Map of life expectancy at birth from Global Education Project.

Saturday, April 30, 2005

Getting What You Wish For

I expect quite a few of the visitors here have already read or know about Bill Moyers's essay in the March 24 NYRB entitled Welcome to Doomsday. Moyers discusses the influence of the so-called "Christian right" on Bush administration environmental policy. The recent, very novel alliance between evangelicals and the Catholic hierarchy is one important development. This movement bases its thinking about enironmental issues on the Genesis account in which God says to Adam and Eve, "Have dominion over the fish of the sea and over the birds of the air and over every living thing that moves upon the earth." Some Catholics and evangelicals interpret this "dominion" as implying a responsibility of stewardship, but most tend to view it as conferring a right of exploitation. (See my post on The Peacemaker at the Dialogue blog for an alternative spiritual relationship to nature.)

This Old Testament stance toward nature might be open to interpretation and negotation among Christians and non-Christians, but Moyers is even more disturbed about the Apocalyptic movement in Christianity. "Google the "Rapture Index," Moyers writes, "and you will see just how the notion has seized the imagination of many a good and sincere believer." No one can say for sure how many U.S. Christians believe that the world is about to end, but there are tens of millions at least. Moyers notes a poll that found that 36% of all Americans believe the Book of Revelation is "true prophecy." You can read all about the bizarre, hate filled and ignorant beliefs of the End Times believers in Moyers's article which is available here. Obviously, as far as these folks are concerned, anybody who wants to rape and pillage the earth can just go right ahead, because it isn't going to be around much longer anyway.

I was moved to tout the Moyers piece today John Heilprin's reporting for the Associated Press. It turns out the EPA has suppressed internal reports about the benefits from limiting mercury emissions from power plants. The EPA claims the benefit nationwide would be only $50 million a year, while its own heretofore secret analysis showed the benefits would be $2 billion for the Southeast alone. The report also found a mercury "hot spot" in the Atlantic Ocean off the southeast coast.

The Bush administration has a consistent habit of basing its environmental policies on fake data, phony analyses, and outright lies; and of suppressing scientific information that conflicts with its preferred policies. While it is impossible to know whether Bush himself believes in the End Times, we do know that he believes deeply and sincerely in making his wealthy friends even richer, particularly the ones in the energy business. The alliance between corporate polluters and despoilers, and Christian true believers may be entirely cynical, but it has an iron grip on the country right now. By the way, those billions of dollars in benefits from limiting mercury pollution are mostly a way of summarizing the cost of deformities and brain damage in fetuses and children. But what the hell, it's God's will.

Friday, April 29, 2005

A picture is worth a thousand words

Addendum: Thanks to C. Corax for tracking down the provenance of this image. It is, astonishingly, a work of 19th Century taxidermy. The resemblance of Napoleon the Wonderchimp to a certain current celebrity couldn't possibly be a coincidence, could it? (Learn more about this weird Victorian era art form here, hit the "back" button at the bottom of the page to learn more.)

The Nucular Option

Cowboy George fell off the chuckwagon a couple of days ago long enough to talk to some small business persons about his "thoughts" on energy policy. He called "our nation's growing dependence on foreign sources of energy" a problem. Astonishingly, this statement was actually true! That was the end of the facts and logic, not to mention the syntax, for the day.

He said, "See, we got a fundamental problem we got to face here in America."* (That's how they teach people to talk at Andover and Yale, of course.) His number one solution? Nucular power, of course! That's why he launched his nucular power initiative, a "seven year, $1.1 billion dollar effort to by government and industry to start building new nucular power plants by the end of this decade." The major components of this "effort" are a $6 billion tax subsidy for new nucular power plants, and federal "risk insurance" to nucular plant builders, which means that the taxpayers would hand them free money if their plants went over budget or didn't get built on time because they couldn't meet regulatory requirements.

Unfortunately, as with the Level 4 biosafety lab proposals, the public debate on this question is likely to focus almost exclusively on the risk of a catastrophe. If you spend enough money on the bioterrorism lab, or the nucular plant, you can make it extremely unlikely that ebola virus or radionuclides are going to blow out the stack and wipe out Boston or Detroit. But that is not, in fact, the issue. The biolab is going to create novel pathogens that otherwise would not exist, which will make us less safe. Cowboy George's nucular plants are going to make us poorer and very definitely much less independent.

If nucular power really was economically beneficial, why would the industry require massive subsidies? In case you didn't know, their liability for a major accident is already capped -- the taxpayers will foot the bill for a disaster. It takes from 10 to 18 years for a nucular power plant to produce as much energy as it takes to build it, and to mine and process the uranium it consumes -- all of which requires burning fossil fuels. That means that investing in nucular power will create a net increase in consumption of fossil fuel, for decades. The plants might repay the fossil fuel burden eventually, but not if they operate unreliably or have to be shut down because of safety or security problems after less than 20 years of operation. Reactors generate 20 to 30 tons of high level radioactive waste every year, and we still don't know what we're going to do with it. The industry has already produced hundreds of thousands of tons of "low level" waste, which it doesn't know what to do with. They're asking to be allowed to recycle it into consumer products.

The social implications of a nucular-based energy economy are terrifying. The security requirements would turn the country into a police state (if it isn't one anyway); the unparalleled capital intensity of nucular power production means that social and economic power would be increasingly concentrated, in the hands of people who also controlled much of that vast security apparatus. There is a great deal more to be said about this complex subject, but it is virtually certain that you will not hear an insightful, informed or honest discussion in the corporate media.

The energy path we take is really the most crucial technological and investment choice facing humanity. But we aren't really talking about it.

Check out: Critical Mass Energy Project (yeah, fuck Ralph Nader but decent people still work for him.)

Also: Rocky Mountain Institute

*Taken verbatim from the transcript at We fact check.

Wednesday, April 27, 2005

A Final Word (I fervently hope) on Terri Schiavo

Now that the dreckstorm has settled, ethicist George J. Annas makes clear for us the non-issues underlying the Terri Schiavo case. (New England Journal of Medicine, 21 Apr.) (And in case you're thinking what I'm thinking, the idea of a professional "ethicist" does seem kinda strange. You need a Ph.D. and a faculty appointment to talk about what's ethical? But George J. is thoughtful and well-informed. The great thing about ethicists is that, in constrast to physicists, you don't have to buy what they say.)

Annas asks,
"How did the U.S. Congress conclude that it was appropriate to reopen a case that had finally been concluded after more than seven years of litigation involving almost 20 judges? Has the country's culture changed so dramatically as to require a fundamental change in the law? Or do patients who cannot continue to live without artificially delivered fluids and nutrition pose previously unrecognized or novel questions of law and ethics?"

The answer is no, and nope. The issues in the Schiavo case were fully settled in law by the precedents of the Karen Quinlan and Nancy Cruzan cases, the latter decided by the Supreme Court in 1990. Essentially, it has been the law of the land for 15 years that a feeding tube constitutes medical intervention, and that people have a right to refuse it. If there is no reasonable possibility of a person returning to a "cognitive, sapient state," life-sustaining treatment can be removed (Quinlan), and the states can establish the standards of evidence to determine what non-communicative persons would have wished (Cruzan).

The dispute in the Florida courts about Terri Schiavo did not concern what her wishes might have been. A judge found in 1998, based on the evidence, that Terri was in a persistent vegative state and that if she could make her own decision, she would terminate feeding. The decision was upheld on appeal and the Florida Supreme Court declined to review it.

Terri's parents returned to court claiming they had new evidence, not about her wishes, but about her condition, claiming she was not in a persistent vegetative state. The court allowed physicians to examine her, and concluded that she was indeed in a persistent vegetative state, and the appeals court upheld the decision, saying, "Despite the irrefutable evidence that her cerebral cortex has sustained irreparable injuries, we understand why a parent . . . would hold out hope . . . .But in the end this case is not about the aspirations that loving parents have . . . . It is about Theresa Schiavo's right to make her own decisions."

The bottom line is that there was no ethical issue involved. This dispute was not about morality, or the culture of life, or Christian belief. It was about facts. Subsequently Terri's parents, persisting in their state of deep denial, enlisted religious fanatics to generate a public controversy based entirely on falsehoods. and shamefully, the Republican Party and the Catholic Church joined them as co-conspirators. It was only then that we started to hear slanders about Michael Schiavo, and doubts raised about Terri's wishes. The dispute was never about that, it was about her medical diagnosis, which was in fact incontrovertible.

