Here's a letter I wrote to my colleagues . . .

. . . along with one of them.

This is a critical time for the future of health care policy, and all policies affecting public health in the United States. The incoming president and congress have promised to take actions that will profoundly change our health care system, along with environmental regulation, immigration policy, labor policy, and much more that will affect the health and well-being of the population. Some of the rhetoric in the recent campaign has also affected the social and political culture of the nation with unpredictable but likely worrisome consequences.

            We were deeply concerned by the scarcity of informed and even accurate discussion of public policy in the recent campaign. It appears that voters have little understanding of what government does or how government policies and practices affect their lives. The news media largely failed to explain the facts and controversies underlying policy choices, and allowed empty rhetoric and personal questions about the candidates to dominate the communal discourse.

            We believe that we, as experts in policy issues that are of the greatest importance for our nation and its citizens, can and should do more to contribute to the public discourse beyond our traditional focus on publishing in journals that are read only by our peers. We believe that we need to define an expanded role for public health researchers that brings our science out into the world and engages with people from all communities and walks of life. Voters cannot make appropriate decisions if they cannot meaningfully evaluate what candidates say and promise.

            We hope to join with our colleagues, starting within the department but perhaps expanding to the entire school of public health and ultimately beyond to other institutions, in an effort to democratize our work. By this we mean listening and engaging communities in helping us to understand what matters to people, and how we can best serve the public interest through our scholarly work, but just as importantly o through effective dissemination of knowledge and empowering people to be informed civic actors.

            We have discussed a few ideas about what some components of this effort might be. We do know that it calls for re-examining the institutional expectation for how public health scholars will focus their time and how their accomplishments will be evaluated. But there is much we can do now, that we believe we should be doing as a matter of urgency. We hope that some of you will join us in discussion leading to action. Please let either or both of us know if you want to join us, and we will convene those interested.

I'm not the only one who feels this way -- for example there's the well-publicized open letter from MIT faculty -- but I'm not just talking about writing open letters or op-eds. I'm talking about working with community-based organizations to engage people directly in understanding the facts underlying policy choices and how government matters to their lives. We cannot survive in a post-factual world.

Not exactly news . . .

The Commonwealth Fund has done the latest in its series of surveys of 11 countries (western Europe, Canada and the U.S.) and, well, you already know:

• Adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs. One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs. This percentage is down from the 2013 survey (37%). [But it's about to go back up!] As few as 7 percent of respondents in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these affordability problems.
• U.S. adults were also the most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.
• Half of U.S. adults struggled to get health care on the weekends and evenings without going to an emergency department. Between 40 percent and 64 percent of adults in the other countries reported the same. The Netherlands had the lowest rate on this measure, 25 percent.
• Adults in the U.S. (19%) and France (24%) were the most likely to say that their medical records or test results had not been available at the time of an appointment or that duplicate tests had been ordered in the past two years. These problems were reported less commonly in the other countries.
• Fourteen percent of chronically ill U.S. adults said they did not get the support they needed from health care providers to manage their conditions. This was twice the rate in Australia, Germany, the Netherlands, New Zealand, and Switzerland.

So the Republicans take over and vow to make all this worse -- much, much worse. My question is simple: what is the constituency for this? Why do we so passionately want to hurt ourselves?

We'll be in for a lot of this . . .

Sam Stein and Matt Fuller for the Puffington Host report on the 21st Century Cures Act, which appears likely to pass. Believe it or not, it does some things Democrats want to do, including providing some additional funding for NIH and money to the states to combat opioid addiction.

But of course, there's a high price to be paid. It also makes it easier to get medical treatments approved without demonstrating that they are safe and effective. Senator Warren has denounced this as a corrupt bargain. The Democrats in congress will be offered more of these corrupt bargains in the coming years, such as the phony infrastructure plan that really consists of giving away public goods to capitalists. The Republicans haven't been afraid to obstruct everything for the past 8 years -- how will the Democrats behave now?

Stay tuned.

Speaking of scams . . .

While the new president and his minions are busy selling out the country for personal enrichment, the pharmaceutical companies will not be left behind.

This is a slightly complicated scam, so you might want to read the essay in NEJM by Dafny, et al. For those with short attention spans, I will try to explain. There are lots of medications available to treat most conditions. The FDA has to approve them if they are safe and effective, but they don't have to be superior to existing treatments. Comparative effectiveness research doesn't always get done, but sometimes we know that a less expensive drug works as well as a more expensive one, at least for most people. Also, of course, once marketing exclusivity expires there are often cheaper generic alternatives to brand name drugs.

So, insurance companies put drugs in different "tiers" with consumers facing higher co-pays for medications the insurers want to steer people away from, because they are more expensive or less effective, or both. This helps them make money, sure, but it also helps keep premiums down for all of us. So what do the drug companies do when they want to keep selling their more expensive brand name drugs?

They pretend to be doing you a favor by giving out coupons that cover the co-pay. But they aren't doing you any favor, they're screwing you. Let's say a drug costs the insurance company eight times as much and they give you a coupon for a 20% copay? You use the brand name drug instead of the generic, which might have a much smaller copay but with the coupon the brand name drug is free. But the cost to your insurance company is much higher. The drug company gets their ill-gotten gains and ultimately, it comes out of your wallet anyway in the form of higher premiums.

I wouldn't count on your friends in congress to do anything about this.

The New Normal

Simon Maloy thinks Trump's corruption will sink the Republican party. To which I say, poppycock.

According to the New York Times and the rest of the corporate media, Hillary Clinton was the corrupt candidate. Can you imagine if Clinton had just settled a fraud lawsuit for $25 million, or the Clinton Foundation had admitted to self-dealing? My imagination can't even encompass what the news coverage would be like.

But they are doing their best to ignore Trump's blatant and proven corruption -- one brief story on each revelation, and we move on. What makes Maloy think that's going to change?

Theories of History

There are several approaches to understanding and writing about history. There is the Great Man (rarely Woman) school, which consists largely of biography. There are grand theories that explain history as a process shaped by large forces in which the choices of individuals have little weight, from Marxism to the inevitability of neoliberal dominance of the planet. The latter didn't exactly have a name but lots of people believed in it.

Then there are those who say, sure, there are grand forces -- technological change, climate, resource depletion, demographics -- but against that background, a lot of shit  just happens. Call this the "for want of a nail" theory of history. Well, it's true.

No-one can enumerate the links in the causal chain that led to our present disaster, but we can spot a few that are both necessary and basically stochastic. Hillary Clinton actually won the election by quite a substantial majority, but thanks to the historical anachronism of the electoral college, it doesn't count. There is no argument that I can see that makes this the right result. A few thousand votes in a key state tips the whole thing. In past elections that has been consequential but in this election it puts the country on a path completely opposite to what would otherwise have been.

Another necessary link was the Comey letter. There is plenty of evidence that it flipped the election, and probably the Senate. This of course would not have happened in the corporate media hadn't been obsessed with the completely bogus non-issue of Hillary Clinton's e-mails to begin with. But they were, and Comey  knew it.

Comey could not have played his dirty trick, however, if he didn't have Anthony Weiner's computer. Ergo, if the ridiculous and ridiculously named Anthony Weiner did not have an incorrigible habit of tweeting his junk, Hillary Clinton would be preparing to assume the presidency and appoint a young liberal justice to the Supreme Court.

In other words, this whole thing doesn't mean shit. It's a horrible accident. Jessica Williams (a Daily Show regular with John Stewart for those who aren't with it) said, "The first rule of politics is, Don't Tweet Your Junk," which presumably Weiner would have learned when it cost him his congressional seat. He did not, causing him to lose his chance to be mayor of New York and prompting Williams to say, "The second rule of politics is, Don't Tweet Your Junk."

Apparently we need a third rule. "Don't Tweet Your Junk."

Resistance

So, Paul Ryan says his first priority in 2017 is to phase out Medicare. He'll give people vouchers that will cover part of the cost of private insurance instead, but obviously the whole point is that they won't be sufficient. Medicare is much more cost-efficient than private insurance, because it doesn't have to pay for marketing, multi-million dollar executive salaries, or profits. And insurance companies have all kinds of ways of avoiding the most costly customers and screwing people out of benefits. Read the linked post if you want more details, but . . .

