This won't end the opioid epidemic . . .

. . . but it might help. The CDC has come up with new guidelines for opioid prescribing in outpatient care which are heavily promoted in the leading medical journals. (The link is to NEJM, which proffers it for free to the subscriptionless rabble.)

The story of how we got where we are is pretty well known, I think. But I'll recap it for convenience.
Chronic pain (CP) is the most prevalent and expensive health condition in the United States, estimated to cost up to $635 billion per year in health care costs and lost productivity. Often pain is from osteoarthritis or other identifiable physical causes, but as I have discussed here previously, it can also be a malfunction in the brain-nervous system circuits that creates pain without an identifiable physical lesion. That makes effective treatment elusive. 

Obviously, having chronic pain can be a serious drag. It is associated with depression, social withdrawal, loss of employment. So, back in the 1990s a movement arose claiming that chronic pain was undertreated because doctors were too afraid to prescribe opioids. People claimed that when they were used to treat pain, people rarely became addicted, that there was little harm in long-term use, and that opioids were the magic balm that doctors were callously refusing to suffering people. No big surprise, the companies that make them sang the lead part in the chorus. 

So now we have an epidemic that is devastating communities all over the U.S., of overdose from prescription opioids, and of addicts who have switched to illicit heroin and fentanyl. Along with this comes ruined lives, crime, HIV and hepatitis C, and death. 

The truth is that long term opioid use for chronic pain does not work. Ever-increasing doses are needed to maintain analgesia, with ever-increasing side effects, and eventually complete failure. In fact people who use opioids long-term may have more pain than people who do not. And yes, it is addictive, particularly as doses increase. The new guidelines make prescribing opioids for chronic pain in people who are not terminally ill a last resort, but if you look at the facts, it probably shouldn't be a resort at all. If you have acute pain, from surgery, or breaking your leg, you might want to go for three days, seven is really stretching it. But longer-term use really doesn't make sense for anybody. 

I had surgery and I took opioids for one day, then switched to high-dose ibuprofen, which was perfectly adequate. I took omeprazole concurrently to prevent stomach upset. Unfortunately, for chronic pain NSAIDs don't really work either, and they can have serious side effects if taken long term. There really isn't any good pharmaceutical option for most people. (A minority seem to respond well to gapapentin or similar drugs, but you need to get lucky and they can also have weird effects.) The most important thing is not to give in to it -- stay active, overcome the natural reaction that the pain signal is telling you not to use the affected limb, lose weight if that's a problem for you, and stay involved in your usual activities. It may well get better in time, but in any case, you can live positively. Dope is not the answer.

Betraying Confidences

My friend Gary has an essay on the NY Times web site about using stories about his psychotherapy patients in his books. It turns out that even though he disguises their identities every which way, the real problem isn't that a patient's confidentiality might be betrayed, it's that the patient might recognize herself. Using the therapeutic relationship as a means to an end feels exploitive to the patient, even if nobody could possibly recognize her.

I don't exactly have the same problem -- when I interview people or record their medical encounters, they know that I'm doing it for research and some version of their story may appear in print, without sufficient detail to identify them. But I still have to be very careful. There's this, for example, which I have published:

Well, I went to three actually detoxes. I said - 'cause when I got out there, they kept on switching me from one to another. I wasn’t - I was quitting and, well, I got kicked out of one of them 'cause I had sex in a closet with a nun . . . .  So they said, "You gotta get out." But I went to three detoxes. I don't want to get off.

(She did eventually quit drinking and she's doing okay now.) No matter what I did to disguise her identity, there must be people who are familiar with this incident, and would know who this likely was if they read the paper. Fortunately, it's very unlikely they will ever read it. But still.

We always exploit our research subjects to some extent. I get the grants and the salary and whatever prestige comes with publishing. They get 20 bucks for an hour of their time. I get to decide what parts of what they tell me matter and what parts don't, and how to present and interpret their experience. I do my best to give them a voice but in the end, it's really mine after all.