Now that this disgraceful episode is over, nobody can even say what point the Republicans were trying to make. There is no issue of public policy to be decided, no law left to be made, no significant controversy over the ethics of such situations. This was a passion play about nothing.

Tuesday, April 26, 2005

New Resource

Old friend John McDonough, former crusading Massachusetts state legislator, author of a fine book on policy making, and now Executive Director of Health Care for All (Massachusetts) has gotten the blogging bug, in his official capacity.

Health Care for All

I'm hoping John will add commenting and not be afraid to get a little sassier. Their web site also has a lot of good resources in addition to the blog.

HCFA has been working to get some form of universal health care in Massachusetts since the president of the United States was a real fake Hollywood cowboy, not just a New England preppie who talks like one. They even got a plan passed once, but it was repealed before it was implemented. (Which I have mixed feelings about, I didn't particularly like it but that's spilt milk over the dam.) But they're always close. If there's any state where we have a chance to break the ice jam, it's Massachusetts, the bluest state which also happens to be home to John E. McDonough. (You have to use the "E" because when he was a politician, the Republicans would get additional people named John McDonough on the ballot just to confuse people. I wish I was clever enough to make that up but it's the truth.)

La lucha continua John E., and Sr. Cervantes is still in it with you.

An ounce of prevention is worth . . .well, sometimes 8 grams

I don't talk much about what's in the medical journals because they're mostly subscription only and I can't give y'all links. (Were I to reveal the secret code, deep the doo doo would be.) But physicians are a new priesthood, it is not for ordinary people to know their secrets.

Iona Heath, writing in the British Medical Journal, cites (the great) Amartya Sen as pointing out that in Bihar, India's poorest state with the lowest life expectancy, rates of self-reported illness are lower than they are in the United States. "It seems that the more people are exposed to doctors and contemporary health care, the sicker they feel." Why? Because they've all been diagnosed with something (hypertension, hypercholesterolemia, etc.) and their expectations are much higher so that aches and pains and getting old are interpreted as abnormalities. Heath sees a massive misallocation of resources with essentially healthy rich people taking all sorts of pills while truly sick poor people don't take any.

The problem with this analysis is, of course, that if we stopped investing so much in preventive medicine in the rich countries, the resources would not be magically reallocated to Bihar and the Congo. What's going to determine what we rich folks do is what's in it for us. In the March 8 BJM Barratt and colleagues calculate that for every 1,000 women who get a screening mammogram over ten years, 167-251 (rising with age) get an abnormal result; 56-64 get at least one biopsy; and from 9-26 have an invasive cancer diagnosed. 3-6 have a so-called ductal carcinoma in situ diagnosed. That means abnormal cells confined to the milk duct, and it is unknown what percentage of them would ever go on to cause trouble. We don't know because we always remove them. However, cancer is also diagnosed in women who are not screened, albeit usually at a more advanced stage. Over 10 years, for each 1,000 women screened, there are .5 fewer cancer deaths for those age 40-50, and 2, 3 and 2 fewer deaths respectively for each successive ten-year age cohort. So if you have a mammogram, you have about a 20% chance of getting the shit scared out of you, a 6% chance of having to undergo a biopsy, a 2% chance of undergoing surgery and/or radiation or chemotherapy, and a .02 percent chance of extending your life.

You persons of maleness out there may have been urged to undergo prostate cancer screening. There is actually no evidence that prostate cancer screening will extend your life by one minute, but it could very well cause you to be diagnosed with prostate cancer (which it turns out, upon autopsy, that 70% of elderly men have when they die, without even knowing it and without it causing them the slightest problem), and the treatment (which, now that you've been told you have cancer, you will almost certainly get) may leave you incontinent of urine and unable to, you know, do it. And in the latter case, Viagra probably won't work.

Just something to think about.

Monday, April 25, 2005

Times change, believe it or not

A new edition of Our Bodies, Our Selves is out. Excerpts and info are here , but if you want to read the book, you have to do things the old fashioned way -- you have to pay money and in return, you get sheets of paper with printing on them, bound together at one edge. OBOS was a real breakthrough when it first came out 35 years ago when physicians, including gynecologists, were overwhelmingly male; patients were not expected to participate in decisions about their own health; and reproductive health and sexuality weren't even spoken about openly. Actually giving women factual, non-judgmental information about their own bodies and health related decisions was, yup, radical.

Nowadays, we more or less take it for granted that people ought to be informed about medical issues, take part in decisions about their own medical treatment, have open, two-way communication with their physicians, and that doctors shouldn't contaminate the relationship with their own moral judgments. We also presume that women are autonomous and have the right to make their own choices about sex and reproduction. Or rather, some of us do. But OBOS has not become quaint -- it's still a great resource and it's just evolved and grown over the decades. Now if somebody would just do the same thing for us guys . . . .

Sunday, April 24, 2005

An Andy Rooney Moment

Friday I hitched up my tiller and headed out to plow the back 40 -- well actually the back three quarters. The tiller has a big label with a cartoon of a guy getting wrapped around the drive line. Warning! Risk of injury or death! Stay away from drive line while tiller is operating! On the other side, is a cartoon of a guy being, well, tilled. Warning! Risk of injury or death! Stay away from rotating tines!

Uhuh. Sounds like good advice. The tractor itself (made far, far away across the mighty Pacific Ocean -- I was gonna do my patriotic duty and buy American but I determined that John Deere buys the exact same tractor in the mysterious orient and paints it green, so I figured I'd save a few bucks and keep the orange paint) has a label showing a cartoon of some clown driving with the loader straight up in the air as high as it will go, right into some power lines. Warning! Risk of injury or death! Do not contact power lines with loader! More sage advice, I have to agree.

On the back, it says, Do not operate PTO without the shield in place! (For you city slickers, the Power Take Off is a splined shaft that drives the equipment attached to the tractor.) Naturally, the first thing I did before I hitched up the tiller was to remove the PTO shield, which is what everybody else who owns this particular model of tractor does. It's a royal pain in the ass, exactly in the way when you're trying to get a driveline onto the PTO which is hassle enough without it. It's function is to protect against the possibility that somebody will walk along beside you while you're tilling, bend over and stick the end of his necktie into the driveline universal joint. That would be really, really bad I have to agree.

There's one of those industry funded "grassroots" organizations out in Michigan that claims our civilization is being destroyed by frivolous lawsuits, and that "wacky warning labels" prove it. They run a contest every year to collect the wackiest and indeed, they have come up with a few. This year's winner is a toilet brush labeled "Do not use for personal hygeine." (It pains me to link to these charlatans but I stole their shit so here's Michigan Lawsuit Abuse Watch .)

These labels do rate a laugh but they only cost a penny or two to apply. The PTO shield, like the blade guard that comes with every table saw to be immediately and permanently removed, is kind of dumb but it does establish the principle -- this thing is dangerous, you're responsible. But what's really important is that the lawsuits that bring these oddities about aren't frivolous and they aren't harmful.

My tractor is in fact a lot safer than the tractors of yesteryear. The most common cause of tractor accidents is hitting a stump or a sinkhole, falling off, and getting one or more body parts removed by the trailing machinery. That can't happen to me. If I'm out of the seat, the engine shuts off, unless the machine is in neutral with the parking brake on. I may someday succumb to the temptation to have a fatal sexual encounter with a rotating drive line, but I won't be killed by accident.

The truth is that consumer products and industrial machinery both, thanks to lawsuits and to regulation, are far safer now than they used to be. Riding in a car is much safer. Your toaster and your food processor are safer. Your household electrical system, the machinery you or your cousin or your daughter uses at work, amusement park rides, and yup, my tractor, are all safer thanks to greedy trial lawyers and their grasping, America-hating brain damaged amputee clients. (On a note of personal pride, my father invented a device to prevent hydraulic shear operators from parting company with their hands. His former employer holds the patent, or I wouldn't be wasting my time with this shit.)

Yeah, the warning labels are amusing. But getting a yuck or two is not exactly a a bad thing.

Saturday, April 23, 2005

Be bioterrorized. Be very bioterrorized.

We've seen how 9-11 changed NIH. So how has it changed CDC?