What is most strange about this is that it has almost no constituency, apart from a few extremist ideologues and plutocrats who don't want to pay taxes. Retired people and people who will retire depend on the program (as do people with disabilities). Doctors and hospitals get most of their revenue from it. The only way Republicans can advance their agenda is to lie to people, which is what Ryan is doing.

It seems to me that now that Republicans have total control over the federal government, and it actually comes time for them to do everything they have promised to do, it's suddenly going to get difficult. The first thing George W. Bush said after he was reelected was that he wanted to privatize Social Security. Funny thing about that, it didn't happen.

We need to resist everything, everywhere, with maximum energy. There is still plenty of life in the American republic and the progressive vision. We will win in the end.

How worried should we be?

I commend to your attention this essay by Ezra Klein. Before I try to very briefly summarize his argument (but do read this, although it's long form) I want to pull this:

He is a man who routinely praises dictators. Of Vladimir Putin, Trump said, "He's running his country, and at least he's a leader, unlike what we have in this country." Of Kim Jong Un, Trump said, "You've got to give him credit. He goes in, he takes over, and he's the boss. It's incredible." Of Saddam Hussein, Trump said, "He killed terrorists. He did that so good. They didn't read them the rights."

It’s not just that Trump admires authoritarians; it’s that the thing he admires about them is their authoritarianism — their ability to dispense with niceties like a free press, due process, and political opposition.

Trump has promised — in public, and repeatedly — to bring this hammer to American governance. He stood in a nationally televised debate and vowed to jail his opponent if elected. He has proposed strengthening libel laws to make it easier to cow the press and antitrust laws to punish Jeff Bezos and Amazon for the Washington Post’s coverage of his candidacy. In a recent speech at Gettysburg meant to preview his first 100 days in office, Trump said he would sue all of the women who accused him of sexual assault. 

During rallies, Trump has exhorted his followers to assault protestors, and has promised to pay their legal fees if their thuggery leads to arrest. He has warned that the only way he could lose the election would be if it is rigged, and has suggested he may refuse to concede.

And all this ignores his more basic flaws. He is cruel, lazy, and reckless. He knows nothing of policy and has not bothered to find anything out. He is easily baited, reliant on sycophants, and prone to conspiracy theories. He is a bigot who slimed an American-born judge for his Mexican heritage and a misogynist who boasted that his celebrity gave him license to commit sexual assault. He has cast doubt on America’s commitment to the NATO alliance and offhandedly encouraged Saudi Arabia and Japan to build nuclear weapons. His business is rife with conflicts of interest, and his campaign has been amateurish and poorly managed.

 Klein wrote this before the election, when he expected Trump to narrowly lose. (Actually, he did lose the popular vote, and it wasn't particularly close. But the problem of the electoral college is for another day. He got plenty of votes.)

Klein's basic claim is that the gatekeepers who once had control of the nominating process -- party elites, mostly, but corporate media as well -- have completely lost influence. But while the parties are institutionally weak, the public is more partisan than ever. The result is that once Trump got the nomination, Republican voters stuck with him despite whatever doubts some of them may have had. And party elites could not afford to abandon him lest their voters retaliate against them.

We can forget about checks and balances because soon, far right extremists will control all three branches of the federal government. They will do whatever they want, and believe me, New York Times editorials won't slow them down.

Gross Domestic Problem

Back when I was a 22 year old Nader's Raider I heard Hazel Henderson speak at one of our conferences and she was already saying what Edoardo Campanella apparently thinks is a radical new idea, which is that Gross Domestic Product is not a valid measure of well-being, and not even a valid measure of economic activity.

Hazel was not the only person to figure this out 40 years ago and plenty of people have kept hammering on the fairly obvious truth of it since, but it's just pissing into the wind. The corporate media and political leaders continue to treat GDP growth as the measure of a "healthy" economy.

The reasons why this is wrong are so many and so gross that nobody should be arguing about it, but apparently we have to do it anyway. Here are a few:

GDP does not account for externalities. You know, air pollution, stuff like that.

It treats resource extraction as production, even though the resource is gone.

It treats harms as goods. For example, a hurricane that destroys houses becomes economic growth because the cost of rebuilding them is counted as a positive while their destruction is ignored. Same with automobile crashes, disease (which leads to health care spending), basically anything that goes wrong and has to be fixed.

As a corollary, saving money is bad. Preventing disease, avoiding disasters, improving public safety - these are all negative for GDP.

It doesn't properly account for the value of technological advances. As the same goods and services get cheaper, we still have the value, or even greater value, but the contribution to GDP goes down.

It takes no account of inequality. If one person gets all the loot and the rest starve, it doesn't matter.

It takes no account of any activity that doesn't involve exchange of money -- from household work to volunteering. Take care of your elderly parent yourself, zero contribution. Hire somebody to do it, GDP. 

More money flowing around does not translate into human happiness. No account of community, friendship, the value of common space, free concerts on the green, mutual respect, you name it.

Do we really need to keep having this pointless discussion?

The grotesque corporate media

Jesse Berney and Matthew Yglesias have posted very similar essays, which means they are channeling a collective consciousness, not that one is stealing from the other. As Berney puts it:

You start with the assumption that Hillary Clinton is corrupt. After all, there have been whispers and accusations and investigations and allegations and scandals with ominous names like WHITEWATER and BENGHAZI for years. Even if you can't describe exactly what she's done wrong, there must be something to all these stories, right?

Or, in the words of Yglesias:

The latest Hillary Clinton email revelations arose out of an unrelated investigation into Anthony Weiner’s sexting. The best way to understand this odd hopscotch is through the Prime Directive of Clinton investigations: We know the Clintons are guilty; the only question is what are they guilty of and when will we find the evidence?

Berney:

When I fired up the New York Times app on my phone Saturday morning, I had to scroll through four full screens before I got to a headline that wasn't about FBI Director James Comey's letter to Congress that the bureau had discovered emails on Anthony Weiner's computer that possibly maybe perhaps might be related to its earlier investigation of Clinton’s private email server. With zero information about what is in those emails, zero information about any connection to Clinton, zero new allegations of wrongdoing, the Times and much of the media treated this story with the kind of wall-to-wall coverage usually reserved for the first moon landing.

Yglesias:

There are several rules that govern media coverage of the Clintons, but this year the Prime Directive has dominated them all. Network news has devoted more minutes of coverage to Clinton’s emails than to all policy issues combined, even as email investigations have not uncovered any wrongdoing. It’s inexplicable news judgment, unless you simply assume there’s a crime out there.

On their editorial and opinion pages, the corporate media from the New York Times to CNN all say that Trump is unqualified to be president and that his candidacy presents an unprecedented risk to the republic. But in their news pages all they ever talk about is phony Clinton scandals, while Donald Trump's innumerable very real scandals are completely ignored, even when they are reported by credible single sources such as  David Corn, David Farenthold and Kurt Eichenwald -- as are issues of public policy.

I am very puzzled by this.

Also, too, what Digby says.

All of this raises a question The Washington Post’s Paul Waldman raised two months ago: How is it possible that Clinton’s email brouhaha has marked her as thoroughly corrupt and dishonest, while Trump’s monumentally nefarious past, present and future are overlooked? Waldman’s assumption is probably the correct one: The narratives were set early in the campaign cycle, with Trump being the bigoted, crazy one and Clinton being the corrupt one. That’s just how the media frames the contest. They got it wrong. Yes, Trump is the crazy, bigoted one. He’s also a misogynist and worse. But he’s also the corrupt one, perhaps even more than most of us who had already understood that ever imagined.

Something vs. Nothing ought to win every time . . .

. . . but it's uncomfortably close. The New England Journal of Medicine informs thusly:

The editors invited the Democratic and Republican presidential nominees, Hillary Clinton and Donald Trump, to answer the following question for Journal readers: What specific changes in policy do you support to improve access to care, improve quality of care, and control health care costs for our nation? Secretary Clinton responded. Mr. Trump did not respond.

