I have good news . . .

and, of course, worse news. The National Association of Attorneys General has just announced that cigarette consumption in the U.S. has hit a 50 year low -- 378 billion sold in 2005, the fewest since 1951 -- although the population has doubled. Credit goes to the Master Settlement Agreement the states reached with the tobacco companies, which restricted tobacco marketing. Since then, state and local restrictions on smoking in public places and workplaces have also helped reduce consumption and help and encourage people to quit.

Smoking just isn't cool any more in the U.S. With pluck and luck, we'll keep driving it down.

Now the bad news. The tobacco companies are doing just fine. In fact, they're doing more than fine. In the words of Dave Wilcox, the young tobacco merchants are still Climbing up the Rungs, by selling you a parasite that's feeding on your lungs. How can this be?

Worldwide, tobacco sales are going up and up and up. According to the World Health Organization, the merchants of death sold 5.5 trillion cigarettes last year. Take a look at the World Tobacco Atlas (pdf), and you will see the hot spots. Asia is where the people are, and not surprisingly, that's where the pushers are. 1/3 of all the cigarettes smoked in the world are now smoked in China.

So, hold on to your Philip Morris --whoops, I mean Altria -- stock, the company which proudly proclaims that "The Philip Morris name has long been associated with high quality tobacco products and globally recognized cigarette brands. Today the name is proudly carried by the leading cigarette manufacturer in the United States, Philip Morris USA, and by Philip Morris International, the world's leading international cigarette business with products sold in 160 countries worldwide."

I think they should try to find something else to be proud of, personally.

Doing My Duty

Like it or not, I am obliged by the insatiable lust of my adoring public to say something about the massive health care reform bill that just passed here in the People's Republic of Massachusetts. The conservative Republican governor is expected to sign it, although he may veto certain line items. If he does, he will no doubt be overriden, so this thing is going to happen.

Now, I'm supposed to be for it, because all my friends were for it - the folks at Health Care for All leading the way. What gives me pause, however, is that a lot of my not so much friends were also for it - including the Gov, the Mass Medical Association (wearing its enrich the doctors hat), the hospital lobby (which spent a fortune lobbying on the bill) and a good chunk of the business "community."

The bill is 145 pages long. I just printed it out but I haven't had time to read it. Based on information from the State House News, the basic ideas are:

• Employers who do not provide health insurance to their workers will be assessed a "fee" of $295/year. This is okay with the Governor because it's not a "tax." Whatever.
• Doctors and physicians get $45 million a year in rate hikes from Medicaid.
• The state will set up an insurance program called Commonwealth Health Care Insurance, that will offer subsidized premiums on a sliding scale for people up to 300% of the federal poverty level. Exactly what the premium and the amount of the subsidies will be apparently remains to be determined by the available funds.
• Everybody else who does not have insurance will be required to purchase it on the open market, so long as an "affordable" plan is available. What constitutes "affordable" will be determined by regulators. People who don't comply will lose their personal income tax exemption and be charged 1/2 the price of the "affordable" product. (What happens when they are hit by a bus is unclear.)
• Based on the assumption that there will be much less need for funds from the so-called "Uncompensated Care Pool," it will be drained to pay for the other stuff.

There are various other goodies in there -- removal of enrollment caps on Medicaid products, increased funding for public health programs, a requirement that hospitals collect data by race and ethnicity and address disparities. One item that some people think is a goodie but is more dubious in my view is a requirement that hospitals post "quality" data on the web. This is supposed to encourage consumers to shop around for the best "quality" care.

Okay, this is supposed to result in maybe 95% of citizens of the People's Republic having health insurance by 2008 or 2009 or some such date. Here are some reservations, problems, and questions to which I need answers:

• The employer tax is the most regressive possible kind of tax. It's a tax on jobs, which is even worse than a payroll tax. (It costs the same for a minimum wage worker as it does for an investment banker.) That only comes out of one place -- wages.
• Once the "affordable" product is out there, what's to stop employers from dropping health insurance for their employees? $295/year is still a lot cheaper than paying for insurance.
• How much will poor people have to pay for the Commonwealth Health Care product? Will they be able to afford it, or will it come out of rent and groceries? What will the benefits be? Evidently it can't have a deductible, but can it have co-pays?

Then there's that individual mandate. I can't really explain why it worries me so much without doing a lengthy lecture on the economics of health care and insurance markets, but here are a few points which may or may not make sense to you depending on what you already know.

• An individual mandate drives further fragmentation of the market and encourages insurers to selectively market to young and healthy people and force older and sicker people to pay more. Whether state regulations will prevent this is unclear.
• Think of Medicare Part D -- people are going to have to choose among a bewildering array of options and try to figure out which product is going to be best for them based on what might happen to them in the future.
• These plans will have high deductibles, which will discourage people from getting basic primary and preventive care, and force people who don't have medical educations to try to figure out what medical services to buy or not buy.
• The insurers will try to craft policies to encourage more desirable consumers to enroll. People who have greater medical needs may have great difficulty finding an "affordable" product.
• The mandate is regressive, forcing everybody to pay the same flat rate based on their age, the industry they work in, and other factors considered by actuaries, without regard to their ability to pay.
• The individual mandate will legitimize employers who drop coverage for their workers.
• The mandate will only increase the percentage of health care spending that goes to administrative costs and marketing, instead of health care.
• What's to stop insurers from offering a relatively affordable and decent quality plan now, and then just jacking up the price and cutting the benefits next year? State regulators will be at their mercy because they can always pull out entirely.