Since the occupation of the White House by God's other son,* the nation's public health infrastructure -- which consists mostly of state and municipal agencies and assets -- has been devastated by the state budget crisis. Here in Massachusetts, we've nearly eliminated our tobacco control program (once a shining light unto the world), devastated HIV prevention, state-funded substance abuse treatment, knocked chunks out of our diabetes, breast and cervical cancer programs . . . I could go on and on but it hurts me to write about this. We've seen community public health agencies with decades of history reduced to shells, hard working public servants out of work. Of course the consequences aren't seen instantly, but we will see them soon enough.

But we're saved! There's substantial new federal funding coming into the states for public health! Err, ahh, it's for bioterrorism preparedness, but you know, money is money, infrastructure is infrastructure, right? Maybe not. This money is going to pay for state-wide exercises. We're going to pretend that the forces of evil sprayed anthrax spores around or invented Ebolamydia or synthesized smallpox and everybody in town has to go to a central location to get a shot or take a pill or maybe have themselves quarantined so they can die in a negative pressure isolation chamber, whatever. Then we're going to see what would happen.

Don't worry, they aren't just throwing money away. I personally got a call from some consulting company in New Jersey last year. They needed a minority subcontractor for their proposal to run these exercises. What were we supposed to do? Who cares, we'll figure that out later, just sign up. My motto has always been anything for a buck, so I signed. Last month I got a call from somebody I'd never heard of before. Oh yeah, I had, I just forgot, it was these security consultants. They got the contract. So what am I supposed to do? They'll send me some stuff to read, I'll comment on it (I still don't know what it is, and I still don't know anything about disaster drills) and I'll send them a bill.

Now you know why I use a pseudonym here.

*Have you noticed how his speech is getting more and more rusticated? By now, he sounds like Wilford Brimley as Cookie in a 1960s grade B cowboy movie. Do his apostles actually know that he is in fact the scion of a patrician Connecticut family who attended Andover, Yale and Harvard? I'm pretty sure he didn't talk like a Hollywood cowpoke at Andover.

Friday, April 22, 2005

The Real Bioterrorism

I had a chance to hear my old friend David Ozonoff speak a couple of days ago at the real World's Greatest medical School (located in Boston's Chinatown, convenient to all the restaurants). D.O. is an environmental health scientist of some renown. He reminds us that since 9-11 changed everything, it had to change the National Institute of Allergy and Infectious Diseases (NIAID) as well.

Boy did it. Billions of dollars have been shifted from research on diseases that people in the United States actually get in large numbers -- you know, the ones make us sick and kill us and stuff like that -- to research on infectious diseases that are extremely rare or actually entirely non-existent. The big ones are inhalation anthrax, botulism, plague, smallpox (extinct in nature) and tularemia. What do these all have in common? It is possible that by developing new strains and novel methods of dispersal -- or, in the case of smallpox, presumably, recreating it in a mad scientist's laboratory -- these could be used as weapons.

How likely is it that "terrorists" (as opposed to, say, the United States military) could do this? Well, if they had billions of dollars to spend like NIAID, they might be able to do it. Fortunately, they won't need the billions of dollars. NIAID is financing biosafety level four laboratories in Montana and Maryland, and wants to build one in the geographic center of Boston, to develop defenses against bioterrorism. Of course, in order to figure out how to defend against novel pathogens, first you have to make them.

So the idea is for the NIAID-funded scientists to sit around think, "Hmm, what would happen if you crossed HIV with the flu? That could be really bad! We'd better get started!" What's the first step if you want to make a vaccine, and a treatment, and a detection kit, for this new, horrific germ? Well, obviously, you have to create some AIDSfluenza. Now think about this. What is the single bioterrorist attack in recent times that killed anyone, in the United States or anywhere else? The post 9-11 anthrax mailing attack, of course. And where did that anthrax come from? Osama? Saddam? Kim Jong Il? God-hating liberal democratic Senators? Why no -- it came from a U.S. army biowarfare laboratory.

There isn't any AIDSfluenza anywhere in the world right now. And there is exactly one institution with the money, expertise and facilities to make some (or whatever other novel pathogen you can think up). And that would be? Yep, NIAID.

Now suppose Iran started building a biosafety level 4 laboratory like the one they want to build in Boston, to do the stuff they want to do there -- secret, military research. What do you think the U S of A would do about that?

Just askin'.

Thursday, April 21, 2005

Don't Forget Medicaid

The hairhatted ones on your TV and the laserjet toner-stained wretches at your local bird-cage liner haven't been bothering to tell you, but Medicaid is still on the chopping block. The plutocrat-in-chief has proposed caps on entitlement programs, and the House budget slashes Medicaid. The Senate was much kinder to children from working poor families and old folks in nursing homes, but it's going to conference committee where compassionate conservatism could still end up throwing grandma out on the street or into the arms of state taxpayers who will then have to choose between grandma's nursing care and your kids' schools.

Do something about it! Go here, where some of our friends have put together everything you need to fight back: information, analysis, sample letters, upcoming events, you name it. And if you happen to live in Oregon, Pennsylvania, Maine or Minnesota, we really need you.

"The major focus for action now continues to be the four states where Republican senators voted to oppose Medicaid cuts, and we want them to stand firm: Senators Spector in Pennsylvania, Collins and Snowe in Maine, Coleman in Minnesota, and Smith in Oregon. "

But we need y'all to work on the rest of the Senate and House as well, to make this a priority. And don't forget your newspapers and your TV news. They need to pay attention to issues that really matter. Do we want to have a culture of life? Fine. We need to pay for it.

Wednesday, April 20, 2005

The Inexplicable Being of Fatness

If there's one thing CDC is very good at, it's confusing the hell out of people. Now they have achieved new heights of public bafflement, something I had thought impossible.

On the same day that they come out with a twelve-pyramid, on-line interactive new and improved version of what us oldsters used to know as the four major food groups,* they issue a massive recalculation and retraction of their previous claims about fatness and mortality. Maybe being too fat is just the seventh leading cause of death, not the second, and maybe they set the official overweight line too low.

On the one hand they have an excuse -- epidemiology is a delphic science, which answers our questions in riddles. On the other hand, they have no excuse. Their job is to communicate clearly and truthfully with the public, and they might as well let the oracle speak for itself rather than further mucking up its muddy pronouncements.

Here's the problem. When we try to analyze the real world factors that affect people's health and longevity, they come all bundled together in most imaginable combinations. If you just look at the relationship between people's body fat content, or even worse though much more convenient, their Body Mass Index and their health, you'll see associations but you won't have learned anything about causation. Some people are slim because they smoke 2 packs a day, or have digestive disorders, or even cancer. People who are healthy and energetic, in our modern food rich environment, are likely to take in more calories than our ancestors on the African savannah, and just maybe, if we could control for everything else, we'd conclude that's a little bit bad for them, but we just can't do it. In the modern world, their other advantages over a portion of the very slim -- fewer people among them who are already sick, getting enough of all the essential micronutrients even though our diets aren't usually of the highest quality, a tendency toward sociability and conviviality, you name it -- overcome the disadvantages of a few too many fat cells.

Epidemiology really can't sort all this out. I would say that it's not a question of where to draw the official "overweight" line, but that the very concept of such a line that is wrong. The story is just more complicated than that. But most people aren't going to use a multiple regression equation to figure out how to live their lives anyway. What the average person needs to know is simple, even if you didn't learn it in kindergarten. It's not good to have a fat tummy. Be as active as you can. Base your diet on vegetables, whole grains, and fruits, throw in some fish and, if you must eat meat, keep it lean (range fed), non-fat dairy or other sources of calcium, and use vegetable oil (not palm oil but definitely olive oil) instead of lard or butter. Don't eat trans fats, which is easy if you stay away from junk food, and save eating sugar for very special occasions. For the vast majority of people, if you stay active and keep to those principles, you don't need to count calories. Just eat when you're hungry and stop when you aren't. Save the pyramids for your mystic practices.

This means doing most of your shopping in the produce department and steers you away from most products of the biggest "food" manufacturers. (The stuff that Frito-Lay and CocaCola produce is not actually food.) That makes it hard for the federal government to say in English. But it ain't rocket science.

*As I recall from my college studies, these were hohos, cheesesteaks, pizza, and beer.

Tuesday, April 19, 2005

How to Achieve Bliss

If you take Thomas Gray's advice -- Where ignorance is bliss, / ‘Tis folly to be wise -- then the quickest route to happiness is to read the newspapers and watch TV.