The Lipid Hypothesis

You may have heard that the long-standing conventional wisdom about the ill effects of saturated fats has come under sharp questioning.  A team of investigators led by NIH employee Christopher Ramsden has resurrected and reanalyzed data from the Minnesota Coronary Experiment, a nutritional trial done back in 1968-73, which was a foundation of the conventional wisdom that substituting vegetable fat for animal fat in the diet is protective against heart disease. They have also done a meta-analysis of published studies and had earlier re-analyzed data from the Sydney Diet Heart Study of the same era.

To make a very long story short, what they found is that diets high in linoleic acid -- a component found particularly in certain vegetable oils including safflower and corn oil -- and low in saturated fat do reduce LDL cholesterol. But . . . 

According to data from these studies which were never published, that did not correspond to a reduction in the risk of heart disease, coronary events, or death. I would say this conclusion is not quite definitive. For one thing, the Minnesota study had a non-representative population of residents of mental hospitals and a nursing home. They had a lot of comorbidity. Also the high linoleic acid diets they were fed are considerably more extreme than the diets people would have in real life. For one thing, olive and canola oil are not so high in in linoleic acid; and most people would continue to consume substantial animal at even if they did try to substitute some amount of vegetable oil. Other problems are that the available data from the study don't allow direct testing of the association between LDL levels and outcomes; and that autopsy data to assess atherosclerosis is available for only a small number of participants.

Still, this work has reopened what the conventional wisdom had long considered a closed can of worms. It's been extremely controversial and of course people who have been entrenched in the conventional wisdom their whole careers aren't about to suddenly "Oops, you got us." This is not my expertise and I'm certainly not going to pronounce a verdict. It is still pretty solid that trans-fats are bad for you, statins do protect against heart disease (although maybe not so much because of their cholesterol lowering effect after all -- something long suspected), and excess sugar is also bad.

But we don't really understand what's going on with lipids in the diet or the blood plasma. It's certainly not as simple as people have long believed. The "low fat" fad of a few years back was definitely a mistake.

Most important of all, science is not like religion. It's open to correction and change. However dug in some people are about the lipid hypothesis, it's not like the Bible. It can be rewritten, and it is being rewritten. Don't get cynical and start down that well-worn path of saying, they're always changing the advice about diet, so why pay any attention? Some advice has been changing lately, but some of it has gotten more solid than ever. It's always getting better, so I say you should keep paying attention.Keep eating your veggies and whole grains, and steer clear of the sugar bombs. But I would say you can relax about dairy if you're okay with it on ethical grounds.

No, you don't need to read the whole thing . . .

. . . but here are the new official U.S. government dietary guidelines for Americans. No, the Nanny State isn't actually forcing you to eat broccoli. (But try it, you'll like it!) They're just giving you information that you can take or leave.

There is one really important nugget in here. It really is very close to a magic bullet. That is the recommendation to limit added sugar to less than 10% of calories per day. This is the first time they've had the nerve to stand up to Big Soda and name a number.

Actually the number is still too high. The American Heart Association thinks it should be 5%. Anyway, just to be clear, one (1) single 16 ounce soda will take care of your 10%. That's it. If you want to eat a cookie or sprinkle sugar on your oatmeal, you can't drink a soda. Americans get almost half of their added sugar from sugary beverages, if you include coffee and tea which you should, because what you get at Starbucks is not actually coffee but sugar with added ingredients.

Want to lose weight? Forget about Atkins and Scarsdale and grapefruit and whatever other fad comes along. Don't drink soda, so-called "energy drinks," phony fruit juice (marketed as name-of-fruit cocktail or "drink"), or pretty much anything that's likely to be in the cooler at your local take-out. For most people, that's the single most important thing you can do. And even if you aren't seriously overweight, eating all that sugar increases your risk for diabetes, cancer and heart disease.

I am not a nut. This is the truth. It really is that simple. Yeah, once you've accomplished that there are still better and worse diets, and you still need to exercise and not smoke. But if people just stopped poisoning themselves with the products of Coke and Pepsi, it would be the single greatest advance in public health since sanitary sewers.

Finishing up on the QALY thing . . .

Fortunately, just as I was beginning to lose the thread, Thomas A. Farley comes along in NEJM to make my point for me. A small explainer is needed -- in order to compare the benefits of various health-related interventions, we need a "common currency." It's not enough just to look at life extension. On the one hand, some interventions don't necessarily extend life at all, but they still have value because they relieve pain and disability. Others may extend life, but with very poor quality.

