Map of life expectancy at birth from Global Education Project.

Thursday, May 31, 2007

Drive by post --

Busy today, so here's my 30 seconds worth. The news media have continued to be obssessed with the XDR TB case, and as usual there's been 5% useful public education and 95% alarmist bullshit. The worst thing they have done is to pry out his identity and post his picture all over the web and the TV. Therefore I'm not going to link to any of the stories.

Yes, he probably was not very responsible in deciding to fly to Europe and back. There is a very small chance that he might have infected somebody in the process. I say a very small chance because he was not symptomatic and he was not coughing. But it's not impossible, and XDR TB would not be a very welcome gift. But treating him like a criminal, and even violating his confidentiality, is incredibly counterproductive. It's just going to mean that people who have, or suspect they may have dangerous infectious diseases aren't going to want to come forward and cooperate with public health authorities in the future.

And hey -- this guy is a white lawyer. With Lou Dobbs on the teevee every night ranting about how immigrants are infecting us all with leprosy, I expect we'll have a harder time than ever getting people to come in for HIV and TB tests and when people do test positive, we're going to have a harder time getting them into treatment. Thanks a lot CNN.

Wednesday, May 30, 2007

Mass Hysteria, and a real issue

No doubt all of you have by now packed your survival kit and are heading for the mountains to escape the coming mass epidemic of incurable tuberculosis. No? Good for you, but to judge by the screaming headline coverage you ought to.

For anyone who missed the details of this story, I'm only going to link to Lawrence Altman's report in the New York Times, for two reasons:

a) It was on page 14, where it belongs;
b) Altman, who is an actual, real expert on the subjects he writes about, knows the difference between isolation and quaratine.

Point b is a matter of intense annoyance to public health experts. Just so you can avoid embarassing yourself at the cocktail party, contrary to what CNN, the Boston Globe, the AP and just everybody except Altman are saying, the gentleman with XDR-TB is not in quarantine. He is in isolation. Isolation is when you confine an infected, potentially contagious person to prevent transmiting the infection. Quarantine is when you exclude people from an area which you believe an epidemic has not reached. Got it?

Now, as for Page 14 vs. Page 1 or the entire upper half of your web site, Extensive (or extreme) Drug Resistant Tuberculosis (XDR-TB) is indeed a big problem - in the former Soviet Union, in South Africa, and elsewhere in Africa and Asia. But it has been for a few years now. Not only that, but it has shown up in the U.S. previously, maybe a hundred times or more, although we didn't necessarily always know it. (Once again, I'm too lazy to look up a number that doesn't really matter.) We didn't necessarily know it because nobody tried to find out. Some patients had what's called Multi Drug Resistant TB, which is not susceptible to the two main drugs used nowadays to treat TB, which are called isoniazid and rifampicin. If these don't work, doctors fall back on any of six other classes of antibiotics. XDR TB is resistant to at least 3 of these. It was first described and named last year, however, and probably has existed for at least a couple of years before that.

Now, put away your survival kits! This is not a problem in the United States. We have very effective TB control policies and programs in the U.S., and TB is not going anywhere within our borders. This story could be useful as a hook to explain to the public what's going on in the rest of the world, but of course your corporate media aren't very likely to do that responsibly or effectively.

As our legions of fans know, drug resistant pathogens, including this one, emerge largely because of poorly managed treatment. Give people a course of antibiotics that is too short, or has too low a dosage, or which the person doesn't take correctly, and you cause (cover your ears kiddies, here comes an affront to the deity) evolution to happen. Organisms which happen to have mutations that confer resistance to the drug survive, and multiply to occupy the space vacated by their non-drug resistant brethren, and voila, you have XDR TB, or Multi-Drug Resistant Staphyloccocus aureus, or drug resistant C. difficile, or any of a number of nasty bugs that plague humanity.

But TB control is not just about antibiotics and isolation. Healthy people with robust immune systems are not very susceptible to TB. Even if they are infected, they are usually not contagious because their immune systems suppress the organism, they have no symptoms, and they shed little or none of the TB bacillus. That's why TB nearly disappeared from the U.S. and Europe even before antitbiotic treatment was available, as the impoverished, overcrowded conditions of the industrial revolution gave way to greater prosperity and better diets.