How many of my 2 1/2 dedicated readers already know that according to a randomised, placebo controlled trial -- the Gold Standard -- published in the Archives of General Psychiatry about two weeks ago -- cognitive therapy, a form of counseling, is just as effective as antidepressants at treating moderate to severe depression, and that in fact, patients treated with cognitive therapy rather than drugs were less likely to relapse? Oh yeah -- cognitive therapy doesn't cause agitation, loss of libido, dry mouth, or suicide.

So here we have a multi-billion dollar annual industry, pumped up by all those television ads featuring ecstatic people running through meadows, advertisements in medical journals depicting your patients going from a lonely corner in a black and white world to a technicolor carnival of life -- persuasive enough that primary care physicians hand out happy pills by the billions. Not that the drug companies had to spend all that money on advertising, really: the corporate media were happy to do the advertising for them, laying forests to waste and treating the planets around nearby stars to the world transforming news of the miracle of Prozac. Did you hear a whisper, a hint, an intimation, that maybe, after all, IT WAS ALL A CROCK? Here's a newsflash you won't be hearing on ABC, Fox, or CNN. Antidepressants do not work. (By the way, cognitive-behavioral therapy is a brief, limited intervention. It does not resemble long term, or lifelong, psychoanalysis.)

A new book by Richard A. Deyo and Donald L. Patrick, "Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises," explains what's going on (although they don't discuss antidepressants specifically.) Judy Foreman, in her review in NEJM, says it better than I could. (Okay, almost as well.)

Deyo and Patrick make a well-documented -- if depressing -- argument that doctors, scientists and laypersons alike are far too easily seduced by industry hype for merely new (as opposed to truly better) drugs and medical devices. . . . [W]e are all too ready to believe that new, expensive or aggressive care must be better than older, cheaper, or milder treatments.

Uhuh. Heroic researchers conquering unhappiness and death make for exciting tales. But there's something else going on here. Cognitive behavioral therapy can't be patented, the profits can't be captured by a giant corporation and oh yeah, there's no advertising revenue to be had from it. But don't dare call the corporate media whores. It isn't nice.

Monday, April 18, 2005

Disability Rights (and Wrongs)

I was fortunate to be a student of the late Irving Kenneth Zola. Irv was one of the founders of the sociological study of disability, and of the very non-academic disability rights movement. He had multiple disabilities himself, but as a young scholar it hadn't occurred to him that his disabilities constituted a social status or that they suggested a field of study. This awareness really grew out of his much broader work in the sociology of health and illness.

Irv discovered in his dissertation research that physicians are influenced in their diagnostic labelling by patients' ethnicity and gender. Then he made substantial contributions to the sociological theory of illness. He was hired to document a Boston community called the West End prior to its destruction in the name of urban renewal. He discovered that there was a sharp increase in diagnoses of disease -- including psychiatric disorders and hospitalizations -- among West Enders in the diaspora. But it wasn't because of post-traumatic stress disorder. It was because their new lives could no longer accomodate their physical and mental conditions. People lost their natural supports: neighbors and extended families who offered mutal assistance and accepted their oddities; local businesses that doubled as places for social contact, or let the mentally disabled daughter pick up groceries to be paid for later; employers who had gradually accomodated to progressive physical limitations over the years.

I suspect, although Irv never explicitly connected the dots, that it was this experience which him to the insight that disability is not a property of individuals, but a function of the interaction between individual and society. Wheelchairs would not be confining if the built environment wasn't filled with curbs and steps. Blindness would be much less of a limitation if we didn't depend so heavily on visual means for recording and trasmitting information. Even more important are attitudinal barriers. If we are uncomfortable around people with disabilities, or make assumptions about what they cannot do, we are discriminating. In fact, ability and disabilty are continua, ultimately social constructions. (After all, I'm severely disabled compared to the Boston Celtics, if the standards of ability are defined by NBA scouts.)

As I can confirm from teaching medical students, young people today generally have no idea how much the world has changed thanks to the disability rights movement and the Americans with Disabilities Act. It was once unusual, indeed almost unheard of, to see people in wheelchairs on the city sidewalks, working in offices, shopping, eating in restaurants, going to movies and concerts and ball games. People diagnosed with mental retardation were locked up in institutions that the courts would not have condoned for criminals. Today, these same people would be living in their own apartments, working, dating and getting married. Our physical environment and our attitudes have changed so radically it's difficult to imagine the United States of only 30 years ago. Of course, we have much further to go and most of the world has even further.

I was surprised and saddened, then, to see a faction of the disability rights movement coming forward to endorse the cynical, hypocritical campaign of religious charlatans to prevent Michael Schiavo from making decisions about the treatment of his brain damaged wife. The fundamental principles of disability rights are equality, empowerment, autonomy. Society and each one of us should honor everyone's potential, value and support each of our strivings. These principles, sadly, did not apply to Terri Schiavo. Although her parents could not accept it, empowerment, autonomy, potential all were lost to her 15 years ago. Her husband did his best to honor her autonomy by respecting what he understood to be her wishes. Certainly the choices of what appliances should invade our bodies, how and whether our lives should be sustained, are in the bedrock of our autonomy.

The choice for Terri Schiavo to die was not based on any prejudice against people with disabilities, or failure to recognize her worth and potential as a human being. It was based on an honest assessment of her situation. It poses no threat and in no way devalues people with severe disabilities who, as moral agents, lead lives of meaning and purpose in spite of physical obstacles and prejudice. The disability rights movement's most important contribution to the culture was in making us define human worth and dignity in new ways. Asserting that human worth and dignity accrue to all human DNA in living cells, even where there is no human consciousness or agency, is to deny and defile everything Irv struggled for.

Saturday, April 16, 2005

It Ain't Just Oil, Stupid

I've been reading the business pages with angst lately. The stock market is heading back toward 2001, job gains are sluggish and slowing, retail sales are down, profits are down, and now the consumer sentiment survey has fallen off the table. The bow-tied brown-shoed business babblers are telling us that the economy may hit a soft patch because of high oil prices.

Yep, mebbe so but that isn't the whole story. Right now it's that time of year when employers have to make a new deal with health insurance plans, and workers everywhere are getting bad news. Very bad news. The share of the monthly premium they have to pay is going up, yet again, and not only that but the deal they're getting is worse. Higher co-pays. Substantial charges -- like $150 -- for "surgical" procedures like a needle biopsy, removal of skin lesions, or colonoscopies; emergency department use, even if it really was an emergency; hospital admission. If you have chest pain, you need to decide -- can I afford to pay fifty bucks just to make sure I'm being paranoid? If it's the end of the month and we need groceries, and I going to die for it?

This is a substantial blow to people's incomes. It registers as a pay cut, because it means there is less money in every check. And then you have to spend more of it. As far as I know there isn't any real time data on this, but I suspect it has a lot to do with slowing retail sales, declining consumer sentiment, and weak profits.

Paul Krugman has started talking about the problem, but who listens to that commie?

Friday, April 15, 2005

News of the Future

I'm working on a couple of stories that will rearrange the tectonic plates in Washington.

  • James Dobson threatens to withdraw support from the Republican Party unless the Bush administration attacks Rupert Murdoch's pornography business. Perp walks of hotel executives for providing obscene pay-per-view programming in rooms begin the next week.
  • Congress votes to establish a National Institute of Creation Science at NIH, with initial funding of $1 billion annually. Bush signs bill in lavish ceremony at Bob Jones University.
  • Tom DeLay realizes that it is his duty to save Joe Leiberman's immortal soul by bringing him to Christ. DeLay takes to spending two or three hours a day on the Senate side, lurking in the corridors for opportunities to buttonhole the Senator and hanging out in Lieberman's office anteroom pressing tracts into the hands of visitors. Lieberman finally complains publicly when DeLay hires a minister to disguise himself as a waiter and "accidentally" baptize Lieberman with a pitcher of ice water at the annual National Press Club roast.
  • Major cabinet reorganization passes, subsuming the Depts. of Health and Human Services, Education, Labor and Energy and the EPA in the new Department of Religious Affairs. Bush appoints General Boykin as its first Secretary. On the way to his confirmaion hearings, Boykin trips on the Capitol steps, falls on his head, and enters a persistent vegetative state. He is confirmed anyway, with Senators Lieberman, Feinstein and Biden voting with the majority. Says Sen. Biden, "The President is entitled to the cabinet he wants."
  • Congress votes to establish system of debt servitude. Major credit card company MBNA establishes a slave labor compound in Alabama, which takes over back office operations formerly located in Bangalore. Move is widely praised as an effective response to the problem of outsourcing jobs to Asia. Ralph Nader issues a joint press release with Grover Norquist celebrating the new system as promising to lower the cost of credit for consumers.