So Quality Adjusted Life Years are a commonly used measure of benefit. They're controversial and I actually buy some of the criticisms. Here's the Wikipedia article. There are a few different ways to calculate QALYs, but basically, they're based on survey data -- asking people how much life expectancy they would trade to be free of a disease state, for example. One major problem with this is that once you actually have the disease state, if it isn't horrific, you probably still want to go on living just as much. The QALY concept can be viewed as devaluing the lives of the sick and disabled. However, that's only when viewed retrospectively -- given the survey, most people can still answer the question.

Regardless, whether you go along with the QALY concept or not, as Farley explains, and as I have already said, resources are limited so we implicitly place a value on human life (or health) all the time. But our ethical intuitions lead us to bizarre conclusions. Farley gives the example of a woman with incurable cancer, whose life can be extended for a few months at a cost of $80,000. Most people insist on giving her the treatment, and by law, Medicare is not even permitted to consider cost in approving treatments. But . . .

We could extend far more lives for far longer for far less money, very easily, but we decide it costs too much. To take an obvious example, anti-tobacco campaigns in the mass media, according to Farley, cost less than $300 per QALY gained, which is a tiny fraction of the cost of cancer treatment; but they occur only sporadically. (Come to think of it, I can't remember seeing one for years.)

Why is cost the main consideration when it comes to prevention, and benefit the only consideration when it comes to treatment? Note that this is essentially the conservative or Republican approach to population health, with a weird exception -- provide every possible treatment, no matter what it costs, to everybody who is lucky enough to have insurance. (Which means that other people -- taxpayers or ratepayers -- are in fact paying for it.) Of course, people who can't afford insurance can just die in the street. But I thought human life was infinitely precious? I guess Sarah Palin's is, anyway. On the other hand, spending money to improve air and water quality, improve children's nutrition, provide better quality housing, or whatever the preventive measure may be that extends life and health, is Big Government, Nanny State, and deprives us of our Freedom.

This obviously makes no sense.

Civilization and its Discontents

The World Health Organization reports that the prevalence of diabetes world-wide has increased 422 million adults, which is an astonishing 8.5% of the population, essentially doubling since 1980. We tend to think of this as a disease of the rich countries,  but WHO says it's worldwide. Oh yeah -- more than 1/3 of adults on the planet are overweight.

Has the human population suddenly turned gluttonous and lazy? Obviously not. This is actually an environmental catastrophe. More and more people have sedentary jobs, and where people aren't starving due to conflict and social collapse, the world is awash in cheap calories. To a large extent this is a product of technological change for which we can't blame anybody in particular. However, it is also true that much of the world's food now consists of manufactured items that are scientifically engineered to induce overconsumption of low quality calories. Sugary soft drinks, sweet and salty snack foods, prepared cuisine -- they are all developed and tested in laboratories to hijack the neuro-endocrine systems that regulate our appetite.

There is no moral distinction between the merchants of soda and the merchants of tobacco. They are selling death, to satisfy their greed. This must stop.

The War On [some people who use some] Drugs

It's hard to believe we're still pissing into the wind on this particular subject. I remember sitting in the science library at Brandeis when I was a graduate student reading policy analysis in Science (the journal of the American Academy for the Advancement of Science) showing that most of the harm caused by illicit drugs was caused by,well, their illicitness. Now we have some 20 years later yet another authoritative finding that criminalization of drug use severely harms public health. Quoth:

"The goal of prohibiting all use, possession, production, and trafficking of illicit drugs is the basis of many of our national drug laws, but these policies are based on ideas about drug use and drug dependence that are not scientifically grounded," says commissioner Chris Beyrer, an epidemiology professor at the Bloomberg School. "The global war on drugs has harmed public health, human rights, and development. It's time for us to rethink our approach to global drug policies, and put scientific evidence and public health at the heart of drug policy discussions."

Oh right, we should base public policy on science. As if.

What is probably most enraging is that the politicians in the U.S. who want to continue to lock up hundreds of thousands of non-violent (mostly non-white) people just for using or selling small quantities of "drugs" -- which does not include alcohol or tobacco -- are the same ones who claim they are all about small government, individual liberty and personal responsibility.  Well, they aren't. They're liars and hypocrites.