But in poor countries, where there are a lot of immunocompromised people with HIV, TB is a big problem today, and XDR TB is scary because it's very hard to kill. Here's the WHO's primer on the problem. Yeah yeah, it's from the satanic one-world government, but it's true anyway. This shouldn't make us worry about ourselves, or our own country, at least not for now; but it should make us want to do more about international poverty and inadequate public health and medical systems in the less fortunate countries. After all, something like XDR TB might come and get us some day.

But not today.

Tuesday, May 29, 2007


While I was driving back to Boston yesterday, NPR inflicted upon me the story of the creation "museum" in Petersburg, KY. No doubt you have already experienced the respectful coverage of this event in your local birdcage liner or over your living room child zombifier. I need not waste your time with my own response, which readers can no doubt write for me, but I was interested in a brief soundbite from one of the self-described Christian fans of the museum, to the effect that without absolute truth, where would we be?

Without absolute truth, we can explore, discover, create, develop, grow. We can be astonished. We can accomplish greatness. We can make tomorrow better than yesterday. We can assure the future of our species, and reach for the stars. We can become more than our ancestors ever could have dreamed.

With absolute truth, we stagnate, shrivel up, and finally blow away as dust. We create nothing, build nothing, discover nothing, achieve nothing. We are not humans, but brutes. And that is what the propietors of the creation museum want for all our children. That's because they have moral values.

Sunday, May 27, 2007

Will the Republican Party . . .

crawl up its own anus and disappear? It's looking that way. To get us started,
here's Peter Canellos in the Boston Globe:

In defending the Iraq war, leading Republican presidential contenders are increasingly echoing words and phrases used by President Bush in the run-up to the war that reinforce the misleading impression that Iraq was responsible for the Sept. 11, 2001, attacks.

In the May 15 Republican debate in South Carolina, Senator John McCain of Arizona suggested that Al Qaeda leader Osama bin Laden would "follow us home" from Iraq -- a comment some viewers may have taken to mean that bin Laden was in Iraq, which he is not.

Former New York mayor Rudolph Guiliani asserted, in response to a question about Iraq, that "these people want to follow us here and they have followed us here. Fort Dix happened a week ago. " However, none of the six people arrested for allegedly plotting to attack soldiers at Fort Dix in New Jersey were from Iraq.

Former Massachusetts governor Mitt Romney identified numerous groups that he said have "come together" to try to bring down the United States, though specialists say few of the groups Romney cited have worked together and only some have threatened the United States. . . .

Michael Scheuer , the CIA's former chief of operations against bin Laden in the late 1990s, said the comments of some GOP candidates seem to suggest that bin Laden is controlling the insurgency in Iraq, which he is not.

"There are at least 41 groups [worldwide] that have announced their allegiance to Osama bin Laden -- and I will bet that none of them are directed by Osama bin Laden," Scheuer said, pointing out that Al Qaeda in Iraq is not overseen by bin Laden.

Then we have Maureen Dowd, who can usually be found ridiculing Al Gore for being fat, or John Kerry for not making his own sandwiches, but on this occasion manages to sound intelligent. She's hidden behind Times Select, but to punish her for her infinite sins, I'm going to go with Stephen Benen's rip off:

The president said an intelligence report (which turned out to be two years old) showed that Osama had been trying to send Qaeda terrorists in Iraq to attack America. So clearly, Osama is capable of multitasking: Order the killers in Iraq to go after American soldiers there and American civilians here. There AND here. Get it, W.?

The president is on a continuous loop of sophistry: We have to push on in Iraq because Al Qaeda is there, even though Al Qaeda is there because we pushed into Iraq. Our troops have to keep dying there because our troops have been dying there. We have to stay so the enemy doesn’t know we’re leaving. Osama hasn’t been found because he’s hiding.

The terrorists moved into George Bush’s Iraq, not Saddam Hussein’s. W.’s ranting about Al Qaeda there is like planting fleurs du mal and then complaining your garden is toxic.