Remember, you read it here first.

Thursday, April 14, 2005

Cultural Competency

According to the U.S. Office of Minority Health,

“Cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations . . . .’Competence’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communities.

People usually think of this as meaning, here we are, European-American doctors and our minions of nurses and social workers and so on, and here come these strange foreigners to our clinic or hospital. We must learn of their exotic ways so that we can more effectively persuade them to swallow our pills. A decade ago, a small industry sprang up of people doing "cultural competency trainings" in which they would explain that Puerto Ricans believe in mal de ojo (the evil eye), and Cambodians complain about their livers when they can't get an erection, and so forth. Once you knew these things, you were presumably "culturally competent."

Well, I think we need to extend this concept. Californians believe in the healing power of crystals. Catholics light candles and pray to the Virgin. Baseball players never change their socks until they lose.

Come to think of it, I have a better idea. It's not everybody else who's weird, it's doctors. Doctors have all spent 7 years or more together learning how to talk their own language and think their own strange thoughts. Barbara Korsch is a pediatrician who figured this out 30 years ago: "Terms such as nares, peristalsis and Coombs titre were Greek to the patients. A 'lumbar puncture' was interpreted as meaning an operation to drain the lungs. In more than half the cases we recorded, the physicians resorted to medical jargon. This did not necessarily leave the patient dissatisfied; some patients were impressed and even flattered by such language. There's no question that unless the patient understands you, the clinical diagnosis or treatment will be poor. So, talk English - instead of medical."

Good idea, but it's not just about vocabulary. It's also about subject matter. Elliot Mishler calls it The Voice of Medicine vs. the Voice of the Lifeworld. The lifeworld is, well, reality. Where we live. We have jobs, families, friends, recreation, interests. What makes us sick is not our idiopathic hypertension or our halix rigidus -- it's not being able to do the things we want or need to do, or our pain and suffering, or watching people we care about who can't do something or who feel pain. Whether we are going to take your pills or eat your rabbit food or do your exercises or let you cut us open has everything to do with whether it enables us to do the things we need to do or makes it even harder; with whether we understand what the hell you are talking about or think you actually said the opposite; with whether you listen to us, let us ask questions, believe us when we tell you the pills are making us sick, allow us to be anxious or to doubt you. It has nothing to do with our Coombs titres or our eosinophils or our proteinuria.

And it doesn't make any difference if we were born in Paramus New Jersey and call it New Joisey, or we come from the mountains of Guatemala and speak Quechecal.

Wednesday, April 13, 2005

Exploitation of Children

True story.

Rosa was frightened. Her little boy Diego was sick again. Diego had asthma, he’d had a positive TB test, he had recurrent ear infections and had been operated on twice to have tubes placed to drain his ears. Two months ago a doctor told her Diego had salmonella, and the clinic had mailed her a letter about it, but she couldn’t read it because it was in English. Now Diego had been up all night with a fever and vomiting, and his ear hurt again. When they came to the clinic, there was no-one to interpret, so Diego’s twelve year old sister Juanita had to do it.

Juanita did her best, but when she tried to translate her mother’s questions, the doctor just ignored her, or wouldn’t even let her speak. Juanita tried to tell the doctor that Rosa was worried about a lump on the baby’s lip, that she wanted to know what the letter said about the salmonella, that Diego had had diarrhea and fever. But the doctor just said the letter was too old to worry about. Then the doctor tried to ask Rosa what Diego took for his asthma, but Juanita didn’t translate the question correctly. The doctor tried to ask how long ago Diego had his last asthma attack but Rosa thought she had asked how often he took medicine for his asthma, and the doctor’s question was never answered. Rosa tried to ask what was wrong with Diego’s ears, and what she should do if he kept vomiting, but her questions were never translated. Then the doctor said to give him Tylenol or Advil, but Juanita told her mother to give him both.

When my colleague Irma Rodriguez interviewed Rosa after the visit, she asked if the family had been back to Puerto Rico to visit. No, said Rosa, nor can we. Why not? “Because the father of the children is hunting us to kill us.” Rosa said she was going to keep on living and fighting for her children, but now they were staying in a homeless shelter. Juanita had seen her father repeatedly beating her mother, and was in psychiatric treatment for post-traumatic stress. But the doctor never learned any of this.

Communication is the most fundamental requirement of medical practice. Taking care of people is not just about biomedical science, although technically precise communication is essential. It depends on mutual trust, rapport, and the exchange of experiences, beliefs and feelings. Facilitating communication across a language barrier is a demanding professional skill. An interpreter must be truly fluent in both languages, but much more than that is required. Interpreters must be conversant with medical concepts and terminology. They must possess special skills for mediating the structural differences among languages and the deeply embedded differences in world view. For example, Spanish grammar is more complex than English, while English has a larger vocabulary. There are nuances of meaning in each language that are difficult to represent in the other. Interpreters must also have skills to mediate culturally determined expectations about interactions, the physician and patient role, and theories of physiology and disease. Interpreters must meet high ethical standards. They must scrupulously respect confidentiality and avoid injecting their own judgments into an interaction that properly belongs to physician and patient.

Obviously, children can never meet these requirements. Furthermore, having children interpret places demands on them that may be overwhelming and frightening, and may expose them to inappropriate or upsetting information. A 15 year old girl told me that she was serving as interpreter for her mother, when she found she didn’t understand what the doctor was saying, so they called for a Spanish-speaking secretary to help. “Don’t you understand what they’re telling you?” the secretary asked her. The girl went on, “’No, I said.’ She tells me, ‘They’re telling you’re your mother has,’ some sort of thing, cancer, I don’t know, I was like, ‘No, I don’t understand what you’re saying’ . .. and the lady was just so rude.”

But it is not only children who should not be acting as interpreters. In another case, a social worker doubled as interpreter. The mother asked for a prescription for her baby’s cough, and the social worker told the doctor that she had asked for a vaporizer. The mother said that her husband sometimes smoked in the house, and the social worker said the mother had asked the doctor to write a letter to the husband telling him not to do that.

In another case, a nurse interpreted. The mother said her baby’s appetite was “regular,” which in Spanish means only fair, but the nurse interpreted this as “normal.” A different nurse interpreted for a mother whose baby was not nursing well. The doctor thought that the problem was probably nipple confusion, because the mother was mixing breast feeding and bottle feeding, and advised breast feeding only. But the nurse had decided that the baby had milk intolerance, and instructed the mother to buy soy-based formula, rather than translate the doctor’s instructions.

Some have argued that requiring trained, professional interpreters would cost too much. But misdiagnosis and mistreatment are even more costly in the long run, and the potential human costs are not measurable in dollars. Having non-professionals interpret, except in emergencies where there is no alternative, is unethical, because it represents a violation of patient confidentiality and results in inferior medical care, which is discriminatory. Having children interpret is doubly unethical because it is exploitive and harmful to the child.

The Office for Civil Rights of the U.S. Department of Health and Human Services has for many years interpreted the Civil Rights Act of 1994 as requiring that hospitals provide professional interpretation when necessary. But the law is not enforced in this country. The result -- misdiagnosis, wrong treatment decisions, traumatized children, family relationships damaged, even fatal misunderstanding.

Tuesday, April 12, 2005

I wouldn't do this for anybody else . . .

But the Dharma Bums want me to accept infection by a "meme,"* specifically:

You are stuck inside Fahrenheit 451. Which book would you be?
[Note: In the novel - because books were burned -
to save the content of books, people memorized one in order to pass the content on to others.]

The Encyclopedia Britannica. At least I'd make a sincere effort, I'd probably start at "K" and work my way outward in both directions.

Have you ever had a crush on a fictional character?

Technically yes, but it was a character I wrote myself.

What is the last book you bought?

How the Mind Works, by Stephen Pinker.

What are you currently reading?

This is what we call a stochastic variable. I'm not sure what conclusions anyone can draw from the answer since it will be different tomorrow. But the answer does happen to be somewhat interesting, it's "Basic Call to Consciousness," written and edited by representatives of the Ho De No Shau Nee, known to the European settlers as the Iroquois Confederation. (Ho De No Shau Nee, they tell us, means People who Build). Specifically the authors were residents of the St. Regis Mohawk reservation in New York and Canada, who at that time also produced a periodical called Akwesasne Notes. The book describes the actions and teachings of a man called The Peacemaker, until the writing of this book known only through oral tradition. His teachings combined metaphysical ideas about the human place in the universe, a principle-based ethical system, and a Confucian-like set of prescriptions for social order and harmony.