Now, I'm going to miss the American Idol results show tonight in order to read the damn bill. In the meantime, maybe somebody out there can answer some of my questions or allay some of my concerns. But I still have the fear that in an effort to satisfy powerful constituencies, the advocates for reform have given away the store. We'll see.

Opportunity Cost

I have been asked to find out how much the U.S. has spent on pandemic flu preparedness, presumably at the expense of other public health priorities. The answer is -- less than nothing. The information I am about to provide comes to me by way of a FOIAA request I made to the Massachusetts Department of Public Health last December. (Sorry, I've been meaning to get around to posting on this.)

There isn't much in the way of a pandemic flu program per se; rather, states are expected to make preparations using two main sources of federal money, the U.S. Health Resources and Services Administration's National Bioterrorism Hospital Preparedness Program (HRSA-NBHPP) and the U.S. Centers for Disease Control and Prevention (CDC) Public Health Preparedness and Response for Bioterrorism Cooperative Agreement.

The word "bioterrorism" in the names of these programs comes from the days when the Bush administration assumed that bioterrorism was the only infectious disease threat facing the country. In Federal Fiscal Year 2004, when they first noticed the possibility of a naturally caused epidemic, the definition of the kinds of emergencies states were supposed to prepare for using these funds was broadened. Hence the CDC program is now called Cooperative Agreement for Public Health Emergency Preparedness, and the HRSA program's mission statement is "is to prepare hospitals and supporting healthcare systems, in collaboration with other partners, to deliver coordinated and effective care to victims of terrorism and other public health emergencies." [emphasis added.]

So, what happened when pandemic flu was added to the scope of these programs? The funds were cut, rather drastically. The HRSA program peaked in FY 2004, and funding declined slightly in FY 2005. I only have the figures for Massachusetts -- $10,686,180 in FY 2004, $10,256,868 in FY 2005 -- but you can find out about your own state's funding if you like at the HRSA web site. The CDC program really got wacked -- Massachusetts' funding in CDC budget year 8/31/03-8/31/04 was $21,141,965. Since then, it's been less than $18 million. The states use part of this funding to support preparedness by local health departments, and that's how the federal money trickles down to the local level. Obviously, that pass-through funding also peaked in 2004 and has been much less since then.

So, those of you out there who are worried about how the fear mongers have stolen billions for more important public health priorities can relax -- although that's not what I'm doing.

Epidemic of fear?

Luc Bonneux and Wim Van Damme, in the new BMJ (off limits to commoners) offer a commentary entitled "An iatrogenic pandemic of panic." They mean to suggest that public health authorities have created such a pandemic by warning the public about the dangers of an influenza pandemic potentially arising from the current zoonotic of H5N1 avian flu. This parallels the dust-up which has been going on at Effect Measure between the proprietors and popular medical writer Marc Siegel, who in most public forums* seems to make approximately the same argument.

I have largely steered clear of this whole bird flu flapdoodle because others are on the case and my social science perspective hasn't really been what is at stake - at least until now. But I feel I should come out and let people know what I think about all this.

First of all, when Bonneux, Van Damme and Siegel actually try elucidate the nature of this devastating mass panic, it doesn't seem to amount to a whole lot. The sole definable ill effect seems to be that a few people are conniving to obtain oseltamivir (Tamiflu) to keep in the medicine cabinet against a rainy day, and the US and UK governments, and some other wealthy countries, are buying up modest stockpiles. There has also been a decline in poultry consumption in some places. It is true that both of these responses are probably inappropriate, however I'm not sure that it is reasonable to label them as "panic." Nobody can point to mobs rioting in the streets to get their allocation of Tamiflu, or terrified masses collapsing with palpitations at the sight of a chicken.

Another rather vague complaint is that pandemic flu preparation diverts resources from other public health problems such as HIV, malaria, waterborne diseases etc. which are already here. I must say there isn't any evident basis for this complaint - it's not as though there was any identifable money in the pipeline to address those problems which has been diverted to pandemic flu preparation. Most of the preparation that is happening -- which is very little indeed -- is essentially generic emergency preparedness which will be equally applicable to any widespread infectious disease emergency, and it is hard to see why anyone objects to that. There is a modestly funded program in vaccine research for H5N1 flu -- so far not very fruitful -- but that hardly seems objectionable either.

Now, just FYI, hording Tamiflu is dumb because a) it doesn't work very well, it only shortens the course of ordinary flu by one day; b) there isn't enough of it in the world to make much of an impact on a pandemic; and c) if there is a pandemic, and lots of people use tamiflu, there's a good chance that resistant strains of the virus will quickly emerge anyway. Also, hording results in misallocation. Rich people in rich countries get it, whereas if it's useful at all its in protecting frontline health workers to some extent so they get back on the job faster, which is really just to say, somebody else ought to be hording it in different places, for different purposes.

In the end, what people are really disagreeing about, when they pretend to be having some ill-defined ideological battle, is the actual probability of a major flu pandemic in the near future. Here, I'm not exactly an expert, but I'm pretty sure this is the correct answer: it is meaningless to try to assign a probability to this. It's a qualitative judgment.