Then the Palm Beach Post -- not exactly located in among the pointy-headed Northeastern liberals -- editorializes as follows:

In a commencement speech this week at the Coast Guard Academy and in a White House news conference, President Bush fell back on the argument that even if the surge doesn't work, America needs to stay in Iraq - to fight the terrorists who are in Iraq because America is in Iraq. "In the minds of Al-Qaeda leaders," he told the Coast Guard graduates, "9/11 was just a down payment on violence yet to come." He linked that potential to Iraq by citing (conveniently) declassified allegations that Osama bin Laden in 2005 ordered Abu Musab al-Zarqawi to set up a terror cell in Iraq to strike at the United States.

But Zarqawi wasn't an Iraqi. He was a Jordanian who went to Iraq because of all the American targets there. Fending off criticism that Mr. Bush was selectively declassifying material, Frances Fragos Townsend, the White House homeland security adviser, told The Associated Press that the information about alleged plots was being declassified now because all the leads had been followed and the players were either dead or in U.S. custody.

Not quite. A U.S. airstrike did kill Zarqawi last year. But what about that other "player," the one supposedly giving him the orders? That would be Osama bin Laden. He decidedly is not in U.S. custody, and if he's dead, the world doesn't have that happy news yet. Instead of pressing the hunt, President Bush diverted resources from Afghanistan, which had harbored bin Laden and Al-Qaeda, and then ordered an Iraqi invasion and occupation that has turned into an Al-Qaeda recruiting bonanza, as his own Zarqawi allegations prove.

I provide all these lengthy quotations to suggest, finally, a change in the zeitgeist. While balance in journalism still requires, for the most part, that truth and lies be treated with equal respect, the endless circular justifications for the Iraq adventure have finally become too much, at least for a few of the braver souls in the corporate media.

And yet, and yet, as Glenn Greenwald shows, the preposterous sophistry that cutting off funding for the war means defunding "the troops" is almost impossible to kill. Americans, it seems, have very nearly lost the capacity to think. Our political discourse consists for the most part of stringing together a small set of nonsense phrases.

I'll tell you what. I stayed up to catch Al Gore on the Daily Show and Letterman on Thursday, and I finally figured something out. I could never understand why the political reporters hated him so much that they sabotaged his 2000 campaign and made the election close enough for Karl Rove to steal. Now I know. It's because he's smarter than they are, and they can't stand that. They loved Bush because he is an idiot, which made them feel an instant connection.

Friday, May 25, 2007

Let's put an end to this nonsense once and for all

I have previously discussed the charlatan Robert Kennedy Jr., who unfortunately due to his ancestry has considerable grossly undeserved star power on the left. He is a liar and a con artist, who engaged in shameless and dishonest self-promotion by exploiting grieving parents in a fabricated campaign to link autism with childhood immunization.

It is now emerging that signs of autism may be apparent in infants shortly after birth, certainly by the age of two months, well before immunization begins. Let us hope this will finally put an end to RFK Jr.'s disgraceful machinations. Unfortunately, his public reputation and his popularity among the stargazers is probably invulnerable.

Thursday, May 24, 2007


What can I add to what far more powerful voices such as Keith Olbermann and Senator Feingold have already said? (Sen. Feingold: "I cannot support a bill that contains nothing more than toothless benchmarks, and allows the president to continue what may be the greatest foreign policy blunder in our nation's history. There has been a lot of tough talk from members of Congress about wanting to end this war, but it looks like the desire for political comfort won out over real action. Congress should have stood strong, acknowledged the will of the American people, and insisted on a bill requiring a real change of course in Iraq.")

I would say that what is worst of all about the seizure of national power by a conspiracy of murderous thieves is that it has been normalized. One expects a country with a democratic tradition, that has experienced an authoritarian takeover, the suspension of constitutional order, and revolting crimes committed in the name of its people to experience a political backlash. Now that we have the chance, one would think that we would turn decisively away from thuggish liars who have brought such disasters upon us.