Five books for your desert island cruise package. this was in an earlier version just a deserted island. guess it evolved. take your pick.

The Penguin Complete Works of Shakespeare. (Maybe this is cheating but it is one book, it's all inside one set of covers.)

A calculus textbook. (I've always wanted to master calculus and what the hell, now I've got the time.)

The "Real Book" -- a jazz fakebook with 100s of what we call "charts" -- melodies and chord changes. I'm assuming I have my sax with me.

Moby Dick.

The Three Pillars of Zen by Phillip Kapleau Roshi.

Who are you going to pass this book meme baton to and why? (only three people)

That's a little tough since the Bums and I travel to a considerable extent in the same blog circles, and I don't want to impose on anyone. Any volunteers to take it from here?

"Examples of memes are tunes, ideas, catch-phrases, clothes fashions, ways of making pots or of building arches. Just as genes propagate themselves in the gene pool by leading from body to body via sperm or eggs, so memes propagate themselves in the meme pool by leaping from brain to brain via a process which, in the broad sense, can be called imitation. If a scientist hears, or reads about, a good idea, he passes it on to his colleagues and students. He mentions it in his articles and his lectures. If the idea catches on, it can be said to propagate itself, spreading from brain to brain.
Memes should be regarded as living structures, not just metaphorically but technically. When you plant a fertile meme in my mind, you literally parasitize my brain, turning it into a vehicle for the meme's propagation in just the way that a virus may parasitize the genetic mechanism of a host cell. And this isn't just a way of talking -- the meme for, say, 'belief in life after death' is actually realized physically, millions of times over, as a structure in the nervous systems of people all over the world."

-- Richard Dawkins (no, not the B-list British comic actor from Hogan's Heroes and later on one of those ultra-sleazy game shows)

Monday, April 11, 2005

Not the Big One

Readers have asked me to comment on the outbreak of Marburg virus in Angola. These hemhorragic fevers (Ebola virus is the more famous one) are definitely nasty. They have a 25% fatality rate with good supportive care, more like 80% in the conditions pertaining in most of Africa. There is no antiviral treatment, and no vaccine. The symptoms are horrific.

However, contagion requires direct contact with the bodily fluids of an infected person, although contaminated surfaces can remain infectious for some time. Since infected people get very obviously sick very quickly, unknowing contact is unlikely. The people either die or recover in a couple of weeks, so they aren't walking around spreading pathogens. These outbreaks can occur in Africa because of inadequate medical facilities, mistrust of medical personnel, and funerary and caregiving practices. They do not currently threaten a more widespread epidemic, although they could conceivably mutate and become more contagious.

If you're interested in the straight dope, here's what CDC has to say: CDC info on Marburg

Regional politics

So okay, you may ask, why is there a New England Minority Health Conference in the first place? Is New England a real concept? Yes it is. The U.S. is a big country -- I'm not sure most of the people who live here entirely grasp the scope and scale of this place. The state borders are largely arbitrary, the result of all sorts of historical accidents from ancient land grants, to surveryors' expeditions, to, yup, wars of conquest. But while historical accidents make for less than meaningful political boundaries in most cases, combined with climate and ecology and patterns of economic development, they make for geographic regions with common interests and cultural commonalities.

New England did develop a north-south divide in the 19th and early 20th century as the southern states -- Connecticut, Rhode Island and Massachusetts -- urbanized and industrialized much faster than Vermont, New Hampshire and Maine, and their industrial cities then became ethnically diverse. But that's changing, and we're reunifying. As you drive from New Haven to Portland the cities still thin out, and the farms and woodlands grow more extensive, but most strangers would be surprised how much of the latter remains in southern New England. If you pull off the turnpike in Manchester, New Hampshire today, the first thing you'll see is a botanica -- a store run by Dominicans that sells medicinal herbs and religious and ceremonial supplies. Vermont is still the whitest state but Burlington is now a good place to find Indian food and more and more Latino migrant agricultural and forestry workers are settling down now in small towns in Vermont and New Hampshire.

Those of us who want to eliminate health disparities recognize that the federal government isn't going to do a damn thing that's any good for the foreseeable future. If we want to accomplish anything we are going to have to work at the state level, and the states and their activist citizens can be a lot stronger and a lot more effective when they join forces. In the coming days I'll talk about state public health and health care policy and what we can accomplish in spite of the march in Washington D.C. back to the 15th Century. The North will rise again!

Thursday, April 07, 2005

The Desperate Character Writhes Again*

* R. Crumb

Some readers of Kunstler (see previous post) will actually find his imagined future rather appealing. All that bucolic, local self reliance, sustainable, back to the earth, small scale stuff is making me downright nostalgic for the 19th Century. Of course he does know that there will be some unpleasantness getting from here to there. On my darker days -- and let's pretend this is one of them -- I think he's a cockeyed optimist.

He's adopted a largely provincial perspective, centered in the United States. He is thinking only about the scarcity of oil and natural gas, not about any of the other profound structural challenges we face living on this planet. Curiously, he dismisses coal with a throwaway line about there not being as much of it as "some people" think. I don't know who some people are, but I happen to know there is a helluva lot of coal, most of it underneath China and Siberia. That is not, in fact, good news.

Friend Philalethes raises the possibility of a massive epidemic in the midst of the oil shortage. I would say, that's not just likely, it's inevitable. More than one, actually. Something like a highly virulent influenza would be bad news, but would probably not cause massive social disruption or make a significant dent in the long-term trajectory of the human population. At least the 1918 epidemic didn't. It caused a spike in the death rate but it was no Black Death -- it left society intact, even in the midst of the War to End All Wars. HIV in southern Africa, however, is already rending the fabric of society. NEJM today reports on staph resistant to pencillin-like drugs having escaped from the hospitals where it used to be confined. Then there are so-called emerging infectious diseases, some of which we've heard of and some we haven't. The density and mobility of the human population makes infectious disease epidemics a continuous problem -- only immunization and antibiotics have made our present population and way of life possible. It's a constant struggle for a massive, well financed medical research establishment to stay ahead of them. It's a struggle we're losing already.

Then there are water shortages, desertification, deforestation, soil depletion, degradation of wetlands -- all the things we're reading about from the UN Millennium Development Project. Resource shortages, as we have seen, have not tended to lead to international cooperation to find solutions, or a political commitment to conservation and technological substitution -- they have led to war. Why do you think our army is in Iraq?

Getting to the post fossil-fuel, post industrial age world of honest country living and genteel poverty, or whatever my dotage looks like, is going to be a slog over billions of corpses, unless we start getting very serious about the problem very fast. Remember, today, petroleum is not just about doing 80 on the interstate -- petroleum is food.

As a youth, I remember reading Robert Heilbroner's Inquiry Into the Human Prospect and being profoundly impressed. So far, we've managed to kick his apocalyptic future down the road, but being off by 40 or 50 years in predicting the grand sweep of history is no disgrace.

It is very difficult for people to encompass the prospect of a radical shift in circumstances. We just extrapolate from current trends and that makes us worry, but also think, hey, a little nudge on the tiller and we'll be okay. But we are confronting the possibility of a sharp, historic discontinuity. All of our current obsessions could turn out to be beside the point.

Wednesday, April 06, 2005

Fool's Paradise

All of the fussin' and fightin' we've been doing here in the USA about the finances of Social Security and Medicare in 2035, whether Jesus wants us to spend a million bucks to keep the bodies of dead people breathing, whether rich people pay taxes or only the little people do, and most of the rest of it, might just turn out to be beside the point.

Our world runs on petroleum. Not just our cars, our whole world. We live where we do, mostly far from where we work and shop, because we can burn petroleum to move ourselves around. The food we eat is fertilized, pesticided, planted, harvested, processed and shipped by petroleum. Most of our stuff is actually made out of it and if not, it was mined or grown, processed and manufactured and shipped, by petroleum. We go to WalMart in our cars, to buy stuff that is made from and with petroleum, and brought to us from China in petroleum powered ships. We heat and cool our houses with petroleum and natural gas.