We're still in the process of learning about the evolution of influenza viruses and the characteristics that make for easy human transmission and virulence. Based on what we know now, the virus that's circulating in birds right now has the kinds of characteristics that could lead to a 1918-type event. Such an event, in the modern world which has many times more dense centers of population, which are much larger; which has far more extensive and rapid networks of international commerce and travel; which has a far more complex and densely connected global economy; and which has a fragile international order; could be a big problem, cost a lot of money, cause a lot of disruption. It would be irresponsible not to imagine such a possibility and try to prepare for it. Nobody can say "there's a 64.3% chance it will happen before September 1, 2008," or "There is less than a 19.5% chance." Nobody knows. But it very well might happen and it would be foolish to pretend otherwise.

Now, people may well exploit fears and various scenarios, likely or unlikely, for ill purposes. For example, Mr. Bush's first reaction, on learning of the possibility of pandemic flu, was to talk about making preparations for mass quarantine and martial law. But that's because he's a malignant clown, it's not reflection on the virologists who drew attention to the possibility of a pandemic. The Emperor Chimpoleon has exploited other fears for malevolent purposes as well, but that doesn't mean that anybody who talks about proliferation of dangerous weapons is being irresponsible. Scientists and public health authorities who work in this area have a duty to inform the public of their findings and concerns, honestly and directly. Other people in authority, and the news media, have responsibilities pertaining to how they respond, which they may or may not discharge appropriately. That's on them.

*(Latin pedantry alert: "forums" is now the standard plural form in English.)

A slightly puzzling result . . .

. . . followed by "Aha!"

In 1999, the last legitimately elected president of the United States directed that the Federal Employees Health Benefits program provide parity in coverage of behavioral health services -- mental health and substance abuse treatment -- with coverage of other health care services. This has long been a major bone in the throat of people in the behavioral health field -- that most health plans sharply limit benefits.

The main justification for relegating behavioral health to second class status is the argument that the need for such services is not sharply defined. The insurance companies are afraid that if they offered open-ended benefits, half of their customers would end up like Woody Allen, in psychoanalysis for life. So, Clinton also directed that there be a comprehensive evaluation of the policy to find out how it affected cost, access and quality of behavioral health care for federal employees.

The results are reported by Howard Goldman et al in the New England Journal of Medicine (abstract here, full text available only to the elect). Federal employees have a buffet of plans to choose from, so the evaluators could compare plans that introduced full parity with others that did not. They found that consumption of behavioral health services went up over the years in both groups of plans, but by similar amounts. The difference, obviously, was that people who lacked parity in coverage paid more out of pocket.

My first reaction was that it seems very surprising that having to pay out of pocket did not reduce people's use of these services. On grounds of equity, this still seems to support providing parity in benefits -- insurance is supposed to spread risk and obviously it does that successfully in this case -- but it doesn't seem to do anything to increase access and appropriate utilization.

Then it occurs to me that 100% of the sample are people with good, steady, fairly secure jobs that provide comprehensive benefits. If these folks need mental health or substance abuse services, they can afford to pay something out of pocket. Furthermore, they are unlikely to be among the most severely mentally ill or they wouldn't have those good steady jobs in the first place.

So what this tells us is that extending parity for behavioral health services doesn't have to lead to abuse, waste, overutilization, or a nation of Woody Allens permanently preoccupied with their neuroses and pipelining money to Madison Avenue shrinks. For needier and more vulnerable populations, it is still likely that it will lead to better access and more appropriate utilization. So let's do it.

Petitioning the Lord with prayer

All the press coverage I read of the recent negative findings on the power of prayer to enhance recovery from heart surgery were fair and balanced. The reporters all went out and found eminent physicians and/or clergy to say that the study doesn't prove that prayer doesn't work. For example, prayer by family and friends, as opposed to distant religious communities, might well be effective.

Why isn't it obvious to everyone that anyone who believes this has a contemptuous view of God? Think about it. Here's Harvey Havemore, a wealthy corporate lawyer, who is diagnosed with lung cancer. His wife, kids, and siblings all pray furiously for his recovery. The all-powerful, omniscient, benevolent Creator and Lord of the Universe was going to let him die, but he sees the prayers pouring into his inbox so he says, "What the hell, I guess I'll cure this one."

On the other side of town, here's Helen Hasnot, whose husband ran off twelve years ago, whose only son died of leukemia, whose parents are both dead, whose sister lives in Dubuque and they drifted apart years ago, who descended into depression and social isolation. Nobody is praying for her. God says, "Tough shit, I don't have a single card or letter on this one." Helen suffers a protracted and painful death.

Then there are all those bumper stickers and signs that say "God bless America." So the idea is, God wasn't planning to bless America, but he sees the bumper sticker, so he says, "Okay, I guess I'll throw them a blessing"?

If that's your God, you can have him.

Science of the people, by the people, and for the people?

I just got back from a symposium about so-called community based participatory research (and variations on the name and theme such as just participatory research), in particular an effort at my university to develop more of this kind of research through a center pulling together various resources of the university. I am a kind of avatar of CBPR since I work for a community based organization, while I'm on the faculty, and my research is based in the CBO and guided by the interests and needs of our clients and the organization as a community asset.