But no. That would be "uncivil," it would be inappropriately "partisan." If the Democratic Party that controls both houses of Congress were to carry out the will of the majority of voters who elected them, and cut off funding for the occupation of a distant land where we are pouring lives and treasure into a bottomless pit for no more reason than the megalomaniacal delusions of a fool -- well, said megalomaniacal fool might call them names. So obviously they can't do that.

Nor can they exercise their constitutional power and civic duty to remove from office those officials who have betrayed their oaths of office, assaulted and dishonored the constitution, and soaked our flag in blood. That would be irresponsible and it's just off the table.

Sen. Reid, Speaker Pelosi, you have betrayed us. You have failed us. The sword of honor was offered to you and you turned away in cowardice, to your everlasting shame.

Update: And tell this guy why you had to give the Decider his war.

A 21-year-old National Guard soldier from Luverne, Minn. is recovering in Germany after being wounded by a bomb in Iraq.

The parents of Spc. Andrew Hanson say their son called them to let them know that the Humvee he was driving had been hit by a bomb. Felicia Hanson said her son called to say his right leg was amputated below the knee and his left leg was amputated at the knee. Felicia Hanson and her husband, Jack, were not told how many soldiers were in the Humvee.

The military doesn't normally announce incidents in which there are not immediate deaths of U.S. military personnel. We can only try to piece them together from local stories like this one. The national media don't bother to try, and seldom mention injuries. They usually ignore deaths as well, although they may do a weekly roundup or something like that. If they have to mention it, they still usually say "more than 3,000 deaths." Actually it will be 3,500 by the end of this month, at the rate we're going.

Hey, at least we put a stop to Saddam's nuclear program.

Wednesday, May 23, 2007

The PSA and errr, that other examination . . .

Okay, since I presumed yesterday to give advice to people about a problem I will never have to deal with myself, Roger wants to know what I have to say about the Prostate Specific Antigen test. Don't mind a bit.

Prostate cancer is a very interesting disease, from a public health point of view. It turns out that upon autopsy, something like 70 or 80% of men over seventy who died of other causes are found to have what would have been diagnosed as prostate cancer had it been biopsied, but they never had any symptoms of prostate cancer. (I don't remember the exact numbers and I don't have time to look them up, but it's not important -- it's the basic idea that matters.) So, the question is, did those men in fact have a "disease"?

There is unquestionably a real disease of prostate cancer. More than 30,000 American men die of prostate cancer every year. But 189,000 men are diagnosed with the disease each year. So the question becomes: how many of those men would ever have had symptoms had they not been treated, and how many would have died?

Answer: We don't know. We just don't know. Most prostate cancers are what they call indolent. The tumor grows slowly, it doesn't metastasize, it doesn't cause a problem, you live with it for years without knowing it, then you die of something else. But a minority of them are not: they become aggressive, they metastasize, they kill. We can recognize a more aggressive, dangerous cancer, but we can't tell which "indolent" ones are going to become agressive, or when, or why.

Okay, there are two methods of screening men for prostate cancer. The first is pretty basic: the doctor sticks his finger up your ass and feels your prostate gland. The second measures the level of protein in the blood, called Prostate Specific Antigen, which tends to be elevated when there is cancer present. The DRE alone can detect about 60% of prevalent cancers; adding the PSA to it brings it up to closer to 80%. Whether that is a good thing or not is the question. Nobody can even agree on the so-called Positive Predictive Value of these tests because nobody knows what a false positive is.

Here's the problem. Once you detect a prostate cancer, you're going to feel that you have to do something about it, but the treatment options aren't very pleasant. Prostatectomy can produce urinary incontinence and erectile dysfunction. Radiation therapy causes tissue damage and even raises the risk for other cancers. So detecting an asymptomatic prostate cancer might not actually be a benefit at all -- it may end up subjecting you to expensive, painful, dangerous and damaging treatment for something that was never a problem in the first place.