No, we aren't going to run out of it, exactly. But we will extract less and less of it every year, starting about now, even as the Chinese and the Indians want to be as rich as we are and use as much of it as we do. The world is going to change. Drastically, and starting yesterday. Our political leaders, corporate news media, and as a matter of fact a lot of our very smart, independent political thinkers, are either ignoring the problem completely, or just scheming how they and their friends can do well while the rest of the world falls into turmoil. GW Bush and Dick Cheney are in the latter category. They know damn well what's going on, but they certainly aren't about to tell us. That's why they invaded Iraq, and made up a tissue of lies about their reasons.

How we go about staying alive is going to change. There is, of course, a conventional wisdom about this situation. It says that there won't be massive social disruption because market forces will gradually bring about technological and behavioral adjustments that will get us through. There is also an unconventional wisdom that petroleum is at the very root of our economy and our society, and when the roots die, the plant has to die. In other words, the transformation will be radical, probably very unpleasant, and will render completely irrelevant all of our present obsessions.

Here's one perspective. Of course this guy is reading his own crystal ball, but he's got a case.

I'm curious, as always, what others think. I'll say more about my own perspective (and my crystal ball is cloudy) later.

Tuesday, April 05, 2005

Acetylsalicylic acid

The system of drug patents is justified as providing companies with the financial incentive to do the expensive research and testing needed to develop new drugs. Without a period of exclusive license, no company would invest the hundreds of millions of dollars it takes to get a drug from the laboratory to the CVS.

True enough, one must concede, but there are several problems with this system. Investors don't like risk, so companies are always looking for a good bet or even better, a sure thing, before they spend the money on clinical trials. Another very serious problem is that they have absolutely no interest in studying compounds on which they can't own a patent. Solution? Try to copy existing drugs that we already know are valuable, change them slightly to make them patentable, and then try to sell physicians and consumers on the idea that they should spend money on the new, patented variant. Even if this works honestly and well, it leads to only incremental improvements in medicine for the billions of dollars invested, not to any important breakthroughs. And it means that many possible benefits of well known substances that are already in the public domain are never studied.

Aspirin is a variant of a drug known to the ancients, found in willow bark. The naturally occurring compound can severely upset the stomach, but aspirin, first synthesized in the late 1800s, is much less likely to cause that problem. Aspirin relieves pain and inflammation, which everybody experiences at one time or another, and millions of people -- more and more of them as we grow older -- have arthritis and have reason to take a drug that can do that every day. This is a huge market, probably the biggest drug market of all. But Merck and Pfizer obviously couldn't make any money from it unless they could get people to stop taking aspirin and aspirin-like drugs, and instead take something that they could patent.

Enter the Cox-2 inhibitors, Vioxx, Celebrex, and their cousins. These work no better than aspirin, so the companies had to get them approved on the basis that they are safer. Indeed, it seems they are less likely than aspirin-like drugs to cause the (fairly rare) side effect of gastrointestinal bleeding. Still one problem left for the companies: most people who take aspirin never experience any serious side effects. Solution: a massive advertising campaign to convince consumers that the new drugs are better, and a less public campaign to convince doctors that the dangers of aspirin are so terrible that no-one should take it if they have an alternative.

It worked, and the companies had billions of dollars in annual sales. They started investing in additional clinical trials to try to get their drugs approved for more uses, such as preventing colon cancer, which it is expected that aspirin may also be good for. But who wants to test aspirin for anything? It's off patent. They wound up shooting themselves in the foot, because the new trials revealed that Cox-2 inihibitors increase the risk of heart attack and stroke.

Aspirin has been proven to reduce the risk of heart attacks in people with heart disease. It can be taken at very low doses for this purpose, so the risk of side effects is minimal. (Healthy people should not take it to prevent heart disease, however, as it has not been shown to work for that purpose.) Most people who have arthritis can take aspirin safely, and the truth is, and always has been, that it works just as well as the newer drugs. It has also just been shown that aspirin is just as effective as the more expensive coumadin (which, if purchased at your hardware store, is rat poison) in preventing strokes and ischemic damage in people with cerebrovascular disease. Tens of billions of dollars have been wasted on Cox-2 inhibitors and coumadin, when the people could have been taking aspirin instead at trivial cost.

We know enough about aspirin to use it safely. It should not be given to children with viral illnesses because of the risk of a rare, serious side effect. It should not be taken by people with ulcers, liver or kidney disease, or uncontrolled high blood pressure. Some people are allergic to it. If it does upset your stomach, try a coated version (such as Bufferin). But otherwise, there is no reason to spend more.

Monday, April 04, 2005

In Other News . . .

When I picked up my paper this morning, I learned that Pope John Paul II is still dead, the Red Sox lost their season opener, and the Ulong Tribe is the worst in Survivor history. Fortunately, I have other news sources, such as the Massachusetts Public Health Association, which offers the following info:

President Bush's budget proposal for Fiscal Year 2006 spells disaster for public health and health care programs. The president has called for a cut of over $530 million-or nearly 7 percent-to the U.S. Centers for Disease Control and Prevention (CDC) budget, including:

  • A 6.5 percent cut-more than $58 million-to Chronic Disease and Health Promotion programs, including cancer, heart disease, and obesity prevention;
  • Elimination of the $131 million Preventive Health and Health Services block grants to the states, 40 percent of which go directly to local public health authorities;
  • A 14 percent cut-$130 million-for CDC bioterrorism preparedness funding for state and local health departments; and
  • Cuts of nearly $240 million-88 percent-in building and facilities funds, including money for CDC research and testing.

In addition, President Bush proposed Medicaid cuts of $45 billion over the next ten years. The president's plan would restructure Medicaid through block grants, eligibility restrictions, and spending caps and would dramatically reduce health care for children, seniors, and low-income families.

You may recall that the Senate voted to protect Medicaid, but the House has voted to cut Medicaid by $20 billion over the next five years -- oddly enough, exactly twice what Mr. Bush proposed. What do you think might happen in Conference Committee?

The American Public Health Association has action resources -- links to issue briefs, connections to your Senators and Representatives, events, organizations -- Here! Stand up for Life!

The Culture of Life Confronts Biology

To be honest with you, I still don't know what the heck "The Culture of Life" is supposed to mean. But whatever values the culture may uphold, they can only be implemented in the context of reality.

The evolutionary theory of longevity, which accurately explains everything we now know about aging and mortality, proposes that natural selection favors overall reproductive success. That means our lifespans are configured for the benefit of our offspring. Since we nurture our young and continue to cooperate with them in social groups after they have grown, there is some evolutionary benefit to continuing life after the reproductive phase is over. As old folks, we can be repositories of wisdom (or possibly of entrenched foolishness but let's hope for the best), babysit our grandchildren, knit comforters, or be Supreme Court Justices and Senators. But then as far as natural selection is concerned, it's time to get the heck out of the way and stop competing for resources with our grandchildren and great grandchildren. And anyway, evolutionary adaptations that favor our vigor and success during the reproductive years frequently turn out to be bad for us later on in life. (No moral principle is asserted here, just giving you the facts.)

In the last century, in the wealthy countries in particular, due principally to better nutrition and santitation, the isolation of humans from animal predators, less dangerous occupations, etc., we greatly reduced early mortality from environmental causes. Increases in average lifespan continued at a slower rate due to some continuing public health measures (everything from airbags to measles vaccine to nutritional fortification of refined flour), and to a lesser extent to medical intervention, which is very expensive per period of life gained.

The environmental and lifestyle improvements, with occasional help from an appendectomy or trauma care, can get us to senescence, but then the parts start to wear out. The joints degrade, the mitochondria become less efficient, the neurons die. Right now it looks like a person with the most favorable genetic makeup, optimal diet and lifestyle, good (expensive) medical care and good luck, can conceivably make it to 120 years old, but most people won't get near that. Eighty to 90 years is a more realistic hope for most of us. And then we have to hope as well that by medical intervention, we can "compress" the inevitable period of severe disability and cognitive decline into a short time before death, but so far that hasn't really happened. In fact, by extending life we've pushed more people into the realm of dementia, severe arthritis, cancer, and of course heart disease and diabetes. Those latter two may be largely preventable in principle, but we are far from having a social environment in which they will become less prevalent.