Typically, public health research is exploitive of its subjects. An academic, motivated by the need to get grants and publish in order to win tenure and promotions, devises a study using the epistemological standards that are required by NIH reviewers -- randomized controlled experiments of strictly specified interventions, or epidemiological studies that extract information from people according to highly programmed procedures. Then the Big Professor goes away and writes a paper, and the community and people who got studied hear nothing about it and get no benefit from it. It probably has little or nothing to do with anything they care about anyway.

So, there are a lot of Mom and apple pie sentiments that usually define CBPR. Representatives of the community are involved from the beginning in defining the research problem. Community people work with the academic investigators to develop interventions and/ or ways of asking questions. Members of the community get hired as interviewers. The results of the investigation are fed back to the community and the academic investigators work with the community to turn knowledge into action -- whether through education of the public, development of services, or political activism and social change.

Who could argue with that? Well, some people can because they just think that people with Ph.D.s know what they're doing and it's a waste of time and an obstacle to good science to drag the riff raff into it. But even those of us who are passionate advocates for opening up the scientific enterprise and making it a public possession know that it isn't easy. There are a lot of conceptual and practical problems.

I'll talk about a few of them as time goes on but for now, just this one. Who decides who "represents" the community? How do you find those people in the first place to join in and help define the problems and chart the path to answers? Are the people you manage to engage with really "the" people, or are you just buying in to some other, less obvious institutional inequalities?

Stay tuned.

The facts of life . . .

Internet bulletin board services and web hosts, including blogger, tend to be pretty tolerant about content. It's no problem to put up porno, racism and hatred, even incitement to murder. But if you even discuss the following topics (no specification of what you say) they'll shut you down:

Conditional Access Systems.

Satellite Test Cards.

Grantsmanship

Us junior faculty and independent research institute types aren't actually living in the post-industrial age, we're hunter/gatherers. Specifically, we hunt and gather research grants. I spend all my time writing proposals so I never have any actual time to do research.

My big mistake was not shooting into the barrel of fish at the John Templeton Foundation, where they will gladly give you a research grant for a Randomized Controlled Trial of remote intercessory prayer. Sadly, it doesn't cure heart disease after all. (Sisters - you can stop saying the rosary for my male pattern baldness now. I'll still make this year's donation to the Bishop's fund.)

Actually, if the Templeton Foundation and the Discovery Institute want to try to prove that religious beliefs are scientifically supportable, I say, Bring 'em on.

And the Galactic Overlord Medal for Most Outstanding Bullshit . . .

in the Delta Quadrant of the Galaxy goes to -- the envelope, please --

The U.S. Department of Defense for

National Military Strategy to Combat Weapons of Mass Destruction™

The report never actually defines Weapons of Mass Destruction™. I guess we're just supposed to figure they're whatever the Generals say they are at whatever particular time they want to say so. It also never says what the strategy is. Instead, it goes on for 30 pages in the following vein. I've snipped this in various places but it doesn't matter because you wouldn't be able to tell the difference if I did or I didn't.

The strategic military framework to combat WMD consists of ends (the military strategic goal and associated end state), ways (military strategic objectives), and means (combatant commands, Military Departments, and combat support agencies) applied across the three pillars of the National Strategy to Combat WMD (nonproliferation, counterproliferation, and consequence management).

The combatant commands, military departments, and combat support agencies are the means to accomplish MSOs. Commander, U.S. Strategic Command (CDRUSSTRATCOM) is the lead combatant commander for integrating and synchronizing DOD in combating WMD. Consistent with this assignment, USSTRATCOM will integrate and synchronize applicable Department of Defense-wide efforts across the doctrine, organization, training, material, leadership, personnel, and facilities spectrum. Combatant Commanders will continue to execute combating WMD missions within their AORs. Military efforts will need to be integrated with other organizations and nations that possess capabilities, resources, or information that can contribute to the mission.

Strategic enablers are crosscutting capabilities that facilitate execution of the military strategy. They enhance the effectiveness and integration of military combating WMD mission capabilities. Commanders must continually assess enabling capabilities and identify required improvements. Three strategic enablers facilitate DoD’s efforts to combat WMD: intelligence, partnership capacity, and strategic communication support.

The military mission is to dissuade, deter, and defeat those who seek to harm the United States, its allies, and partners through WMD use or threat of use. This mission is in direct support of the three pillars (nonproliferation, counterproliferation, and consequence management) of the national strategy for combating WMD. Across the four military strategic objectives, U.S. Armed Forces may be called upon to carry out eight missions: offensive operations, elimination, interdiction, active defense, passive defense, WMD consequence management, security cooperation and partner activities, and threat reduction cooperation. Capabilities development should address and prioritize the critical capability needs of these eight mission areas. Offensive Operations may include kinetic and/or non-kinetic options (e.g., elements of space and information operations) to deter or defeat a WMD threat or subsequent use of WMD. Elimination Operations are operations systematically to locate, characterize, secure, disable, and/or destroy a State or non-State actor’s WMD programs and related capabilities. Interdiction Operations are designed to stop the proliferation of WMD, delivery systems, associated and dual-use technologies, materials, and expertise from transiting between States of concern and between State and non-State actors, whether undertaken by the military or by other agencies of government (e.g., law enforcement). Active Defense measures include, but are not limited to, missile defense (ballistic and cruise), air defense, special operations, and security operations to defend against conventionally and unconventionally delivered WMD. Passive Defense includes measures to minimize or negate the vulnerability to and minimize effects of WMD use against U.S., partner, and allied Armed Forces as well as U.S. military interests, installations, and critical infrastructure.

