review of what we already know.

The truth is the absolute risk is pretty small, although it certainly pertains to amounts that carnivores do commonly consume. A steak or two strips of bacon a day is the kind of dosage they are looking at, and if you aren't a DFH you probably eat at least that much. This represents something on the order of a 1% lifetime increased risk of cancer. It's far more important not to use tobacco in any form, not to drink to excess, and to maintain a healthy weight. Steering clear of formaldehyde and nuclear waste are also good ideas but you're probably already doing that.

I think the public should be informed, of course. The problem is keeping things in perspective and in proportion. The meat industry is destroying the planet because it produces immense carbon outputs. Making a pound of beef takes 8 pounds of feed. If people ate the vegetable products directly, we'd multiply the product of our farmland, fertilizer, and machinery 8 fold. And we'd cut our risk of cancer by 1 or 2 percent.

 

Norlins

My hotel is at the corner of Bourbon and Canal St. and I have to say, I haven't had an opportunity to do any extensive exploration, but I'm disappointed so far. It's incredibly tacky around here, nothing but CVS, McDonald's, store selling junky tourist crap, and yes, strip clubs. Not the New Orleans  I expected at all. I'm sure I'm just in the wrong place.

Anyway, everybody here thinks like I do, which means so far I don't have a lot of revelations for you. But I will say this -- modern medicine is very complicated and it is legitimately difficult for doctors and patients to get on common ground, understand what's important from each other's perspective, and understand each other's explanatory models and reasons for feeling how they feel. And yes, doctors do have feelings -- yes they mostly do care about their patients but not necessarily in a good way from the patients' point of view, because they take it personally when people don't do what they want. Also, when that happens, they usually don't try to find out why.

I'll have more to say soon. At least it's stopped raining.

Jacamo Fina Ne

And I'm off to N'Orleans tomorrow for the International Conference on Communication in Healthcare. Never been there before, glad I'm getting a chance to go before it's under the ocean.

I'll be presenting some of my research on physician-patient communication. Long story short, and probably not a news flash, but doctors still aren't doing a lot of the stuff they should be doing to help us understand and remember what's going on, and make decisions together that work for us.

The way a medical visit ought to go is first, set an agenda. What do you want to accomplish today? And here's what I want to accomplish. If it's too much, what is the priority and what can wait? Then go through it in an organized way. The doctor should ask open questions to invite the patient to express concerns or ask questions of her own. The doctor should explain that there are alternatives, not just say what he or she thinks is best without explaining why. Patients should have a chance to say why they might find it hard to follow advice. They should have a chance to state their own relevant values and goals. The doctor should ask the patient to repeat back, in his or her own words, any important information and instructions. ("Do you understand?" is a waste of oxygen.) And there should be a wrap-up at the end that reviews the important points.

Doesn't sound too hard! Also hardly ever happens. Doctor visits are a disorganized mess and doctors just tell people what to do. And people only remember half of it without prompting. Even with prompting, if there are too many things to remember, people remember fewer of them.

Have you ever been frustrated by a visit with a physician? Why?

The Profoundest Evil

Yes, this will be the hottest year globally in recorded history, and it's accompanied by widespread drought in Africa, drought in Australia, a heat wave in India and Pakistan that likely killed several thousand people. It's already here, and it's just going to get worse.

Sorry Atrios, but your "worse humans in America" awards trivialize the real worst humans in the world. They are fossil fuel industry executives, including the executives of Exxon who have known since 1977 that their industry would eventually destroy much of civilization, and who chose to spend millions to cover up and deny this fact so they could keep getting richer.

You know what? That may actually be worse than Hitler.

I guess I shouldn't be so puzzled . . .

by the ability of serial sexual abusers and harassers to get away with it over many years. I have personally seen little of it at my own workplaces. Once a woman I supervised came to me with a complaint about a co-worker, but he was a low status employee and our executive director dealt with the guy quickly and decisively. We also had an executive who behaved inappropriately toward women but they fired him, mostly because of more general incompetence, I think.

I've been in academia full time for 10 years now, and part-time for 10 years before that, and I have to say that tales like that of Geoffrey Marcy and Colin McGinn came as a bit of a surprise. (Here's PZ on Mcginn, and we are talking about a world historical creep here.) So astronomer John Johnson, who had the opportunity to hear stories from many of his female colleagues, helps by explaining the enormous power senior academics have over junior colleagues, and the elements of human nature that make us reluctant to tell others when we have been conned or betrayed. There's a shame that goes along with it, we feel as though it's our own fault. Psychos like McGinn and Marcy know that, and they also know who the deans value more if it does come down to a she said/he said.