Well, does screening have a benefit in life expectancy at the population level? That is unknown. You can get the lowdown from the Agency for Healthcare Research and Quality here. I'll offer a brief excerpt:

The [U.S. Preventive Services Task Force]found one randomized controlled trial (RCT) and three case-control studies examining the effect of screening on prostate cancer mortality. The single RCT of PSA and DRE screening, which reported a benefit from screening, was hampered by a low rate of acceptance of screening in the intervention group (23 percent) and by flaws in the published analysis.11 No difference in the number of prostate cancer deaths was observed between the groups randomized to screening versus usual care using "intention to treat" analysis.3 Three case-control studies of screening DRE produced mixed results.12-14 A number of RCTs of PSA screening for prostate cancer are underway in both the United States and Europe, but they are not expected to report results for several years.

Data are also limited to determine whether and how much treatment of screening-detected cancers improves outcomes. Radical prostatectomy and radiation are the most commonly used treatments for localized prostate cancer, yet few well-conducted randomized controlled trials have been completed to determine whether these treatments reduce mortality or are more effective than "watchful waiting" (deferring treatment until symptoms or disease progression is evident) for organ-confined prostate cancer.

In other words, not only do we not know whether screening has any real benefits, we don't even know for sure if it's worthwhile to treat cancers that are detected by screening. It seems to me that if you aren't going to do anything even if you do find cancer, then why be screened? But if you are going to do something, and you don't even know whether it's likely to do more harm than good, then I personally would rather not know.

The bottom line?

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).

Rating: I recommendation.
Rationale The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.

And yet, and yet, I would venture to say that 90% of the primary care doctors in the U.S. browbeat, bully and coerce their male patients into getting screened. Why? Because given the choice, doctors always want to "do something."

PS: Roger asked whether I personally submit to that, err, other test. I had to recently because I had symptoms that might have been prostatitis (turned out not to be), so it was diagnostic. What will I do in the future? Haven't come to that bridge yet, but I see no particular reason for me to undergo a DRE in the absence of any relevant symptoms. As always, though, individual risk factors, particularly family history, may change the calculus for some men.

Tuesday, May 22, 2007

A dissent worth pondering

ABC News sends me all their health-related stories, which makes me feel important but I assume their blogger mailing list has a couple of hundred thousand entries.

Anyway, it usually results in a quick click on the delete button, especially when ignorant blowhard and pathological liar John Stossel is involved. Stossel has been caught repeatedly in flagrant lies and journalistic fraud, including by me, which I'm sure rattled the teacups in the ABC boardroom. So how does he still draw a paycheck and get access to the public airwaves, you ask? Too easy for a hint. ABC needs a conservative voice in health and consumer affairs, but it is impossible to simultaneously argue for conservative positions and tell the truth. Ergo, ABC must sacrifice any requirement for truth in reporting in the much higher interest of balance.

That said, a piece came across my virtual desk today that you might want to read. I've written about screening mammography before, but nobody cares what I think. However, Nortin Hadler, M.D., who feels about the same way I do, shares access to the grand stage with the liars and fools who usually dominate, and he says what needs to be said clearly enough. Screening mammography has a very specific meaning: it means that women with no known symptoms or signs of breast cancer, and no known elevated risk factors, are encouraged to undergo mammography every year or every two years, depending on their age and who is doing the recommending. This is so deeply ingrained in medical practice and public health ideology that most women do it, and feel virtuous about it.

The problem is that a very respectable case can be made that there is no good evidence that it saves lives, or at best it might prevent a breast cancer death in one out of some hundreds of women who are screened. And there is a huge cost. Most positive findings on screening mammography are false positives, but you still have to go through biopsy, anxiety, etc. And, the majority of true positives are non-invasive, symptom free lesions call Ductal Carcinoma in Situ, which result in surgery, chemotherapy, pain, expense, terror and all that; but many of which would never have become invasive or caused any problem. We don't know how many, and we have no way of knowing which ones.

Now listen up! That does not mean that you should not get a mammogram. First of all, see my post linked above for a further link to a discussion of Bayes Theorem. It makes much more sense to have a mammogram if you have a family history of breast cancer, or other risk factors such as never having had children, or having used HRT for an extended time; it is imperative if you have any symptoms such as a lump in the breast or an abnormal discharge; it may well make sense if you're just the right age, say somewhere between 55 and 65; and it makes sense if you personally are more anxious about getting breast cancer than you are about the possibility of a false positive and the expense and pain and other negative consequences.