Etc., etc., etc.

After you boil out the bullshit, what this says is, we'll bomb, invade or kill whoever we want to, however we want to, whenever we want to, from wherever we want to. Period.

(Thanks to Blake for the link.)

It might not just be the drug companies . . .

. . . who have inappropriate influence on what gets published in the major medical journals. It's the doctors as well -- not in their guise as biomedical researchers and healers, but as a political interest group. Most of the leading medical journals are owned by physicians' associations - associations that represent the political and financial interests of their members and lobby on their behalf. JAMA used to stand for the Journal of the American Medical Association, and that's who owns it. The Massachusetts Medical Society owns the New England Journal of Medicine, and the British Medical Association owns BMJ. JAMA also owns a lot of important specialty journals. (The specialist societies and colleges, such as the Society of General Internal Medicine, which also publish journals, are more focused on research and practice than on the personal interests of their members.)

There have been some significant disputes in recent years about the editorial independence of some of these journals in the U.S. JAMA's editor of 17 years, George Lundberg, was fired by the AMA in 1999 for publishing an article which concluded that 60% college students did not consider fellatio to be "having sex." The AMA board concluded that this was an attempt to downplay the importance of Bill Clinton's statement that "I did not have sex with that woman." (What a country.)

NEJM editor Jerome Kassirer was fired by the Massachusetts Medical Society in the same year for refusing to go along with the Society's schemes to make money by selling the Journal's name and logo to manufacturers of medical devices.

Now, although the lay media in the U.S. have ignored the story (probably because they are afraid to go to Canada to investigate due to the hazard of flying hockey pucks), the excrement has hit the ventilator in the international world of medical publishing, at least, over the firing by the Canadian Medical Association of Canadian Medical Association Journal John Hoey and his deputy Anne Marie Todkill. (PDF) Their crime? They published an article revealing that Canadian pharmacists were asking women who were trying to buy the Plan B "morning after" contraceptive intrusive questions about their sexual histories. The CMA is closely allied with the Canadian Pharmacists Association, which complained about the article. The CMA was already annoyed over earlier articles which had cast some physicians in an unflattering light.

This story continued, with Jerome Kassirer brought in to do an inquiry, the CMA apparently not accepting his conclusions that the journal should have editorial independence, and most of the editorial board resigning.

Medical journals must not have a mission of protecting the interests of physicians, as particular associations of physicians construe them -- and let's not forget that many U.S. physicians are not members of the AMA and do not approve of its policy positions. They must represent the public interest. Perhaps we need a new model of ownership.

A confusing decision, but one you need to make

The subject of screening tests comes up here a lot. There are a lot of these tests that doctors really like to do, and to most people, it seems obvious that there's nothing to lose by having a test that might catch cancer or some other serious condition early, while it's easier to treat. The story is not nearly so simple, but most of the time our doctors don't burden us with the complexities, they just tell us to get the mammogram or the Prostate Specific Antigen test, and we do it.

I've written in the past about Bayes' Theorem -- how even a highly specific test (one that only reads positive in a small percentage of people who don't have the disease) can be wrong most of the time when the underlying prevalence of a disease is low. But the issue with breast and prostate cancer screening is even trickier. The problem is, we aren't even sure what constitutes a false positive.

Some proportion of these cancers -- in the case of prostate cancer, we know for certain that it's actually a majority -- will never cause a problem. Either the person dies of something else before the cancer becomes clinically significant, or the cancer is what is called "indolent," that is it doesn't grow very much and it doesn't metastasize, it just sits there. Is that even cancer? It's a semantic quibble -- the problem is that we don't know how to tell them apart from the ones that will go on to cause trouble.

So if you're considering screening, you have to weigh the possible benefits -- that you might find a cancer early, when it can be effectively treated, that would eventually have killed you otherwise -- vs. the costs and risks, which include the possibility that you will end up having surgery, and/or radiation, and/or chemotherapy, with attendant risks, pain, high monetary cost, and in the case of mastectomy disfigurement, and in the case of prostatectomy incontinence and erectile dysfunction, plus the anxiety and general sturm und drang for yourself and your loved ones, all for no good reason at all.

A new study by Zackrisson, et al, published in BMJ, based on a randomized controlled trial of screening mammography done in Sweden in the 1970s, estimates the rate of overdiagnosis to be 10%. They got this number in a simplistic way: 15 years after the trial ended, there had been a total of 10% more cancers found in the screened group than in the unscreened group. The logic is that that many additional cancers must also have existed in the unscreened group but never caused a problem and so were never detected.