Did I ever mention that we need universal, comprehensive, single payer national health care?

I may have noted that once or twice.

Anyway, as I have also noted, Obamacare is an improvement on what we had before. In fact it's worked better than expected! But it's a very kludgy fix.

The consulting firm Avalere Health, which for some reason sends me free excellent analysis every couple of days, finds a lot of "churn" in the exchanges from year to year. Specifically, only 1/3 of people who were enrolled in 2015 kept the same plan in 2016. They figure this is because most people who buy insurance through the exchanges are low income, and very sensitive to price. That means they are always shopping for a cheaper deal.

On the one hand, that doesn't sound like such a bad thing. In fact, if you're a conservative free market ideologue, you should be super duper happy. Consumer choice! Competition! Adam Smith!

The bad news is, however, that this likely means for many of them that they end up changing providers. Continuity of care is very beneficial. You know your doctor, your doctor knows you. You don't have to tell your story all over again, get records transferred, navigate unfamiliar systems. You get better outcomes. Even if your doctor retires or moves to Borneo, she can manage a smooth transfer to a colleague.

There isn't actually any benefit in this phony choice among insurance companies. If we had universal, comprehensive, single payer national health care then you could pick any doctor who had an opening and stay with him or her if you liked the relationship, or move on if you didn't. The single payer would get a single, fair price from everybody, and could pay for results, not volume. And the insurance companies wouldn't be skimming off profits, marketing and administrative costs. We'd all be better off.

But you know, soshulism.

The Chronosynclastic Infundibulum

As Vonnegut fans know, that's an anomaly in space-time where every possible belief is true, more or less. Or more accurately, where there are infinitely many ways to be absolutely right about everything. It's somewhat like post-modernism, or the 2016 presidential campaign.

My greatest philosophical conundrum is that I want to be respectful of democracy and to promote open discourse and dialogue; but you know, there are just some things that are true that I am right about and some people are flat wrong about. But how do I know this when the people who are wrong also know that they are right?

You most likely heard about Robert DeNiro back-dooring the Andrew Wakefield fraudumentary "Vaxxed" into the Tribeca Film Festival, only to reverse the decision after an organized outcry from the scientific community. (I've covered the issue here extensively but not for a while. Wakefield was a British physician, now de-licensed, who published a fraudulent study in The Lancet claiming evidence that the measles vaccine causes autism. He's disgraced, the paper retracted, and immense overwhelming evidence shows that it just isn't true, but Wakefield still has a small army of believers.)

So, of course, reporteth The Guardian:

By Monday, conspiracy theorist websites were portraying the decision to pull Vaxxed as an act of censorship perpetuated by the “vaccine mafia”. Wakefield and the film’s producer Del Bigtree put out a statement saying: “We have just witnessed yet another example of the power of corporate interests censoring free speech, art, and truth.” 

Now here's the problem. Corporate interests do have a big influence on what ideas and facts make it into the corporate media; and they have succeeded for long periods in concealing the truth from the people -- about lead, tobacco, climate change, and other important issues. How do I know if I'm being duped?

Well, in some areas I'm enough of an expert that I can read the scientific literature critically. I know enough about epidemiology that I can do that in the case of vaccine safety, and I have. There is a describable process of inference that has been applied to this question and there is an answer that satisfies everybody who understands how to read the literature critically. I can see the motivated reasoning and/or ignorance on the part of the anti-vaxxers.

In other fields, however, I do have to put more faith in the expertise of others. I've read enough about climate change to be convinced,  and honestly, I approached the question skeptically. But I haven't actually evaluated the models used to make predictions. I'm not competent to do so. I do know, however, that the proposition of a conspiracy involving thousands of scientists, hundreds of research institutions, and most of the world's governments, to promote this as a falsehood, is preposterous. I have to go with the maximum likelihood solution.

So no, you can't verify every question for yourself, but you do need to have a smart idea about which institutions to trust.

This and that

Sorry for the absence, been busier than I have been motivated.

Dan Drezner is right: it's no use writing about Donald Trump. What is there to add to the obvious?