I'm not practicing medicine here, I'm just urging you to talk this over with your doctor and then make your own decision. My doctor is constantly trying to get me to take a PSA test and I am just as steadfastly refusing. He doesn't like it but that's tough, he works for me, not the other way around. There is a very powerful industry and entrenched interest behind this screening mammography thing, and it's awfully hard to fight it. But it's worth questioning.

Monday, May 21, 2007

Here we go again . . .

You don't need me to tell you about the news that Avandia (generic name rosiglitazone), a drug widely prescribed for Type 2 diabetes, has been found to be associated with an increased risk of heart attacks and associated deaths. This is definitely bad news, because one of the major reasons why you don't want to get Type 2 diabetes, and presumably want to control it once you do get it, is because diabetes is associated with an increased risk of heart attacks and death from heart disease.

So, the value added I can give you here, that you probably won't get from your nightly news or your local fish wrapper, is that it points to a fundamental flaw in the FDA drug approval process. This drug, like other drugs for Type 2 diabetes, was approved based on mostly fairly short-term trials (a year or less) that showed that it reduced blood sugar, and that in turn largely based on a marker called glycolated hemoglobin that responds to blood glucose levels over time. Doctors and patients who are trying to manage diabetes generally measure their success based on glycated hemoglobin levels.

This is what we call a "surrogate marker." The real reason you would want to take a drug for Type 2 diabetes is because you want to avoid the complications of diabetes, including death. But the drug approval process isn't based on any evidence that the drug actually does that. It's based entirely on this surrogate end point. While it seemed a reasonable assumption that better glucose control would mean less heart attacks and longer life, it appears not to be true after all.

The study is a so-called meta-analysis, that is it is based on data available from studies that have already been done, none of them with the actual purpose of demonstrating the cardiac benefits or harms of rosiglitazone, so it's not as revealing as we would like. Actually, this means that chances are the stuff is even more dangerous than the investigators were able to determine. But I'll let them speak for themselves:

These emerging findings raise an important question about the appropriateness of the current regulatory pathways for the development of drugs to treat diabetes. The FDA considers demonstration of a sustained reduction in blood glucose levels with an acceptable safety profile adequate for approval of antidiabetic agents. However, the ultimate value of antidiabetic therapy is the reduction of the complications of diabetes, not improvement in a laboratory measure of glycemic control. Although reductions in blood glucose levels have been shown to reliably reduce microvascular complications of diabetes, the effect on macrovascular complications has proved to be unpredictable. After the failure of muraglitazar [a drug that failed to win approval due to demonstrated cardiac risk] and the apparent increase in adverse cardiovascular outcomes with rosiglitazone, the use of blood glucose measurements as a surrogate end point in regulatory approval must be carefully reexamined.

I'll spell it out one more time: Disasters like this one would be much less likely to happen if we had an FDA that worked for us, not for the drug companies. And we won't get that until we have a president who works for us, which we do not have. Enough!


As I have said many times, do your very best to stay out of hospitals. They are extremely dangerous places, for a number of reasons -- e.g., as in my case, they might suddenly decide to cut you open and remove some part you would prefer to keep -- but most important, they are full of extremely vicious, hard to kill microorganisms, and also full of people who are debilitated, and who have extra holes in them with tubes going into the holes, into and out of which the bugs merrily stream.

Atul Gawande has just about given up on infection control. He doesn't spell it out, but I conclude from his disturbingly honest essay that it is essentially impossible with current technology and procedures. We need fundamentally different ways of going about hospital care -- including, I would say, doing less of it -- if we are to solve this problem. And it's a moving target -- the bugs just keep evolving, getting nastier and harder to kill, and they are moving from the hospitals into the community. Who knows how bad this could get?

(Tip o' the hat to Dr. Rick.)