It seems this behavior is actually very widespread. If you read the comments on Professor Johnson's post on the Women in Astronomy blog, you'll get the impression that it's the norm in astronomy departments. I don't think I'm so obtuse that it's going on all around me in the School of Public Health, but I am certainly unaware of it. I don't think it's nuts to think that we have a somewhat different culture -- we aren't nearly so male dominated, there are lots of women in top faculty positions in public health. But I'm not so sure what's going on at the medical school . . .

Greatest Headline Ever

Man tries to put out garbage fire by driving over it in a van loaded with ammunition.

Yet another incident in the annals of responsible gun ownership.

Yet another one of those campus free speech/political correctness flapdoodles ...

...this time at an Ivy League university in Providence, Rhode Island which shall remain nameless. It seems a student whose real name is Emma Maier wrote two opinion pieces for the student newspaper, the [redacted color] Daily Herald, under the pseudonym (for some reason) M. Dzhali Maier. One of them, which apparently said the native Americans should be grateful for the European invasion, I have not been able to read because the Herald took it down, claiming they did not intend to publish it in the first place, but didn't get the word to the printer in time.

The other, which you can read here, accompanied by an editor's note repudiating it, recounts some largely (though not entirely) accurate history of how technological advances in southwest Asia and Europe led to Europeans being able to conquer distant lands. However, it puts a spin on this history which seems to endorse or justify colonialism and genocide as the privilege of the more technologically capable "race." You actually have to read it carefully to get that, it's not a blatant racist manifesto, but that does look to me like the subtle point.

So, there has been a lot of complaint about the diversity of the Herald editorial board and whether it is proper to publish stuff like this. It so happens that Columbus Day (or Dia de la Raza as others call it) was the occasion for Scott Lemieux to note that the late Christopher Hitchens made the same argument about how the Injuns should be grateful for the European conquest, and published it in The Nation magazine (which also was happy to run his aggressive promotion of George W. Bush's imperial conquest of Mesopotamia).

Of course, The Nation's editors didn't have to publish anything they didn't want to, nor does the Daily Herald, and one may rightly complain. However, once something is published I think the best response is to write your answer. The various statements and proclamations, from the university president and other senior officials, and from various campus organizations, don't really answer these essays so much as just condemn them by labeling them as racist, and insisting that racist statements should not be permitted at the University.

I don't actually agree with that. Racists don't think of themselves as evil, or mistaken. They have what appears to them to be a coherent world view. Not permitting them to express it on university grounds or within the formal means of communication characteristic of the university won't make their beliefs go away, it will just prevent anybody from explaining why they are wrong. So were I the university president, I believe I would have responded somewhat differently. I find this personally offensive, and many others do as well. Let them speak out. But we must be very clear that we don't suppress what we find offensive.

There are lines not to be crossed, of course, including gratuitous insults to specific people, and threats of violence. E.g., don't call people offensive names, don't hang up nooses, that sort of thing. But telling people they aren't allowed to express specific stupid ideas is counterproductive, not to mention a slippery slope. (No, the First Amendment does not govern the policies of a private university. But the rationale for it does apply here.)

Yet another smack down of libertarianism

Brad DeLong presents a quotation from Daniel Kahneman which evokes one of the deep problems with the idea of liberty. I want to dig even a little deeper. Go ahead and read the whole thing, it's just three paragraphs, but here is a snippet:

For behavioral economists, however, freedom has a cost, which is borne by individuals who make bad choices, and by a society that feels obligated to help them.

With respect to this observation, I have previously remarked on motorcycle helmet laws. If you suffer a traumatic brain injury in celebration of your individual liberty and personal responsibility, we the taxpayers are going to pay for your life-long institutional care. You have therefore deprived us of a bit of our liberty. If you have children, it's even worse. This, in a nutshell, is why we sometimes need the nanny state to make us more free, not less.

But it goes deeper than that. We obviously can make choices that we later regret. We want to save the biker from himself because, as Kahnemann points out, we will be obliged to take care of him if we do not. His personal misfortune is still left as his own problem.

But consider. A tobacco addict would be freer today had he never chosen to smoke that first cigarette. Many people with diabetes would have more liberty had there not been a soda machine in their high school, even though it gave them the liberty to drink soda at the time. (Let us presume they can pay for their own health care.) One can endlessly invent such examples. We often appreciate somebody saving us from ourselves, so why not the state?