I expect he found it difficult what with his 200 word vocabulary. Anyway, you can read Hillary Clinton's response here. Sure, there's a lot of rhetoric in there and some non-specific promises but there are also some very specific, real and progressive items. Of course, they won't get through Congress unless Nov. 8 is nuclear, but for what it's worth here are a few highlights:

• Enhance tax credits to make insurance on the exchanges more affordable
• Public option in every state
• Medicare buy-in for people 55 and older*
• Streamline approval of generic drugs
• Require drug companies to justify their prices
• Allow Medicare to negotiate drug prices
• Expand payment reform
• Promote integrated medical and mental health care
• Expand funding for community health centers
• Assure access to affordable contraception and abortion
• Increase investment in medical research 

This is a real, progressive platform that would make a huge difference in people's lives. You can vote for it, or you can vote for nothing.

*Sets up the slippery slope to single payer national health care, in case you didn't get that.

The 60s

The death of Tom Hayden is a timely reminder of a previous turbulent time in our history. I was a teenager, and I just missed the Vietnam draft. (I turned 18 in the last year of the draft and had a high lottery number.) To me, and in my circle of friends and acquaintances, it as just normal and natural to view the U.S. as war in Vietnam as a crime against humanity, to see the government as largely an agent of plutocrats, the society as fundamentally racist, and capitalism as fundamentally exploitive.

I haven't really changed those views, but of course I'm more jaded now. The revolution never came, though we did make some progress. The 1960s left was male dominated and took patriarchy for granted; women were largely placed in a subservient role. As Hayden's obituary notes, he was part of the problem, and he eventually got slammed for it as feminism rose up within the left. Nowadays we see gender equality -- and gender equality going beyond the binary male/female categories we took for granted -- as being essential to progressivism.

George W. Bush got his illegal war of aggression but there was much more resistance early on than there had been to the Vietnam atrocity. We learned the hard lesson that the widespread resistance to the Vietnam war that eventually emerged was driven in considerable part by the draft that threatened middle class white kids. With no draft, the Iraq war, while controversial and ultimately repudiated by most responsible commentators and the public, generated far less passionate dissent.

Women and gender minorities have come a long way since the '60s, we did get Medicare and Medicaid, but the plutocrats still rule. In fact inequality has only increased. Racism is less socially respectable but I'd be hard pressed to say there is a whole lot less of it. The military-industrial complex is as entrenched as ever and we can't say the national surveillance state is less intrusive than it was in the days of J. Edgar Hoover. And what progress we've made on environmental protection faces continual rearguard action and we're pretty much neglecting the existential crisis of civilization facing humanity.

An extremist ideology has taken over one of the two major parties and managed to insert some false premises into the conventional wisdom, particularly that the national debt is an urgent problem and we need to cut entitlement spending, threatening the gains of the New Deal and Great Society. (Viz. Krugzilla.) Voter rights are under assault once again. I'm not sure whether Hayden looked back on his lifetime of advocacy with some small degree of satisfaction or if he felt essential despair. My own feeling is that progressive ideals generally have wider currency but do not have proportionate political effectiveness. I wouldn't say we've gone backwards but we're climbing the ratchet of progress very slowly.

Providence, RI exercises common sense

Our previous Director of the state health department convened an Emergency Medical Services working group, consisting mostly of fire chiefs and EMS personnel but also including me as the token academic. It was fun. I would wear the firefighter jacket I inherited from my father.

Anyhow, one of the big issues for EMS is what they call Frequent Fliers. I forget the exact percentage, but the majority of ambulance runs transport a small number of people who ride anywhere from once a month to, seriously, one guy who was transported 235 times in 2014. How can this be, you may ask? Well, a lot of them are incorrigible alcoholics. The problem for EMS is that they had no place to take them but the emergency department. There were legal and financial issues involved, as well as the simple lack of an alternative. As you presumably know, emergency departments are expensive and they have a lot of what drunks don't need and nothing that they do need. They'd just sit there until their blood alcohol went down, get kicked out, and come back a few days later.

So, it required an act of the legislature to do three things: protect EMS from liability for transporting people elsewhere than the ED; allow them to be paid for doing so; and create the place to take the drunks. The place hasn't opened yet but it's under construction. The people will get counseling and other services. Whether that will lead to any of them getting sober is unclear, but it will save the city and state some money and who knows, maybe it will actually help some people.

The strange thing is that it took so long to figure this out, and that most cities still operate as Providence has done until now. We just get stuck doing things the wrong way, it seems.

Back to the Knitting

Haven't posted for a couple of days because it felt like, what's the use? The world has gone insane. But what the heck, we're still here and there are still problems that matter so let's talk about some of them.

This week's NEJM puts the focus on serious mental illness -- the people who used to be in what were called "insane asylums" but are now more commonly living on the street or in prison. Lisa Rosenbaum discusses the history and the dilemmas created by the current situation. In a companion essay, Christine Montross discusses mentally ill people in prison.

You probably have heard about conditions in mental hospitals back in the day. They were indeed totalitarian realms in which patients were often degraded and abused. When antipsychotic drugs became available that could control symptoms of severe mental illness, a movement sprang up to move people out of mental hospitals and into supportive community settings. Everybody thought that was a great idea so they largely closed down the state hospitals and moved the people out. However, they didn't do part B, which was to create the supportive settings in the community. Part A saved a lot of money, or seemed to; part B would have required spending money.

So homeless shelters and prisons, rather than group homes, ended up replacing the asylum. Many people with severe mental illness can't behave the way prisoners are supposed to behave so they end up in solitary confinement. People who are (maybe) lucky enough not to be in jail are sleeping on the street. If you live in the city you see them all the time. And no, we aren't saving money. Prisons are expensive, and so are hospital emergency departments which people with serious mental illness land in with sometimes astonishing frequency. (Providence EMS, I am told, transported one individual more than 200 times in 2014.)

We might have a discussion of these issues in our political campaigns, or so you might think.

Threatened Sanity

As I may have mentioned once or twice, I have a long commute. I have what I am increasingly deciding is a bad habit of listening to National Pubic Radio under the misapprehension that I am making some positive use of the time.

Currently they are doing the common lazy journalistic stunt of rounding up random nobodies-in-particular and getting them to talk about why they are going to vote for candidate A or B.. In this case 50% of them are going to vote for the Cheeto dusted megalomaniac.

These people all have one thing in common. They are blithering idiots who presumably are able to dress themselves or they wouldn't be out in public, yet that seems implausible. I discovered that I cannot listen to their drivel so I have to turn the radio off for a couple of minutes until I'm sure it's safe.

Many people are now questioning the viability of our electoral republic. The tolerability of letting idiots vote is dependent on the proportion of idiots in the population and it is evidently much too high. Of course there is a disease vector for the epidemic of idiocy -- the corporate media.

There are signs that some editors are waking up to the horrific danger they have created. The New York Times has improved a bit in the past couple of weeks, although they are still gasping desperately for balance, as with a recent long-form piece discussing Bill Clinton's extramarital adventures. But even the victories are Pyrrhic. We're talking about how the candidate insulted a former beauty queen and whether he pays taxes. As Krugzilla notes, we aren't hearing a word about the crisis facing industrial civilization; and I could add, pretty much anything else of substance. Apart from the border wall and the Muslim ban, both of which may or may not currently be operative, the people don't know anything about policy differences. Well, okay, one candidate doesn't really have policies but he will sign everything that Paul Ryan and Mitch McConnell put on his desk and appoint Rush Limbaugh to the Supreme Court.

The discourse is so debased and depraved that it makes you wish for a philosopher king.

Why premiums are rising on the ACA exchanges -- and the deeper meaning

Health economist Uwe Reinhardt professorsplains it for you.

There are a couple of moving parts to keep in mind here. The first is that for any given health care service or product, the price is higher in the U.S. than in the rest of the world. It just costs more to deliver the same amount of health care here as it does elsewhere. There are a couple of reasons for this, which I'll mostly leave for another day, but this is a hard problem to fix because obviously those high prices are going into the pockets of people who are politically influential.

The next point, which Reinhardt shows you in graphic form (do lick link) is that 50% of people account for 97% of all health care spending, and the top 10% account for 65%. That's okay -- that's the whole reason why we have health insurance at all, because very few people in the top 10% have even a fraction of the income they would need to pay their own way. Health care is completely unlike other basic goods. We all need about the same amount of food, and the cost of basic shelter and clothing are about the same for everybody.