Now there is a movement -- disturbingly cult-like, although it is led by scientists -- of people who claim that the human lifespan can be greatly extended, that the average person might make it to 112 and that 120 would not be uncommon. I say cult-like because a lot of these people are True Believers, whose enthusiasm goes well beyond the evidence. But even if they are right, there are some serious problems with this proposal which they don't like to talk about. Let us suppose that by some very expensive interventions, we could maintain people's lives to an average of 112 years, and that by some additional, probably even more expensive interventions (joint replacement and more speculative technologies such as growing new organs from stem cells) we could keep at least a portion of them reasonably independent and capable. (Although no cure for Alzheimer's disease is yet in sight.) Resources, of course, will continue to be scarce. Some people in the wealthy countries will have access to these technologies, presumably, but it might cost more than the gross economic output of the planet to extend them to everybody. In any case, we would have to sacrifice a great deal for such interventions, including providing for basic needs of billions of younger people many of whom would never make it to the realm of life extension.

Without referring to any specific cases, what does this suggest about how we should think about medical intervention to keep people alive in general? Does it make sense to talk about the "sanctity" of human life, however we define human life (which is question #2 of course)? Is "life" the highest moral value? If not, why do so many people seem to think it is?

Saturday, April 02, 2005

A National Disgrace

Our good friend Speechless has shared with us in a comment that she has a son who was lead poisoned. This is an issue with which I have long been involved, so I feel obliged to make this possibly boring, but compelling post.

For centuries, lead has been used in paint for white color. It has also been used in plumbing, and various other applications where the public may come in contact with it. In the 1920s, automobile companies discovered that by adding a compound called tetraethyl lead to gasoline, they could build engines with higher compression ratios and more power. Soon lead was spewing out of tailpipes, and entering the dust and soil near roads. Workers involved in the manufacture of leaded gas started getting sick, so the Surgeon General briefly suspended the sale of leaded gas in 1924. President Coolidge appointed a commission dominated by the industry, which reported back in 7 months that there was no danger to the public from leaded gasoline, properly stored and handled. Lleaded gas was back. Some people warned that there could be long-term effects of low-level lead poisoning and that the safety of lead in the environment could not be assured, but they were ignored.

Concern about lead poisoning grew gradually over subsequent decades. Lead was banned from house paint in 1978, but the industry maintained that only people with acute symptoms of lead poisoning had reason to worry.

In 1979, Herbert Needleman, a researcher at the University of Pittsburgh, reported that children who had lead in their teeth, but no obvious symptoms of lead poisoning, had lower average IQ levels and shorter attention spans than children without elevated lead exposure. The industry mounted a furious counterattack, accusing him of incompetence, dishonesty, and "junk science." Further research has not only proven Needleman correct, but demonstrated that there is no safe level of lead exposure for children. Down to the lowest levels we can detect in children's blood, lead exposure reduces IQ and may cause behavioral problems. Children are at most risk as infants and toddlers, and remain at risk until the age of 5 when the brain has largely finished developing. (Of course lead is bad for everyone, but only young children are at risk of permanent neurological damage from very low exposures.) Most recently, Needleman has showed that juveniles convicted of delinquency have average lead levels 10 times those of a comparison group from the same area.

Although we no longer add lead to the environment in paint, gasoline and plumbing solder, little proactive effort has been made to remove the lead that is already there. CDC estimates that nearly 1 million children in the U.S. are affected by excessive lead burdens. Most of these children are from low income families, because the paint must be old and deteriorating in order to pose a major hazard. Poor children are also at disproportionate risk from lead in soil and dust because they are more likely to live in undesirable areas near major highways, bridges and viaducts (which were painted with leaded paint which was typically sandblasted off when the structures were repainted), or manufacturing plants that emitted lead pollution.

A federally funded program pays to screen children for lead poisoning, but no action is taken when levels are below 10 mcg/dl, and even at levels above that action consists only of counseling. When children test above 15 mcg/dl, public health workers will inspect the child's home. However, there is little funding available to remove the lead paint if it is found. Wealthy landlords may be required to abate the hazard, but it can take years to force them to do so and meanwhile, the family may have no safe place to live because of the shortage of affordable housing in much of the country. If the homeowner is of modest means -- as is often the case in inner city multi-family housing -- some subsidized loans may be available but the resources are insufficient. Because of the danger of losing their housing, families are often reluctant to cooperate with the authorities and allow an inspection.

The lead industry has never been held to account for this invisible disaster. It would be expensive to finally remove lead contamination from the low-income housing stock, but it would cost far less than the war in Iraq.

Meanwhile, if you suspect there may be leaded paint in your home, and you have young children or children visit you, you can have an inspection done inexpensively, or possibly free. If there is lead paint, don't try to scrape it off -- that just creates contaminated dust. The best thing to do is replace the woodwork, but professionals can remove or encapsulate the lead by less expensive means. This should only be done by licensed professionals!

If you can't afford to remove the lead, keep the house scrupulously clean by wet mopping all of the surfaces. TSP is the best detergent for this purpose. Window wells and window sills are the worst places for lead dust so vacuum and wipe those areas frequently. Have children wash their hands often, and definitely before eating.

Now that our national leaders are committed to a culture of life, perhaps they will take note of what is happening to children who are actually alive.

Friday, April 01, 2005

Culture of Life: Mathematically Rigorous Update

On account of my commitment to the scientific method and all that jive, I entered into my statistical software package (SPSS™), for each of the 50 states, the percentage of the vote received by George W. Bush in the 2004 presidential election (at least as reported) and the number of years of life lost prematurely per 100,000 population, as computed by the Centers for Disease Control. The correlation (Pearson's r) was .269, p=.059. Removing Utah, an obvious outlier, the correlation is .338, p=.017.

For each hundred years of life lost prematurely per 100,000 population, the percentage of the vote received by Bush goes up by about 2.

Oddly, I haven't heard Mr. Bush promising to do anything to save the lives of all those weak and vulnerable people who voted for him. I'm sure he's planning to get around to it.

Billions and billions

For reasons that may be obvious to some, I was inspired to pull down my old copy of Broca's Brain. Sagan looks back from the perspective of the late 20th Century on the greatest of human voyages, outward to discover the universe and inward to discover ourselves.

Many modern people, including many scientists, would agree with Siddhartha Gautama that this is really one journey -- that our regarding of ourselves as special, as somehow apart from, and as consequential as the rest of the universe, is illusory. But it is necessary, if we are to make sense of the world, that we pay particular attention to the being that is doing the apprehending, in other words us. The circularity of the project is disconcerting, but not fatal. There is nothing contradictory about turning tools on themselves. It is perfectly sensible to look at a lens through a microscope. And it is simply our nature to be particularly interested in ourselves.

It's obvious to everyone how far the outward journey has taken us. Since Galileo looked through the telescope, our place in the universe has changed so radically that many people simply can't accept it. The universe of billions of galaxies of billions of stars and billions of years, the harsh news that all of humanity is just a bit of slime on a grain of sand in a vast desert, can't possibly be true, so they retreat to the comforting cave of ancient superstition. (Sorry Carl, although you always denied it, you really did say "billions and billions.")

There may be less general awareness of the distance we have gone on the inward journey and the implications of what we have discovered. Broca found that specific parts of the brain are responsible for specific functions. Since his time we have learned an immense amount about where specific cognitive, perceptual, motor and somatic functions are located in the gray and white mass inside our skulls. Our consciousness, our selfhood, our humanity, is not one unitary entity but the sum of innumerable parts, which can be removed or altered one by one. Sometimes the structure of our cognitition turns out to be astonishing to us, as in the stories of Oliver Sacks -- the Man who Mistook His Wife for a Hat, people who can see perfectly but who cannot distinuish among human faces, people who speak with perfect fluency except that they cannot name any fruits.

Our brains evolved. The human claim to distinctiveness among the beings of the earth rests on one feature, the cerebral cortex -- the outer rind of brain cells, which, some 2 million years ago, began an enormous expansion. In evolutionary terms, this expansion was so valuable that it continued even though the enormous heads of fully developed human fetuses barely fit through the birth canal and women's risk of dying in childbirth sharply increased. The cortex could not finish developing in the womb, or even for many years after birth, so human infants remained entirely helpless for at least two years and highly dependent for many more.

But there it is. Every thought, every memory, every sight and sound, every caress, every sting, every emotion that comes to our conscious awareness consists of patterns of chemical signals passing among neurons in our cerebral cortexes. (Pedants: the Latin plural cortices is no longer standard in English, so take it somewhere else.) These phenomena are generated and shaped elsewhere in the brain, but their conscious apprehension is a function of the cortex. If our cortexes are damaged, consciousness can be lost piece by piece -- sight of the left half of the universe, the ability to think about animals, the memory of last Wednesday, the knowledge that this person is your uncle, the color pink, verbs, desire. At what point are you no longer there?