The simple fact is it is always a tradeoff. There is no such thing as liberty. The universe always limits our possibilities. Granting me one liberty inevitably deprives me, and other people, of others. Whatever freedom I am granted to choose unwisely may cost me less freedom tomorrow.

You see? Moral philosophy is hard. That is why some people never seem to outgrow Ayn Rand.

The Nut Party

While Republicans are completely wrong, about everything, one of their weirdest wrongnesses has been the refusal of Republican-led states to accept the Medicaid expansion. While this obviously leaves a lot of vulnerable people unable to obtain medical care, it also does substantial economic and institutional damage to their states. That physicians and hospital owners and executives, who are well-to-do and often Republican, have been unable to howl loud enough to overcome the mindless ideological opposition to the Affordable Care Act, is disturbing.

Reiter et al, in Health Affairs, give us an idea where this might be going. States that refused the Medicaid expansion have a disproportionate number of poor, and rural residents. Since the ACA presumed that all the states would accept the expansion, it reduces federal funds that used to go to hospitals that served a disproportionate share of uninsured people. This means that those rural hospitals in the red states are coming under increasing financial pressure. They are financially vulnerable, often losing money, and may start to go our of business. As the authors write, "Policy makers need to formulate strategies for maintaining
access to care for rural populations residing in nonexpansion states."

Do yuh think? But that would mean, you know, spending money. Which Jesus specifically said not to do for the benefit of poor people. It's right there in the Republican Bible. But then what happens when the rich people who live in the same area lose their hospital?

The Ruling Class

I haven't posted here for a few days because I've been busy with events in Afghanistan, which have been quite outrageous. Anyway, I'm back here now with a different outrage.

You may recall a whiff of corruption affecting my employer, which I recounted a week ago. Well, the ever reliable BMJ is back with the subject for this Monday's post. It seems, according to Anderson et al, that of 442 publicly traded health care industry companies in the U.S. for which information on their Board members was available, 180 had at least one director who was affiliated with academic medicine. That includes 19 of 20 top NIH-funded medical schools. They include 8 medical school deans as well as 121 professors and 15 university presidents or provosts.

Oh yeah -- their average compensation was $193,000 per year. As far as I'm concerned, this is completely unacceptable. As David Rothman says in an accompanying editorial, if the companies want advice from these people they can get it without putting them on the board of directors and matching their academic salaries in exchange for attending a few meetings a year. This is bribery, and it has to stop.

A mighty wind

The current National Hurricane Center forecast puts the bullseye for hurricane Joaquin precisely on my ass. Fortunately for me, though possibly not for some other people, the meteorological blogger Jeff Masters at Weather Underground (no link because this is so ephemeral) explains that this is just splitting the difference between models that take it out to sea, and models that bury it in the mid-Atlantic. It's far too soon to know what will happen, but regardless they are predicting a lot of flooding rain and onshore wind.

That will cause a lot of damage, and maybe kill some folks, but it would be a lot less if congress didn't spend your money to encourage people to build houses in places where they will inevitably be destroyed. The National Flood Insurance Program is incredibly stupid for many reasons. Here, according to the General Accounting Office, is the first one:

The National Flood Insurance Program (NFIP) is a key component of the federal government’s efforts to limit the damage and financial impact of floods. However, it likely will not generate sufficient revenues to repay the billions of dollars borrowed from the Department of the Treasury (Treasury) to cover claims from the 2005 and 2012 hurricanes or potential claims related to future catastrophic losses. This lack of sufficient revenue highlights what have been structural weaknesses in how the program is funded. While Congress and the Federal Emergency Management Agency (FEMA)—the agency within the Department of Homeland Security (DHS) responsible for managing NFIP—intended that NFIP be funded with premiums collected from policyholders and not with tax dollars, the program was, by design, not actuarially sound. As of December 31, 2014, FEMA owed the Treasury $23 billion, up from $20 billion as of November 2012. FEMA made a $1 billion principal repayment at the end of December 2014—FEMA’s first such payment since 2010.

Another reason it's stupid is that it uses private insurance companies as intermediaries, rather than administering the program itself, and like all corporations, insurance companies are evil and they screw claimants even as 40% of premiums go to administrative expenses, most of that paid "to private insurance intermediaries who sell and manage flood insurance policies on behalf of the federal government but do not bear any risk."

Finally, of course, the sensible thing to do would be to retreat from the rising seas and allow salt marshes and barrier beaches to replace the shore front developments which keep getting wiped out and rebuilt with taxpayer dollars. That would also be good for the marine ecosystem, since the destruction of those regimes has meant loss of spawning grounds and marine biomass production. In the long run, it's inevitable.

But you know, people are stupid.