Now obviously if you're well off you can buy fancier food and clothing and bigger houses, but that's pretty much beside the point. Few of us want to consume more health care than we need -- with the exception of a very small number of people with psychological disorders, it's no fun at all, in fact it's often painful and otherwise unpleasant. And vanity cosmetic surgery is not paid for by insurance so that's also beside the point. Those people who are consuming a lot of health care need it.

So the way civilized countries solve this problem is that they give everybody basic health care coverage and finance it from some sort of a universal levy that has people paying a share they can afford -- simplest is a system funded from a progressive income tax, but some countries use kludgier systems just because.

Before Obamacare, people generally either had coverage through employment; or through government -- Medicare, Medicaid, military service and veterans' benefits. People were eligible for this coverage regardless of their need for health care, which meant broad risk pools including people who consumed relatively little health care, making the whole thing affordable. But people who didn't have coverage through these means couldn't buy insurance if they happened to be sick and actually need it, because it would be very expensive, precisely because otherwise uninsured people who were healthy would not choose to buy insurance and therefore they would be joining a very expensive risk pool.

So the Affordable Care Act forced participating insurers to issue policies to all comers, and to offer them all the same premium. The individual mandate was necessary to force young and healthy people into the pool, but for political reasons, the penalty was set much too low. Therefore insurers discovered that policies sold through the exchanges were costing them more than they expected, therefore they are jacking up the rates (or getting out of the market), which is just going to cause even more relatively healthy people to forego insurance and pay the penalty and so on. This is called the death spiral.

Solutions:

A) Jack up the penalty for not buying insurance. Stat.
B) Pay for universal health care through the tax system. Yes, that means higher taxes but you won't be paying insurance premiums, so you'll actually save money. (And if you get health care through your employer, you're paying for it whether you know it or now.)

But we have a weird, ideological aversion to anything called taxes. We want what they buy, but we don't want to pay for it. Because Freedom.

Brave New World?

There has been a lot of yammering but very little explanation or understanding of the baby recently born to a Jordanian couple which is purported to have "three parents." The technique which made this possible is illegal in the United States and apparently for some reason offensive to many people.

The baby does not have three parents, he has two. What he also does not have is Leigh's disease, which is the whole reason the procedure was done. But in order to really understand what happened, you need to understand something about the history of life on earth, which was not created in seven days 10,000 years ago.

Some time around 2 billion years ago (no way to be at all exact) one cell absorbed a smaller one, which survived and reproduced inside it and so the smaller cell's descendants continued to inhabit the larger cells descendants after the larger cell divided. The two cell types then evolved together as a symbiotic community. The smaller cell gradually lost most of its genetic material (some of it may have migrated to the nucleus of the larger cell) and was reduced to specialty functions, most notably as the manufacturer of Adenosine Triphosphate, the cell's energy source. The DNA that remains in the mitochondrion is only what is needed for mitochondrial functioning. It has not influence on the development or characteristics of the organism beyond any effect of defective mitochondrial functioning, an example of which is Leigh's disease.

The nuclear DNA is the DNA that combines chromosomes from the mother and father, and determines everything else about our genetic inheritance. The mitochondria are inherited exclusively from the mother through the cytoplasm of the ovum. You could vacuum out all the healthy mitochondria from a fertilized ovum (gamete) and replace them with equally healthy mitochondria from a different, completely unrelated person and the resulting human would be completely unaffected.

In this case, the mother had some healthy mitochondria and others that had a fatal mutation. She had enough healthy ones that she was not ill, at least not seriously; but there's no telling what the proportion of functional and non-functional mitochondria will be in any of her ova. Unfortunately, she'd had the bad luck to have two babies who were severely affected and who died young. What the doctors did in this case was simply to transplant the nucleus from one of her ova into another woman's ovum from which the nucleus had been removed, and fertilize it with her husband's sperm. Result: baby with two parents and no mitochondrial disease.

It had to be done in Mexico because it's illegal in the U.S. I await an explanation of why this is unethical.

Social Psychology vs. Parapsychology

Hard to say nowadays which is less credible as science. Here's a lengthy post by Andrew Gelman about the so-called "replication crisis," which is a fancy way of saying that the entire field of social psychology is looking like mostly bunkum.

The defensiveness of its practitioners is to be expected, but let's check our own walls for glass before throwing stones. The main problems in the field of social psychology are not ones to which other social sciences or for that matter biomedical research are immune. It's a bit hard to explain if you haven't taken much in the way of statistics or research methods generally, but the keystone issue is the worship and misunderstanding of the concept of "statistical significance."

If I compare two samples from a given population, with an equal (or at least known) probability of being selected at random, and some with characteristic A are more likely to have characteristic X than are those without A, I want to know how likely this is to just be a coincidence. If the observed difference is expected to occur less than 5% of the time when there isn't really a difference in the total population, we say the "p value" is less than .05 and we declare the observation "statistically significant" which is presumed to be more or less synonymous with "true." If the probability is 6% we declare the observation "not statistically significant" which is presumed to be synonymous with "false."

This is so wrong for so many reasons it makes one feel foolish to point them out. One is that the p value depends on sample size as much as it does on the magnitude of the effect. If my sample is too small, I will be likely to get an insignificant p value even if a meaningfully large effect exists. If the sample is large, I will likely get a "significant" p value for an meaninglessly small effect. A bigger problem is that if I make multiple comparisons I will likely find a "significant" value in there just by chance, because you have to multiply the values by the number of comparisons. Cherry picking the ones that are "significant" is basically fraudulent, although it seems most people who do it don't know that.

Other problems are that in social psychology, dependent variables are typically quite subjectively measured and it may be difficult to detect observer bias; independent variables may be associated with other, unmeasured variables that are actually responsible for any effect; there are all sorts of rationales for excluding cases selectively after the fact; and samples are rarely representative of any broader group than (quite typically) undergraduates at a selective university from which they are drawn -- who, by the way, are quite likely to divine the research question and consciously or unconsciously alter their behavior in response.

Gellman points to all sorts of other design flaws but the overall lesson is that it's just too easy to find what you are looking for. These studies get a lot of press because they seem relatable and often directly relevant to our own lives and supposed behavioral predispositions and those of the people around us. But they're largely gahrbahzh. So sad.

Too many emergencies

Yes, the Trump Foundation and the border wall and birtherism and all of the dreck that spews from Ronald T. Dump should get news coverage.

However, there is shit happening in the world that is like, really, really important and probably ought to be discussed by the candidates. You know, that little climate change problem, nucular weapons, mass extinction . . .

There is also this. When antibiotics stop working, it's not just those poor dusky-hued people in distant lands currently dying of tuberculosis who will be shit out of luck. It's you. Not only might you die from an infected scratch on your hand, common surgical procedures will be far too risky, women will die in childbirth and children will die from strep throats. Gonorrhea and syphilis will be incurable.

Of course, avoiding this fate requires paying a few cents more a pound for pork, beef and chicken, so we can't possibly afford it.

What are the chances it will come up in the debate on Monday?

San Quintin

Many years ago, I visited the small town of San Quintin in Baja California Norte with my then-girlfriend. There is, or was, a small resort there catering to United Statesian surfer bums and retirees. Pensioners would live there because it's cheap and the weather is always sunny and warm. They never bothered to learn Spanish and would order the staff around arrogantly. (Of course.)

We visited the town which consisted of a few cinder block shacks, a Pemex station, and a fly-infested general store. The people had a few wilting cabbages and starving cows. One guy owned the whole place, he had a farm down the road where the women and old men who hadn't gone north labored in the dust to fill trucks with tomatoes for the journey up the peninsular highway. He had all the water rights so the peasants couldn't irrigate their pathetic gardens. There was a big field with a fence around it and a sign saying "no cazar." (No hunting.) There was a guy sitting on a horse with a rifle to make sure nobody did. Mostly though there was nothing to hunt. More than a mile or so from the ocean was high desert, just coarse sand and the meanest cacti you ever saw.