The trouble with writing about Trump is that he has no complexity. There is no subtext to what Trump says or does — it’s all on the surface. He’s so basic that it’s impossible to find any deeper meaning or counterintuitive take.

As usual, you have to read European media to learn that the CIA took naked photographs of people before sending them off to be tortured by foreign co-conspirators. This was ostensibly to prove that the CIA hadn't beaten them up too badly before having somebody else do it (some of them were bruised, however) but sexual humiliation is also a war crime. But you know, we're looking forward, not back.

All these "Christian" legislators voting for bills to permit discrimination is getting old. Fortunately, Republican governor Nathan Deal is more beholden to business interests than he is to religious fanatics so he is going to veto the Georgia version. Note that these Christians who hate gay people are no doubt very supportive of the CIA sadistic psychopaths who got off on shoving various items into prisoners' rectums (as the Spencer Ackerman piece in the previous link reminds us). Today is a good day to say that I have had far more than enough of Christians.

Happy Birthday!

to the Affordable Care Act, which became law 6 years ago today. Now that we have all grown accustomed to the Death Panels and the government bureaucrats sitting between you and your doctor, not to mention the destruction of millions of jobs and the forced abortions, we can take stock of the good stuff:

• 20 million people have gained insurance
• Share of the population without insurance is below 10% for the first time ever
• Workers with no limit on out of pocket spending fall from 18% to 2%
• Health care prices have risen at the slowest rate in 50 years
• Premium growth for job-based coverage is sharply lower
• Federal deficit between now and 2025 is reduced by $353 billion
• Medicare trust fund projected to remain solvent for an additional 13 years
• Rate of patient harm in hospitals has fallen by 17%
• 565,000 Medicare hospital re-admissions have been avoided
• Businesses have added 14.3 million jobs

Thanks Obama!

I get e-mail

I have previously defended open access publishing here. It's a model of scientific publishing in which publication costs are paid for out of the grant funds that support the research, rather than subscriptions. Subscriptions to scientific journals can cost hundreds of dollars a year or even thousands, which means that only people with access to major university libraries can read many of them; and that even university faculty in low-income countries often cannot.

Science should be a democratic enterprise, available to all. So I'm all for open access. And there are important, reputable open access publishers, notably Public Library of Science (PLoS) and BioMed Central, among others.

Alas, the model invites scams. Just found a phony scientific journal, publish pretty much anything that comes over the transom, and collect the publication fees (typically $750-1,500). These execrable enterprises are proliferating like cockroaches; I have to delete solicitations from my in-box every day. They usually have a phony address in the U.S. but obviously originate abroad, and typically by people who do not speak English. This one I got today is pretty funny! Worth a laugh:

Peertechz salutes you for your compendium of writings which immensely help the global society and their descendants understand and shed light on and about Archives of Nursing Practice and Care. Your published manuscripts are evidence that you have innate ability and prodigies for research and writing. . .

But then again, we know that to gain the affection of an elegant author like you, we require some unmatchable spheres. So, here we are for you with some expounding uniqueness.

Join your writing ambitions with us and we assure that your manuscripts reach maximum hands. We invite you passionately to join Peertechz family.  

Should I go for it?

Comparative Terrorism

The bombings in Brussels are wall-to-wall in the corporate media and blogs. And yeah, it's a terrible occurrence. Funny thing though, there were two bombings in Turkey that killed as many people just last week, and you could be forgiven for not even knowing it happened. There were also numerous bombings -- terror bombings of civilians, not collateral damage of combat -- in Iraq, but that's pretty much routine so who cares, right?

There is a good deal that can be said about the many wrong and counterproductive responses to such events. But I'll just say that the tribalism shown here -- Christian, European victims matter, southwest Asian Muslims don't --  is a good place to start thinking about the problem in a different, and better, way.

You can't put a price on human life, right?

An odd glitch in the conservative mind is the claim, on the one hand, that human life is infinitely precious and it would be a crime to "ration" health care; and on the other that environmental, worker and consumer safety regulations are intolerable because they cost too much.