But as some letter writers point out, this is actually a considerable underestimate of overdiagnosis. Gilbert Welch, Lisa Schwartz and Steven Woloshin of Dartmouth note that real issue is the percentage of cancers found by screening that represent overdiagnosis. Since some cancers in the screened group were not found by screening but by clinical diagnosis; and as cancers in both groups continued to accumulate after the trial ended 15 years ago, the percentage of positive mammograms that represent what they call "pseudocancer" was 24%, not 10%. Peter Gotsche points out that some of the women in the control group actually got screening mammograms after the trial ended, which pushes the rate of overdiagnosis up even higher. He thinks at least 30% is the right number.

Now that doesn't mean you shouldn't get a screening mammogram. Important additional considerations include your personal risk factors (e.g., if your mother or sister has had breast cancer, or you haven't had children, you might be more inclined to be screened), and how averse you feel personally to the treatments for breast cancer, as well as your age and your philosophy of life. There is reasonably good evidence that in the long run, screening does reduce the breast cancer death rate in a population, so all things being equal it might give you a chance of living longer -- but it's a small chance.

What I advocate for is not screening or not screening, but knowledge, and autonomy. Doctors should inform women much more fully about these issues than they typically do. Rather than blindly following recommendations from such bodies as the American Cancer Society (which have a vested interest in promoting treatment since they are closely allied with drug companies, surgeons, radiologists and oncologists), women who are so inclined should make up their own minds.

I'll get to prostate cancer screening another time.

Back on the job

The new Gallup poll says it all.

What's the number one concern of American voters? Is it the War on Terra? Is it saving the blastocysts, or the brain dead? Is it keeping homosexuals in the closet? Is it illegal immigration, or crime, or drugs, or even social security? Nope. It's

The availability and affordability of healthcare

68% of respondent say they worry about that "a great deal," up from 60% last year, and leading the list of voter worries not by a little, but a lot. Social security comes in second, at 51%. And guess what? Democrats worry about it the most, but it is the leading concern of Republicans and independents as well.

So then, who should win the November election? If we can avoid getting drawn into a lengthy discussion about The 10 Commandments, flag burning, the homosexual agenda, and who eats brie, I think the answer is obvious.

But then, if the Democrats reclaim Congress, will they stop listening to the voters, and just listen to the lobbyists? Watch this space.

The desperate character writhes again . . .

I started this blog mostly as a form of self-discipline. I have often attempted to keep a journal of my professional interests - to write every day about the subjects I study and the work I do - but the project always seemed to lapse after a while. When web logging came along, it seemed to offer that essential psychological prop - the illusion, at least, that there was an interlocutor out there, somebody reading. As with cooking, that makes writing more satisfying, gives me an incentive to do it at least acceptably well, and gives me a kick in the pants to do it at all lest I let my reader down.

Well, it worked. I have indeed written every day now for about a year and a half, except for some Saturdays when, as long time readers know, I am out in Windham County Connecticut, building a house. Sundays I usually get off the explicit topic of public health and say something vaguely philosophical. With those indulgences, I've been able to keep it going. Even better, I actually have readers -- I presume the number is modest, but the commenters here are fabulous. I can hardly believe the knowledge, wisdom and good humor of the people who contribute. That makes it worthwhile. I've also been able to spin off some other activities in the blogosphere from this site, and it's all been very gratifying.

So, now, I feel some responsibility to meet expectations, to have a clear definition of what I'm doing here that is both potentially of interest to others and within my capabilities to do well, and to try to keep improving. My biggest challenge, it turns out, is limiting the terrain. Public health is about, well, everything. It provides some standard analytical tools, it adopts scientific theories of knowledge, and there are some topics that people in public health tend to focus on, such as disease entities and their causes and prevention (with treatment a less prominent concern), health disparities, concepts of well-being, measurement problems, etc. But really, if it has to do with Homo sapiens, it has to do with public health.

And right now, I'm mostly worried about subjects that don't get a lot of ink in the American Journal of Public Health. We aren't going to get any positive changes in public health or health care policy so long as the present gang remains in power, and ven if they collapse like Enron, we'll be digging out of the wreckage for decades. It seems feckless to write about social and economic disparities in health, the Millenium Development Goals, the obesity epidemic, the nefarious pharmaceutical industry, pathogen drug resistance, the marginalization of mental health, the Rule of Rescue and the perverted priorities of health care, environmental justice, and all those other subjects that have occupied us here, when the country is ruled by a gang of murderous thieves who are doing everything in their power to destroy any chance we have to make progress on these problems.

The public discourse in this country right now is utterly inane. A headline in my local birdcage liner today read "Two lawmakers call on the president to obey the law." Which means that 533 did not. $10 billion a week of money the U.S. government borrows from the Chinese and the Saudis goes down the rathole in Iraq, which just descends deeper into nightmare. Corporate CEOs are paid tens of millions of dollars a year while their employees don't have health insurance and their standard of living keeps going down. We keep spewing more and more CO2 into the atmosphere, climatic catastrophe approaches, while our political leadership claims the entire issue is nothing but a left-wing fabrication intended to destroy capitalism and the corporate media continue to portray it as a political dispute rather than a settled scientific question.

I'm could continue but I'm sure you can extend the list as well as I can. So we have a democracy, right? The people can put a stop to this, right? Elections in this country are contested over the issue of whether the earth is 10,000 years old and whether letting some people get married will destroy everybody else's family; whether people who say that we should pursue national security by trying to apprehend people who actually attacked us or plan to, rather than invading unrelated countries in order to control oil fields are traitors; and whether candidates drink beer or wine. All of this critical thinking is disseminated by means of television advertisements, which means the real fundamental issue is who can get people and corporations to fork over hundreds of millions of dollars to spew this dreck into people's living rooms.