Oh yeah. The farm had pumped out so much groundwater that salt water was intruding into the aquifer and the water in the resort was spoiled, so they had to use bottled water. It hardly ever rains there. It looks like that's about to change:

The storm is taking dead aim at San Quintin. When we were there I found some old cattle bones sticking out of the sand. The people told me the beast had drowned in a storm some years ago. So, once every thirty years or so they get a tropical storm. I imagine the desert blooms.

ClinicalTrials.gov (wonky)

Krugman does the "wonky" trigger warning on his blog so I figured I should too. A major problem with biomedical research is what's called "publication bias." This takes a couple of forms. One is that negative findings -- i.e. "A does not cause B" or "is not associated with B" -- are unlikely to be published. Journal editors and reviewers just don't think they're exciting. However, if there are three trials that show that A does not cause B and one that does, and the last one is the only one that gets published, we wind up with a false view of reality.

A second form is that -- oh, did I ever mention that drug companies are evil? They choose not to publish studies that are unfavorable to their products. Same result, we come to believe that drugs are much more effective than they really are.

Another problem is post hoc analysis. If your initial hypothesis isn't borne out, dredge through the data to find some sort of significant association, say with a sub-group or a variable that you originally intended as a covariate rather than an outcome. The problem with this is that the p values are spurious, because if you make a large number of comparisons some associations will appear significant just by chance, when nothing is really going on.

Recognizing these problems, the FDA requires that all clinical trials for drugs be registered in advance, so that a) we'll know what the original hypotheses and protocols were and b)  we'll know about trials that aren't published. The penalty for not reporting your results within a year is supposed to be $10,000 a day.

Surprise! It isn't happening, and the law is not being enforced. We know that results aren't being reported in many cases, but we don't know how many trials aren't even being registered in the first place. Things appear to be getting a bit better, but there are still a lot of drugs being prescribed that probably should not be. This is a huge scandal that is almost completely ignored while we obsess over Hillary's e-mails.

Science for Sale

As my 2 1/2 long time readers have probably noticed, nothing frosts my pumpkin more than corrupt science. Well the gourd has a thick layer of ice right now. Stanton Glantz - a major figure in exposing corruption of science by the tobacco industry, has turned his guns on the sugar industry. They too were paying scientists to say that sugar is good for you.

You may recall that we had a consensus for a couple of decades that the way to avoid heart disease was a low fat diet. It's taken a couple of decades more to eradicate that falsehood and it's still clinging to life. Food manufacturers touted their "low fat" products as healthful while they were full of toxic sugar. What we're finally getting around to understanding is that dietary fat -- other than transfats -- and dietary cholesterol do not cause atherosclerosis. But sugar does, and it also causes a glycemic spike in the blood which contributes to diabetes. Plus it makes you fat. The entire edifice of nutrition science from the late sixties right into the nineties was a fraud erected by the sugar industry and its scientific prostitutes in academia.

That's really evil.

Celebrity Jeopardy

So one way I dispose of 1/2 hour of unneeded consciousness from time to time is by watching Jeopardy! For those of you who aren't familiar with the program, they have special tournaments for categories such as high school students, college students, teachers and what not. They also do a celebrity tournament every year which features people who for one reason or another are famous. As it turns out famous people tend not to be very smart so they make the questions really easy.

This year many of the players as it turns out are "journalists," among them Chuck Todd and Anderson Cooper. Apparently the only reason they agreed to go on the show is because of the Dunning-Kruger effect. As it turns out they are both astonishingly ignorant of the most basic facts of history (e.g., Cooper thought that Alexander the Great presided over the golden age of Athens, and also couldn't figure out that "tank" is a word that means both an aquarium and a war fighting machine) and incapable of the simplest deductive thought. They revealed themselves to be total airheads. Louis C.K., on the show with Jonathan Capehart and Kate Bolduan -- who are maybe a small notch above Cooper and Todd but not much when it comes to gray matter -- destroyed them both. I will venture to say that comedians in general are probably much smarter and better informed than journalists.

The way you get to be a talking head on TV is by being pretty and having good diction. Being an idiot who will read whatever drivel and propaganda your corporate overlords put in front of you is how you rise to the top and make millions of dollars.

Rapid Testing

Reading between the lines -- and not very far between them -- it appears the whole Theranos corporation thing was never anything but a scam, although as with most cons it is likely that CEO Elizabeth Holmes on some level believed her own bullshit.

For those who don't know, this was a silicon valley start up that promised to do a whole suite of medical tests from a drop or two of blood. No more getting the needle and giving up vials. The company attracted billions in venture capital and Holmes was briefly recognized as the world's wealthiest female entrepreneur. Turns out, the technology doesn't work and the billions have melted away like the snows of March.

What you may not know is that this probably didn't seem preposterous to investors because in fact you can get some reliable test results from a fingerstick, in just a few minutes. Many large practice now have on-site rapid testing for blood lipids -- i.e. cholesterol -- and what is called the HbA1c,* which is an indicator of what your blood sugar has been over the past few weeks and is the standard for monitoring diabetes control.

When practices have these things, it makes diabetes care better, easier and cheaper. You come in for your visit, the medical assistant pricks your finger and gets a drop of blood for the HbA1c and a small pipette for the lipid test. Then she (yeah, usually it's she, that's the real world) goes down the hall, sticks them in a machine, and in a few minutes has the numbers to give your doc before the visit. The alternative is for the doctor to give you a test order and for you to make a second visit to a lab, in which case the doctor won't have your test until after the visit when obviously it's much less useful. Plus which you might not bother to get the test at all.

Unfortunately, other than simple blood glucose that's all we've got right now. Other tests require more blood and can't all be run by one machine either. It is probably impossible even in principle. But what the Theranos story tells us is that with sufficient audacity and a convincing act, even smart rich people can be conned. Viz. Bernie Madoff and Ken Lay, among too many others to name.

* Stands for hemoglobin A1c, and the way it works is that the glucose in your blood gets attached to the hemoglobin in your red blood cells. The more glucose, the more of it is attached. This is also called "glycolated hemoglobin."

Yuck

Clostridium dificile is a bacterium which is an opportunistic pathogen in humans. Specifically, it infects the intestines and causes severe diarrhea, which can be fatal but is always indescribably unpleasant. Much C. dificile is now antibiotic  resistant as well.

For the medical industry, additional bad news is that it is mostly iatrogenic. While community acquisition occurs, the most likely way to get C. dficile disease is to be in the hospital, wherein it lurks, and to receive a massive antibiotic bomb that wipes out our normal intestinal microbia. C. dificile then moves into the abandoned territory.

What to do? How about restore the intestinal microbia. How to do that? Well, don't think about it too hard. What you need is a shit enema. So that's what they are doing, and it works. Adding to the unpleasantness, if you have recurrent infection it works much better to use donor poop than your own, which obviously has not been up to the task. (You may only be able to read the first paragraph.)

I note this not to gross you out, particularly, but because it points as dramatically as possible to our evolving understanding of ourselves not simply as clonal colonies of eukaryotic cells derived from a single zygote, but as ecosystems including not just those, but also a much larger number of prokaryotic organisms. Our eukaryotic genome has co-evolved with the rest of the ecosystem such that it supports beneficial  symbionts that not only are essential to digesting our food but also protect us from unfriendly organisms and quite possibly do other stuff we don't yet understand.

That doesn't mean that the stuff you buy at the GNC that purports to be probiotic will actually do you any good. We're still just beginning to figure this out and  come up with evidence based interventions. But it will become a bigger deal in coming years, I hereby predict.

Have I ever mentioned that drug companies are evil?

They aren't really of course -- corporations aren't people nor are they moral agents. But human beings do act on their behalf. With price gouging by pharmaceutical manufacturers all of a sudden in the news (despite it has been going on forever), some of our friends from Hahvahd, aka World's Greatest University, explain some of the ins and outs of drug pricing wonkery (and wankery).

Some of the main points are:

• The U.S. grants long periods of monopoly over new drugs, and let's companies use various loopholes and fancy tricks to extend their monopolies.

• Even when they lose legal monopolies, they often have practical monopolies for various structural reasons in the industry. The simplest is that if you are in a competitive market for generic drugs, there isn't much profit there in many cases, so you don't get a lot of competition.

• Medicare is not allowed to negotiate drug prices, and drugs can't be imported, even though they're cheaper everywhere else in the world.