Obviously nobody actually believes that human life is infinitely precious or that you can't put a price on it because we put a price on human life all the time. Cars and highways, workplaces, stores and restaurants, homes, sidewalks, public parks, every environment that people spend time in could be made safer by spending more money. The air and water could be cleaner, the food supply could be safer. But we balance the benefits of regulation against the costs. (I'll leave war, guns and the death penalty out of it for now because that leads into other thickets.)

Conservatives generally favor spending less on public safety in all of these domains, because it would "burden business" and force people to pay taxes. Yet for some reason the equation flips when it comes to health care. Not spending hundreds of thousands of dollars to extend a life -- even a hopelessly compromised and limited life -- by even a short time is unconscionable. Note that this only applies to people who happen to have insurance, however. Which means that other people are paying for it. People who don't have insurance, and can't pay? The rest of us have no obligation to them.

Before you can even being to think about health care policy, you have to get your thinking straight on this. Resources are finite. There has to be some mechanism for allocating them. You and I may have different ethical principles, but at least you need to be consistent. Conservatives, of all stripes, whether libertarian or religious, are not.

Why we need the death panel

The UK's National Institute for Health and Clinical Excellence, which is abbreviated NICE because a) that sounds, well, nice and b) the word health was added to the name later, is an essential institution. I do not expect to see an equivalent in the U.S. in my lifetime. (I'm not sure if you can get behind the paywall for the link.)

This is a subject I used to write about a lot here and then I figured okay, I've been there and done that. But it was a few years ago and the political context has changed, so I'll revisit. NICE is not actually much like Sarah Palin's imaginary death panels. It doesn't rule on individual cases. (Well, there's a bit of an unfortunate exception, which I will get to, but it has been mostly reversed.) Rather, it decides whether the National Health Service will pay for specific treatments for general classes of people, and yes, it includes cost in the calculation.

I will write about the complexities of this at greater length in future posts, but today I will just set up the basic problem, which is absolutely inescapable. The National Health Service provides comprehensive health care for all of Her Majesty's subjects. The parliament approves a finite budget for the NHS every year. Ergo, said comprehensive health care must have limits, because it must be provided within said finite budget.

Q.E.D.

Our situation in the U.S. is comparable to the extent that we do provide government funded health care for everybody 65 and older. We do so as an entitlement, which means Congress does not limit spending on Medicare. This means that Medicare has to pay whatever the drug companies want to charge for say, cancer treatments that might extend a person's life by a couple of months. We do not, however, provide universal comprehensive health care to everybody under age 65, the ACA notwisthstanding. And there is a lot more we don't do that the Brits do, even under their current comparatively stingy Tory government. The point being, resources are finite and every country makes political decisions about how much to spend on what. In those decisions, some people die who would not have under a different allocation scheme. There are always death panels, even though they are mostly invisible. There always will be and there always must be.

So, how does NICE actually make these calculations? We'll discuss that next. 

Hillary's Brain Fart

I'm sure you already know that Hillary Clinton praised Ronald and Nancy Reagan for their courageous advocacy on behalf of people with AIDS . (I give you Dan Savage's horrified response.)

As with the recent death of thuggish legal sophists and enemy of humanity Nino Scalia, there seems an inexplicable reflex on the part of people who ought to know better to come up with praise for the departed which is a) completely the opposite of the truth and b) counterproductive to the interests and purposes of the speaker.

Death does not erase history. While it is arguably impolite to offend people who are acutely grieving, I do not think that Nancy Reagan's family and friends particularly needed to hear Hillary Clinton say something nice about NR that wasn't true. I actually don't have anything nice to say about Nancy Reagan, and I think it's important that political discourse be ruled by fact, so I won't make anything up. I don't think she was particularly important, except as a bad example. Her signature cause as First Lady was going around saying "Just say no to drugs," which was singularly unhelpful because it did not cause people to say no to drugs and it substituted for actually doing anything about drug abuse (which includes alcohol and tobacco and therefore the slogan was doubly misleading.)

Other than that she advised her husband on the basis of astrology. Those were her contributions. Enough with the crocodile tears.