Sometimes, in other words, I feel like I just can't go on. But, now that I've got that out of my system, I will. Thanks for your indulgence.

An Apology

I feel I haven't been keeping up with the public health blogging as much as I would like recently. I have been distracted by some other matters, including, obviously, Iraq. There are a few issues which I feel I should have written about in the past week. I'm saving them up, and I'll get to them, but for the rest of today I'm going to be composing my feelings about the current state of affairs and I may not post until tonight or tomorrow.

It's very gratifying to see some new visitors here. Don't worry, we'll be back on topic soon.

Moral Values

A few years back, police in Hudson, Wisconsin were baffled when an undertaker and his apprenctice were found shot dead. It soon emerged that a Christian organization, the Rest of Jesus Ministry, had been sending threatening letters to funeral homes around the state:

Thus saith the Lord, because you have heard not the words of the Lord, I take from you your sons and daughters into early graves. And prepare for burial yourself. Amen.

It turns out that the Rest of Jesus Ministry is led by Kathryn J. Padilla of Lincoln, Wisconsin, who speaks in tongues and is believed by her followers to be a prophet. According to the Ministry,

Respect for the body comes by wrapping it in white linen and laying it in a place prepared -- pickling of the body, by the draining of the blood, by the draining of the leftover blood, is an abomination to Me and this practice must cease! Failure to comply to cease from the pickling of the body and the adoration of the dead, will bring a judgment of much death upon this land.

The group denied involvement in the murders and as far as I can tell, they were never solved.

Back in 2002, a Hindu scholar wrote a book demonstrating that beef was routinely eaten in the time of the Vedas. Due to death threats, he was obliged to accept police protection. The publisher withdrew the book. But in fact Indian scholars have known this for well over a century.

Real Truth Ministries of Keene, Texas, invites me to a Revelation Seminar, A Biblical Prophecy Adventure. There, the visions of the apocalypse will be made simple and understandable. Who is the Antichrist? What is the Mark of the Beast? 88 Golden Keys to Unlock the Symbols.

Vineyard Christian Fellowship of Cambridge invites me to join them. Is Jesus Good? the flyer asks. Their members have the answer. "Jesus healed me of breast cancer." "Jesus has financially provided for me." "Jesus healed our unborn baby's heart condition." That Jesus is a good guy, for sure, although it's kind of too bad that there so many other people whose breast cancer he hasn't healed, who he hasn't provided for financially, whose babies were born with heart conditions after all. Maybe he's only good when he's in a good mood.

Then there's Tony Alamo, pastor of the Holy Alamo Christian Church of Alma, Arkansas, and Canyon Country, California. I held on to his literature because it contains the only plan of salvation, and he warned me not to toss it. God has given Tony many visiosn, signs wonders and messages that he hasn't written about previously, but Susie and Tony have had an experience with UFOs. I won't go into all the details but it turns out that "God, Who is the Truth, tells us that every abomination on earth comes from the devil who has chosen Rome as the center for his cult and for his government. . . . Noone must know that his church, his false prophet, and hsi one-world system is the incarnation of Satan."

Saint Matthew's Churches of Tulsa Oklahoma has sent me a Holy Annointed Prayer Rug. It's soaked with the power of prayer. After I use it, I just need to send it in to them with my prayer needs checked off on the letter they sent me -- a better job, a new home, a new car, my health -- you name it. Satisfied customers write that "God blessed me with %5,000," "I received $10,000 in a financial blessing," "God made it possible for us to buy 17 acres of land, "I've gotten a new car and a job," etc.

All very amusing. But if you think these religious beliefs are wrong, how do you know that yours are right?

And, relevant to the below

Here's a link from Blake to an article on Jay Cohen's Medication Sense site, discussing drug industry corruption of the medical profession. Dr. Cohen points out that it's not just a matter of individual physicians being influenced to push drugs inappropriately in exchange for the ball game tickets, the note pad and the triangular pen -- it goes right up the ladder to the highest levels of the medical institution.

I like Cohen's site, I hope you'll check it out.

A Scientific Circle Jerk

We (the We being royal) have written on a few occasions about the dubious evidence for the efficacy of antidepressants. (Here's the key post.) Now, in one week, our two leading medical journals have come out with major research reports which are intended to persuade doctors to prescribe more antidepressants. Both journals made a big PR push on these "studies" (we'll get to the scare quotes momentarily), so you may have read about them in your favorite bird-cage liner.

Since, unlike We, you are mere commoners, you can only read the abstracts, but that should be enough. In the New England Journal of Medicine we have Bupropion-SR, Sertraline, or Venlafaxine-XR after Failure of SSRIs for Depression by Rush, et al; and Medication Augmentation after the Failure of SSRIs for Depression, by Trevedi, et al. In JAMA, we have Remissions in Maternal Depression and Child Psychopathology, by Weissman, et al.