The companies claim they need to haul in the big bucks to pay for R&D, but that's a total crock. They conclude:

High drug prices are the result of the approach the United States has taken to granting government-protected monopolies to drug manufacturers, combined with coverage requirements imposed on government-funded drug benefits. The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices.

The problem is, of course, that the companies own congress, so none of this is going to happen.

The Party of Ignorance

A United States senator says that there is no need for college professors, students can just watch documentaries. He specifically proposes watching the Ken Burns documentary instead of paying some egghead to teach Civil War history.

By the way, this clown has a college degree.

Burns is a Republican, He is not from the South, but I presume he must know that many of his colleagues and their constituents actually wouldn't like that proposal because they think the Civil War was actually the War of Northern Aggression and it was all about state's rights and the preservation of heritage and tradition. How do universities deal with these differences in point of view?

Unless they are Liberty or Bob Jones university, we expose people to basic facts, often in the form of a textbook; and to various interpretations and viewpoints on those facts through diverse reading assignments. We then encourage them to discuss and debate the issues, along the way teaching critical thinking skills and the technique and etiquette of adversarial dialogue. Then we ask them to express their own ideas and conclusions through written essays, which we evaluate and critique.

In other words, we don't just stuff them full of single viewpoints on complex issues. We develop the capacity to learn and think for oneself. A capacity sadly lacking in Ron Johnson.

The Chrono-Synclastic Infundibulum

Vonnegut fans will recognize the title of this post as a singularity in the space-time continuum where all possible opinions are true. That is perhaps not quite the same as saying that there are no facts. Peter Pomerantsev, in Granta, finds that we are living in a post-factual society, a development for which he blames a combination of mendacious politicians, Your Intertubes, and post-modern philosophers.

I don't think our situation is as yet quite that bad. In Putin's Russia, it probably is, but that's because he controls all of the mass media and can maintain a fact-free environment. Pomerantsev invokes the counterfactual, emotion-driven Brexit campaign, but as we know the Brits woke up from their dream the following morning to find themselves doused in the ice water of reality. Karl Rove mocked the Reality Based Community but ultimately, he discovered that he could not create the new realities of his imagination: the Weapons of Mass Destruction™ weren't there, and Iraq did not become a bourgeois republic allied with the West. Donald Trump's fans are impervious to facts but they will discover on November 9 that they are in the minority and their hero is a loser.

I do share Pomerantsev's contempt for post-modernism and it's bizarre claim that truth is the servant of power, that scientific claims are arbitrary, and that denial of intersubjective reality is liberating. And I am as frustrated as anyone by the power of confirmation bias and motivated reasoning, which has indeed been amplified by the instant availability of whatever congenial bullshit you are looking for at the click of a mouse.

Nevertheless, sitting here in a university, I know that we still have the tools to recognize truth and a large corps of people who live by them. We may go down the infundibulum soon, but not today. 

Fat Al told you so

With California burning  and Louisiana drowning, NASA informs us that we've just lived through the hottest month in recorded history. If you go to the last link, to Joe Romm's blog, you'll see a graphic that ought to terrify you.

What appears to be happening is a long-anticipated step up in global temperature -- with 2016 landing close to .2 degrees centigrade hotter than last year, which was already the all-time hottest year by a lot. The Middle East is literally becoming uninhabitable -- Baghdad has had temperatures above 109 Fahrenheit every day since June 19, and other places in the region are even hotter. In case you didn't know, the collapse of agriculture in Syria due to climate change was the main reason why Syrian society disintegrated, leading to the greatest humanitarian catastrophe since WWII.

One of the presidential candidates says this is not actually happening, it's a hoax perpetrated by the Chinese. The other one never mentions it. It is the single most important thing that is happening on earth.

Yep, they're still evil

That would be the drug companies. Boston University School of Public Health prof. Alan Sager (with whom I am acquainted) runs down their profiteering at society's expense. I would say, do read the whole thing because it takes him 11 pages to properly debunk all of the prevalent falsehoods about this. I'll just offer you this excerpt which reiterates stuff I keep saying here, which is that the mythological and non-existent "free market" bears absolutely no resemblance to the reality of pharmaceutical development, manufacture and selling:

Unfortunately, functioning free markets are simply unattainable in health care, and the drug sector is no exception. That’s because not one of the six requirements for a competitive free market is met, or can be met, in the realm of pharmaceuticals. A market of small buyers and sellers doesn’t make the price; drug makers with patents or market power are dominant. Price competition among generics, biosimilars, and me-too brand name drugs does little to cut U.S. drug spending. Sovereign consumers don’t make decisions; they rely on physicians who are often swayed by drug makers’ marketing or detailers. Entry of new competitors can be hard; drug makers merge with competitors or acquire them to reduce competition; big vertically-integrated drug makers often finance smaller ones or buy up their discoveries. Information is asymmetric; patients lack it and doctors and drug makers have lots of it. Subtly, but importantly, the price of drugs doesn’t remotely track the cost of production. And the injunction that buyers should beware and mistrustful carries little weight in the absence of good information about which drugs are needed or valuable.

There are actually additional reasons why the fictitious "free market" doesn't come near this reality, but those are probably enough for now. As Sager explains, it is the immense political power of the drug companies, along with our generally brainwashed population, that let's them keep ripping us off.

Sager is an advocate of single payer national health care, but given that isn't happening any time soon, he offers some interim measures. Not on Hillary's docket, however, at least not so far.

Down the Rabbit Hole

John Ioannidis is what I would call a science critic. I don't mean that he's anti-science. On the contrary. He's a science critic in the same sense that a movie critic or a literary critic likes movies or books, but has something to say about which ones are better than others, and how they are composed and achieve or fail to achieve their artistic objectives.

He joins colleagues in critiquing the Big Science initiatives of NIH, which has been directing more than half of its funding to genomic and stem cell research. Contrary to early expectations, it turns out that the relationship between the genome and specific diseases is far too complex to provide targets for prevention or treatment. Even when a specific genetic cause of a disease is known, as in sickle cell anemia, the knowledge doesn't necessarily translate into a therapeutic target.

Similarly (and relevant to the cancer "moon shot,") the extremely diverse mutations associated with cancer, and the adaptive nature of tumors (they evolve in response to selection pressure from treatments), mean that understanding the specific mutations associated with cancers is of limited value for treatment. Stem cells have also so far failed to yield any approved treatments.

The writers call for a redirection of NIH funding away from these "big ideas," and to more strictly evaluate proposals in these areas. The challenge is that right now, these fields are academically prestigious, and yield high impact publications, promotions and tenure, and awards. Furthermore, scientists get pigeonholed in their narrow programs of research, and proposal review committees generally don't like it when they try to step out in a new direction. So there are vested interests which are difficult to overcome.

I actually think that there is more to be gained by what they call translational science -- getting doctors to do what we already know is best for patients -- and investment in social determinants of health, than by the "blue sky" biomedical research Ioannidis and friends call for. Sure, we should do some of that, but we can save lives and improve the health of billions of people just by putting what we already know to work. But that isn't very glamorous.

Assault and battery for money

NYT's Gina Kolata tells you what all of us health services researchers already know far too well. Surgical procedures don't have to be approved by the FDA or anybody else, and even when they are proven to be useless, surgeons keep doing them. She leads with the most notorious example, spinal fusion.

In fact this goes way back. In the 1990s, what was then called the Agency for Health Care Policy and Research concluded that there was no evidence that spinal fusion was beneficial to patients. So, the spinal surgeons society persuaded the Republican congress to eliminate the agency entirely. Quoth:

AHCPR was also confronted in 1995 with an advocacy organization’s active efforts to get it defunded. The source was an association of back surgeons who disagreed with conclusions reached by the [agency] on low-back pain and with practice guidelines based on that work. . . .