Suffer the Children

JAMA has an interview with Mona Hanna-Attisha, a pediatrician in Flint Michigan who oversaw the tests on children's blood lead levels after the contaminated water was discovered, and now leads efforts to take care of the kids. This is a disaster that will reverberate for decades, cost taxpayers untold tens or hundreds of millions of dollars, and of course most important, damage hundreds of children. As Dr. Hanna-Attisha says,

[T]he consequences of lead exposure are forever. It [has long-term] impacts [on] cognition and behavior: those are the 2 we care about most. It affects every organ system. It drops IQ. Imagine what we have done to our entire population: we have shifted the IQ curve down. It impacts behavior, so it causes lots of problems with learning, focusing, conduct disorder, impulse disorder, and it has even been linked to criminality. Lead has these life-damning consequences.

 The doctors found that the prevalence of acute, detectable lead in blood in flint more than doubled, to 4.9%, but that's an underestimate. We don't even know how many children are affected because many of them were poisoned as infants and may not have been tested in time to discover it. We haven't worried much about infants in the past because most lead exposure has come from paint and kids who aren't crawling around on the floor yet and aren't engaged in hand to mouth activity weren't considered at risk. But Flint is a different story. As the good doctor says:

Our population was already rattled with toxic stresses. We have a 40% poverty rate, high rates of unemployment, high rates of violence, and high rates of single parents. We have no grocery stores in Flint. The people in Flint have a 20-year lower life expectancy than people in a neighboring suburb. We were already struggling with every barrier to our children’s success. Then we gave them lead. This is added toxic stress to the toxic stresses we already had. . . .  Parents are traumatized. For almost 2 years, we were betrayed. There is a huge lack of trust in the government and a fear of the unknown.

Rick Snyder is still the governor, still drawing his salary, still sitting in the corner office, putting his own kids in private school, no doubt. [I don't actually know that.] That's not where he belongs.

Cartoonist David Rees has only one shortcoming . . .

He can't draw. Therefore, he asks readers to render his ideas for cartoons in actual art work.

I fear this particular idea is impractical, but if you have a knack with a pencil, do give it a try.

I get that you're worried about who might have his finger on the button next January . . .

but this should take your mind off of that. (Sorry, no consolation.) Eric Holthaus discusses the ongoing global temperature anomaly and it's yuuuuge. The climate goals negotiated last year in Paris aimed at limiting warming to 1.5 degrees centigrade by the end of the century. Well, it's probably temporary but the last couple of months, we're already there.

There is no snow on the ground in Anchorage, so they sent in a trainload of snow to make the Iditarod sled dog race possible. The arctic sea ice reached its lowest maximum extent since data collection began, and the south Pacific just experienced the strongest cyclone in history.

We aren't talking 2030 or 2050. We're talking right now. Today. But who needs Miami Beach anyway?

We've always known drug companies are evil

Now it turns out they sell expensive cancer drugs exclusively in doses that are too large for the average person, forcing $3 billion a year in excess chemicals to be paid for, and then discarded. (Basically the clinics that administer the drugs aren't allowed to keep the excess to use on somebody else.)

Yes, drug companies are evil. But the reason this continue is because there is plenty of evil to go around. The doctors who administer the drugs sell them to patients (or their insurance companies) at a markup, and they charge for the waste. So they aren't complaining. And the FDA can only regulate drugs based on safety and effectiveness, Congress does not allow them to regulate based on considerations of cost. In Europe, these same drugs are sold in smaller quantities so there is much less waste.

Yes, this is the magic of the Free Market™ at work.

Descent into the maelstrom

I'm obviously naive, because it had not occurred to me that a corrupt, vulgar, pathologically lying bully would endorse Donald Trump for president, but that's what Chris Christie just did.

He would not have done this if he wasn't damn sure orange marmot-head was going to be the nominee. If there is any other outcome, Christie will be political compost. But the endorsement will be a self-fulfilling prophecy, quite possibly opening the floodgates.

After the spectacle of a "debate" last night consisting incoherent yelling, with white supremacists mobilizing to back the Trump campaign, it's obvious what this is all about. It isn't about health care, or taxes, or foreign policy, or abortion, or same sex marriage, or infrastructure, or climate change and environment, or public health, or education, or any of the myriad critical issues facing the nation and humanity.

It's about racism and racialized nationalism, authoritarianism, and cult of personality. We're going there.

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.