The JAMA article finds that children of depressed mothers do better when their mothers' depression improves. (Another open door crashed through.) Their conclusion? "These findings support the importance of vigorous treatment for depressed mothers in primary care or psychiatric clinics and suggest the utility of evaluating the children, especially children whose mothers continue to be depressed." There is only one problem with this conclusion: 100% of the mothers in the study were being vigorously treated. Some of the mothers improved during the course of the study, some did not. The study provides no evidence whatsoever that the treatment made any difference.

Then there are the two NEJM articles. Both of them report on similar strategies: people who were taking antidepressants, who did not improve, were switched to other antidepressants or given additional ones. In both cases, about 30% of them eventually showed some improvement. Again, however, 100% of the patients in both studies were being treated. There was no control group in either study. Depression sometimes remits on its own, given time, and the placebo response in depression is very strong -- as a matter of fact, it's at least 30%. (What a coinkydink!)

In other words, it's no longer considered necessary that research using antidepressants actually provide any evidence that they do any good whatsoever. That is now considered axiomatic. Having assumed that they must be working, you can then write in your conclusions that they ought to be prescribed. Well, think back to your high school geometry class. If you use your axioms to prove your conclusions you are guilty of what? That's right class, circular reasoning.

Remember the study (also in JAMA) that showed that St. John's Wort was no better than placebo? That same study also showed that Zoloft was worse than placebo at alleviating depression, but the authors refused, for no particular reason, to draw that conclusion. How could they? It would have been like claiming that parallel lines meet. It would have violated the axioms of psychiatry.

Stuff that's hard to talk about

This post is inspired by Bridget Kuehn's news story in the new JAMA (off limits, as usual, to the common rabble) about fecal incontinence in women, but the issue is much broader. Kuehn begins, "Fecal incontinence can have a devastating impact on a woman's life, yet few women with this problem seek help from their physicians." New surveys find that the prevalence among women is something like 7-10%, and rises with age. Of course men can have it too, but women are at higher risk mostly because of childbirth -- especially if they've had forceps or vacuum-assisted deliveries. In one of these studies, only 10% of the women who had the condition had consulted a doctor about it in the past year. Physicians can help, depending on the cause, through medication, recommending exercise regimens, biofeedback and, as a last resort, surgery.

Well, there are a lot of important issues that people often don't talk to their doctors about - the obvious ones, of course, are sex, drugs, alcohol abuse. Slightly less obvious is domestic violence, then there's urinary as well as fecal incontinence, itching and rashes in embarassing places, hemhorroids, psychological and emotional problems (mental illness is stigmatized). You can probably think of a few more. The problem is, even though they've seen everything, doctors are still just as socially embarassed as everybody else to talk about these things, unless they've learned to get over it. Most physicians just don't ask about such issues, and if they aren't proactive, patients are unlikely to bring them up. (That explains all those erectile dysfunction ads on TV, of course. The drug companies figure the guys need a push to get over the embarassment, and they know the docs aren't going to bring it up.)

Physicians are also just about as likely as most people to be morally judgmental, and to have their particular hangups. They may not be comfortable with sexuality. (The gynecologist at the student health service where I went to college used to give the young women a lecture about the importance of chastity if they asked for contraception or he determined then to be non-virginal. So that pretty much cuts off communication.) They may be uncomfortable with homosexuality specifically. They may feel helpless or conflicted about what to do in a case of domestic violence, and as for emotional problems, they definitely don't know what to do, they just push pills.

One of the most difficult challenges in fixing medicine is finding ways to help physicians be better communicators, and this is just one more steep ridge in that broad terrain. How do you get people to talk about all that icky, humiliating stuff, and have it be okay?

Yes, you can help

In response to an inquiry, I have determined that it is possible to support humanitarian relief in Iraq by making a donation to the International Federation of the Red Cross and Red Crescent, and earmarking your donation for Iraq humanitarian relief. The web site is here. You can direct your donation to Iraq by selecting Iraq humanitarian relief from the list box next to "I would like my donation to go to:" (I believe that if you make a donation to the International Federation, it is not tax deductible. Whether the American Red Cross makes it possible to earmark money for Iraq I do not know, but I suspect that if you do so, they will just subtract the earmark from whatever they were going to send anyway. That's how they operate.)

However, the Iraqi Red Crescent is having great difficulty operating in the war zone. Our friend Whisker sent me this story.

BAGHDAD, 22 March (IRIN) - Aid agencies say thay have been prevented from entering the city of Samarra, in central Iraq, where a major US and Iraqi military operation is underway.

"Our convoys sent on Sunday and Monday have been prevented from entering the city by US troops and our information from inside is that families are without food, power and potable water, particularly because they cannot leave their homes," noted Abdel Hameed, a spokesperson for the Iraqi Red Crescent Society (IRCS). This, they say, has left hundreds of families without medical assistance and food supplies.

"Innocent people and especially children are suffering from a lack of supplies in and on the outskirts of Samarra," said Muhammad al-Daraji, Director of the Monitoring Net of Human Rights in Iraq (MHRI). "US and Iraqi military groups have prevented the entrance of local NGOs as well as the media to show the reality of human rights violation inside it," he added.

According to al-Daraji, no citizens have been allowed to leave the city, some 120 km north of the capital, Baghdad, since the operation began on 16 March. US forces along with Iraqi commandos say the operation is necessary to flush out insurgents in the area.

So you can help them buy the supplies, but whether the supplies reach the people in need is up to General Casey.