The surgeons found sympathetic ears among House Republicans who, for reasons already discussed, were prepared to believe the worst about the agency. The events of 1995 followed many years of controversy over the merits of surgical procedures for low-back disorders. AHCPR entered this fray when its PORT on low-back pain reviewed the research and concluded that there was no evidence to support spinal fusion surgery and that such surgery commonly had complications.³⁰ The North American Spine Society (NASS) created an ad hoc committee, which attacked the literature review and the subsequent AHCPR practice guideline on acute care of low-back pain. In a letter published in 1994 in the journal Spine, the committee not only criticized the methods used in the literature review and expressed concern that the conclusions might be used by payers or regulators to limit the number and types of spinal fusion procedures, but it also charged that AHCPR had wasted taxpayer dollars on the study.³¹ An entity known as the Center for Patient Advocacy was formed by Neil Kahanovitz, a back surgeon from Arlington, Virginia, to lobby on the issue. It organized a letter-writing campaign to gain congressional support for its attack on AHCPR. Kahanovitz used personal contacts to gain the support of Representatives Bonilla, who had a staffer who was Kahanovitz’s patient; Johnson; Gerald Solomon (R-NY); and Joe Barton (R-TX). Solomon, Bonilla, and Johnson led the effort in the House to end the agency’s funding, energetically promulgating the NASS/Kahanovitz argument that it was supporting unsound research and wasting the taxpayers’ money.

The agency managed to survive, but it endured a 21% budget cut. (It's successor is now known as the Agency for Healthcare Research and Quality.)

Here we are, 20 years later, and surgeons are still doing this procedure, even though, as Kolata reports, randomized controlled trials since then have consistently found no benefit. It's finally stopping now that insurers have decided not to pay for it.

Similar phenomena happen all the time. The hue and cry when the Preventive Services Task Force recommended against routine mammograms for women in their 40s was orchestrated by radiologists, oncologists and surgeons who feared losing business. (Debbie Wasserman Shultz, bless her, was their willing dupe.)  We are finally seeing a movement in medicine to eliminate useless or harmful procedures, as spearheaded by the Choosing Wisely campaign lead by the American Board of Internal Medicine and joined by many other medical specialty societies. Still, physicians' financial incentives work against the goal, and we really need more than voluntarism.

The Cancer Moonshot

I'm not entirely sure how much I've written about this here before, but the cancer moonshot that president Obama recently announced isn't sitting all that well with me. It will apparently re-allocate $1 billion in NIH funding to cancer research. Since congress obviously hasn't appropriated any new money, this is coming out of competing research interests.

The first problem with this idea is that, as the linked NIH fact sheet states quite clearly, cancer is not a disease. It is an umbrella term for hundreds (at least) of diseases -- quite likely it's conceptually impossible to define any finite number of cancers. Cancer means a failure of regulation of cell division such that abnormal cells proliferate. This can happen in innumerable ways to innumerable different kinds of cells. So there can never be one "cure" or one answer. Many different lines of research will lead to better approaches to different sets of people diagnosed with cancer, or to dead ends.  The mission is essentially undefined.

The second problem is that the risk of cancer rises steadily with age. While it's been a high priority (and an astonishing success story already, in fact) to effectively treat cancer in children and young adults, the vast majority of cancers occur in people who are older than 70. This means that people who are successfully treated for cancer are quite likely to come down with another, or to succumb within a relatively short time to some other cause of death. Given that available treatments so far are mostly very burdensome, have terrible side effects, and leave people with shortened life expectancies and, yes, disproportionate risk for recurrence, one has to question the cost effectiveness of making a huge investment without regard to the specific type of cancer, age of onset, or other risk.

There is hope that breakthrough technologies such as immunotherapy may ultimately benefit many people without horrific side effects but that would seem to argue against the scattershot approach of the current effort. I would like to see this discussed much more broadly, and the mission and strategy much better informed and defined. As it stands, it seems like a political stunt.

This is incredible

I don't know if anyone remembers Fat Al Gore, but back in 1998 he proposed stationing a satellite at the Earth-Sun L1 point to continuously photograph the earth from deep space. Flaky, no?

The L1 point is one of five locations called Lagrange points, which exist in any system of two orbiting bodies, where a smaller body can remain stably. L1 is nearly 1 million miles from the earth, well outside the orbit of the moon. Somehow I missed it, but NASA actually did it! The satellite is now called the Deep Space Climate Observatory, or DSCOVR (get it?) and it was launched by SpaceX in 2015. Now it gives us this amazing image:

That is the moon transiting the earth. We're seeing the side of the moon which can never be seen from earth. Although it's called the "dark" side of the moon it isn't really dark - it is illuminated just as often as the near side. Since we're seeing the lighted side of the earth (L1 is in a direct line between earth and sun, so you always see the day side), we're also seeing the far side illuminated. You can see the transit in motion here, courtesy of your tax dollars at work.

That's everything we have, folks. There's no place else to go, and nothing else to live on.

When ideology trumps reality

(I took a few days off to rest my brain. Results are mixed, but I'm back.)

You may have heard about the HIV outbreak in Scott County, Indiana. (Not sure how much of this the grand poobahs at New England Journal of Medicine will let you read, but I'll run it down for you.)

This is a rural area, almost entirely white, with high unemployment and poverty. The governor of Indiana, Mike Pence, is now the Vice Presidential candidate of the Republican party. Prior to 2015, with Pence's backing, Indiana outlawed needle exchange programs. Needle exchange has been shown to substantially reduce the risk of transmission of HIV and Hepatitis C virus (HCV); and it does not increase the prevalence of injection drug use. On the contrary, by bringing users into contact with service providers, it increases the chance that people will enter treatment. However, conservatives have succeeded in banning the practice in many states using the argument that it "enables" illicit drug use. Of course, addicts will inject any way they have to, and if they can't get clean needles, they'll share.

One more thing -- free HIV testing had not been available in Scott County since the Planned Parenthood clinic closed in 2013.

Early in 2015, a disease intervention specialist (DIS) discovered a cluster of 11 HIV infections in Scott County. A DIS is a public health worker who interviews people diagnosed with an infectious disease such as HIV and tracks down people they have potentially infected, or who potentially infected them, in order to diagnose additional cases and gain an understanding of transmission networks. Previously, there had only been 5 HIV infections identified in Scott County since 2004. All of the infected persons had crushed, dissolved and injected extended release oxymorphone.

As a result, the CDC and Indiana state government declared a public health emergency, and began intensive contact tracing and population screening. Ultimately they found 181 people with HIV in the county, nearly all of whom reported injection drug use. As a result, Pence relented and allowed needle exchange in April, 2015, after which the cumulative diagnoses leveled off and finally stabilized. As the authors also write:

A lack of health insurance could have been a barrier to the response to this outbreak, but fortuitously, in January 2015, Indiana received a waiver to provide Medicaid insurance [which] helped to ensure health care coverage in the largely underinsured and impoverished community . . . and facilitated the immediate enrollment, coverage and access to critical health care services.

I might note that people who are effectively treated for HIV are essentially non-infectious, meaning that treatment for all can stop the epidemic in its tracks.

Is there a lesson here? Yes. We were right and Mike Pence was wrong. But who do you think the good citizens of Scott County are going to vote for?

An informed perspective on the ACA

Former law professor and current federal employee Barack H. Obama offers an assessment of the Affordable Care Act in last week's JAMA. While I don't know if we can count on him to be an entirely disinterested observer, this does have some fair and balanced elements.

He rightly notes that the law has resulted in a huge decline in the proportion of people who lack health insurance, and is plausibly linked to observable improvements in beneficiaries' health status and financial security. He also gives credit to the ACA for slowing the growth of spending on health care, which is a big more speculative at this point.

But he also observes that affordability is a problem for some people. Fixing this would require increasing the funding for subsidies and changing the structure of subsidies to fix some quirks.

The big news, however, is that he notes that the ACA has not succeeded in creating competitive insurance markets in all parts of the country. Therefore, he embraces a publicly sponsored insurance option, a Medicare for all style program, where competition is lacking. This goes part of the way toward Bernie Sanders, who of course wants that everywhere. It's a pretty kludgy fix -- it would need an on/off switch depending on the current competitiveness of the market in a given region, which doesn't seem very workable.

Biggest problem, of course, is that there is no way in the Delta quadrant of the galaxy that a Republican House would ever pass this. But, it does give Hillary something to campaign on.

Side Note: That the major scandal to come out of last night's hate fest on the lake is that Melania Trumps speech contained some purloined words tells us everything we need to know about the corporate media. Blatant ugly lies; bigotry; depraved fear mongering: all okay worthy only of stenography. Non-politician given ghost written speech that contains a bit of borrowing -- that's your screaming headline. Bring on the giant meteorite.

It doesn't take a genius . . .

. . . to figure out that the entire basis of the Republican presidential candidates appeal is racism. Kevin Drum gives us a more opionated discussion of this obvious fact.

As a friend just ranted at me, however, the corporate media for the most part (Confessore piece above obviously excepted) and even, it seems, many Democratic politicians have at best tip-toed around this. Hillary Clinton obviously doesn't have nice things to say about him, but just calling him a con artist and a fraud is not mentioning the elephant in the room.

For the teevee news, of course, the candidate is good for ratings and that's all they care about. That's what made him the Republican nominee, his ubiquity on cable news. They obviously don't want to alienate his fans.

But the same goes for many Democratic politicians. The Bill Clinton presidency was largely about trying to win back the Reagan Democrats by pandering to their racism. Hillary knows that accusing racists of being racist is the best way to make them feel offended. Telling the country that racism is foundational to white working class culture would be the truth, but it would also be an excellent way to make sure you could not be elected to office outside of Berkeley or Jamaica Plain.

How worried am I? Not very worried about hearing the Marine Band playing Hail to the Cheetoh Dusted Thief, but disturbed by the weakness and corruption of our institutions. Donald Trump may be too vain and undisciplined to carry his schtick over the finish line, but somebody smarter and emotionally stable might come along and carry off a more successful version of the act. In the meantime, we could see a lot of unpleasantness.  

Anybody who isn't paranoid is nuts

One of my research projects was to develop a questionnaire assessing the knowledge and beliefs of people living with HIV about the disease and treatment. I did qualitative interviews first to harvest the kinds of ideas people have and then translated those into structured questions. One of them is:

 "Some doctors are paid by drug companies to prescribe certain HIV medications."

People can call that correct, partly correct, or not at all  correct, but I didn't score this question when I calculated their overall accuracy because it's not exactly true and it's not exactly false.

Susan Chimonas, in the journal Democracy (which I very much commend to you as a most excellent freebie)  uses this recent study in JAMA Internal Medicine as the occasion to write about the problem of pharmaceutical industry influence on prescribers. I say she uses it as the occasion because we already know all this. Even very small gifts can have a substantial influence. They talk about $20 meals but even pens and sticky note pads have been shown to have an effect. My old office at Tufts Medical Center had boxes of office supplies stamped with the pharmaceutical brand names. The drug companies obviously wouldn't waste their money on this if it didn't work.

Now, there isn't any stated quid pro quo. You don't actually have to prescribe Toxovan to get the free lunch or the triangular pen. This is actually a weird trick about human psychology. It's surprising how well it works. Transparency is often touted as the solution -- drug companies should have to disclose their gifts to prescribers, prescribers should have to disclose the gifts they accept. But that doesn't work. The only solution is to ban the practice. Drug companies should not be permitted to give anything to prescribers. The information they need is in the so-called "label" (actually a substantial pamphlet) approved by the FDA. The docs should read it. That is the only interaction between prescribers and drug companies that should be permitted.

What rough beast . . . slouches toward Bethlehem to be born?

I'm kind of an old guy now, and I lived through the '60s -- the Civil Rights Movement and massive police and KKK violence in response, the Vietnam War protests and the Chicago convention, the assassinations, the urban riots, the Weather Underground, the Black Panthers . . .

It seemed as though everything was spinning out of control. People got scared enough to nominate Barry Goldwater,  and then elect Richard Nixon, but eventually everything calmed down and the country held together. The truth is though, the underlying fractures in our society didn't heal, they just got painted over for a while. Is this historical moment more dangerous, or do we have more cultural resources now to overcome the turmoil and fear?

I'm not sure yet. Has progress been an illusion, or are we just seeing the one step back after two steps forward? We'll just have to stay tuned.

Opioid Prescribing Policy

A major political deal in my former home state of Massachusetts has been reform of opioid prescribing regulations, and you can read all about it here. This law had strong bipartisan support from the Democratic legislature and Republican governor as well as the Massachusetts Medical Society. The opioid abuse epidemic has gotten the attention of lots of state governments and many of them had passed laws like this a few years ago.

Speaking of the Massachusetts Medical Society, they publish the New England Journal of Medicine which today has this from Ellen Meara and colleagues. Alas, they can't find any evidence that these laws do much good at all, if any. Their data came from people under 65 who receive Medicare benefits because of disability. That's obviously not representative of the general population but on the other hand they have high rates of receiving opioid prescriptions and account for a highly disproportionate share of related adverse events. Furthermore, there is no obvious reason why these state laws would not affect opioid prescribing to them as much as it would to others.

There are several sorts of provisions they looked at, many of which are components of the Massachusetts law. These include limiting the quantity of initial prescriptions, requiring prescribers to consult a Prescription Drug Monitoring Program (which tells them if patients are also getting prescriptions somewhere else), and various other provisions. But it turns out that there is no meaningful difference in long-term prescribing, high levels of prescribing consistent with addiction and overdose risk, multiple prescribers, or actual overdose, when states adopt these laws.

Now maybe they take more effect over more years, maybe they have a small effect that the study couldn't detect, and maybe non-disabled people are different. But the takeaway seems to be that this problem is not solved by trying to impose restrictions on physicians. We need to change the culture and practice of medicine, and that means for one thing doctors' skills to communicate with patients and manage pain without overusing opioids. The legislature doesn't have any magic bullets.

About the death panels . . .

(This is a repost from a while back but I want to re-start a discussion.)

Uwe Reinhardt wrote the following:

The . . . opponents of cost-effectiveness analysis [include] individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

Yes, believe it or not, the James Madison Professor of Political Economy at Princeton University does not believe that human life is infinitely precious. Of course he's going to hell, but what about you? Let me try something out. My colleague Peter Neuman did a survey of oncologists in the U.S. and Canada. He asked them whether they agreed strongly, somewhat, neutral, somewhat disagree, disagree strongly - the usual survey question -- with the following statement:

Everyone deserves access to effective cancer treatments, regardless of the cost.

What's your response? You'll probably be happy to know that most oncologists agree. Then he asked them another question. (I've altered the parameter slightly to get this over with faster.)

Suppose a new treatment for cancer is introduced that costs $200,000. How much added life would it have to offer someone -- let's even say it's you! -- before you would pay for it out of your own pocket? How about if it were paid out of shared social resources? How much extension of life would it have to offer before paying is justified?

One day? One week? One month? Six months? A year? I don't know what your answer is but I'll bet there are very few people who think it's worth spending $200,000 to extend somebody's life by one day. And if you think we are morally compelled to do so, then consider: More than 2 million children die every year from water born diseases; a child dies from pneumonia every 15 seconds; for $250,000, we could save tens of thousands of them.

Why is tobacco legal? Why do people go down into coal mines? Why do we start wars? Every time you get in a car you are proving that the value of life, to you, is finite, because riding in cars is dangerous and lots of people die from it.

The intuition that life is infinitely precious is closely tied to an idea called the Rule of Rescue. Little Timmy fallen down the well is the classic example, but coal miners are a good one also. When miners are trapped under the ground, the coal company and government agencies spare no expense. Drilling equipment is shipped in, high tech seismic equipment, skilled crews work 24 hours, and of course it’s also all the cable news, all the time. If the miners are rescued, the people give thanks to God, although they generally spare him the blame when rescue fails. But the same company has likely been evading safety regulations all along in order to save a few dollars, and the worst that happens to them is a small fine, and there’s little or no public outcry or even any attention paid.

So how we view the preciousness of life depends very much on the obviousness and imminence of death.

The rule of rescue is important to this discussion not only because of the way it affects our allocation of resources, but because it refutes the liberty claim against compulsory insurance. Someone who can afford insurance, but exercises a choice not to buy it, and then is hit by a bus or has a serious illness, will impose a claim on others – family, purchasers of insurance, taxpayers, somebody somehow will pay for their urgent care – and thereby others will be deprived of property and their liberty impaired. No-one can be said to have a right to do that.

Further implications of these observations, which ought to be thought of as very mundane but which are in fact, completely outside the bounds of acceptable political discourse in this country, are to follow.