Friday, May 18, 2007


I've never been entirely convinced by the popular portrayal of the White House Occupant as a boy in a bubble, shielded by his handlers from bad news about his unpopularity, the unaccomplished mission, the non-existence of an actual conspiracy among Saddam Hussein, Osama bin Laden, Mahmud Ahmedinejad, and Nancy Pelosi, etc. But who knows? At the very least his delusional view of himself (see above picture) is bound to mislead him about the consequences of his actions.

In any event, as you probably know by now Paul Krugman has metaphorically extended the Bush Bubble to the Republican electorate. (Subscription only but Atrios gives us an excerpt here.) Yes, based on what we've seen so far on the campaign trail, if you want the allegiance of Republican primary voters you have to either be, or pretend to be, foaming at the mouth insane.

But that got me to thinking. I heard on the radio this morning that the Branch Davidians have reconstituted themselves. Their new leader says that God will bring his justice down on America if the state of Texas builds a highway through the site of the notorious Branch Davidian compound. On the one hand, I believe that all religions are equally ridiculous but I do concede that some are more equally ridiculous than others. The people who went off on Comet Hale Bopp, the people who flew the airplanes into the WTC, the people who sold all their wordly goods to await the apocalypse with the Church Universal and Triumphant, the people who donate to the creation "science" museums, Scientologists. And then, in the secular sphere, the followers of Lyndon Larouche, the people who insist that the WTC was brought down by controlled demolition, David Ickes -- who claims that humanity is actually under the control of dinosauroid-like alien reptiles who must consume human blood to maintain their human appearance -- all believe, or apparently believe, stuff that strikes me as highly unlikely.

It seems that we are, after all, entitled to our own facts. I feel quite confident of mine, but when you really think about it, most of what you know you got second hand. I did not personally witness the moon landing. I read about the experiments demonstrating that electrons have both wave and particle properties, I didn't conduct them. For that matter, why should I even believe there is such a thing as an electron in the first place?

For the most part we believe, not because we have seen with our own eyes, but because many pieces of knowledge -- most of which we take on some sort of authority -- fit together into a convincing whole. We use various means to assess the credibility of authority, of witness accounts, of historical records, and we combine these assessments with whatever relevant facts we are lucky enough to have been able to verify more directly to evaluate specific factual assertions, but actually the most powerful reason why we believe or do not believe specific facts is that they do or do not accord with our working overall framework explanation.

Once you believe in evolution, or in creation, you will evaluate new factual assertions in light of one of those controlling frames. It is very difficult to bring about a radical paradigm shift in the mind of a single individual, no matter how many seemingly convincing facts you throw at them. If the facts don't fit, a person can question the credibility of the authority who asserts them, the integrity of the chain of possession of the evidence, the theory used to calibrate the measuring instrument. Authorities who tend to validate our framework beliefs seem more credible to us in the first place - hence Fox News has its audience.

So, ironically (I think that is a rare correct use of the term), the most important reason why I feel fairly confident about many of my beliefs is because I embrace uncertainty. I am willing to see my beliefs overturned, and indeed that has happened several times; I take the time, as painful as it often is, to learn about the counterarguments and try to evaluate them systematically; I have degrees of certainty about matters, withhold conclusions in many cases where I would much rather be sure, and remain completely agnostic about some questions; and, when facts that seem convincing don't seem to fit with other beliefs, I allow myself to be troubled by it and I look for a resolution. It is a balancing act. There is much that I believe strongly enough to act upon as though I were convinced beyond all doubt, but only "as though." Doubt is inescapable. All of reality could be an illusion, after all. But it would make no sense to behave as though that were so.

And that is why, if you have faith, you are most likely wrong.

Thursday, May 17, 2007

I'd just like to point something out

No doubt you have read about this study that finds that so-called "Gulf War Syndrome" may be related to low-level exposure to sarin gas. Subtle changes appear in the brains of soldiers who were exposed to sarin at levels that produced no acute effects.

Not that anybody but me is going to notice this, but the biological effect of such low-level exposure to sarin is identical -- precisely the same, indistinguishable from, not different, congruent with -- to exposure to organophosphate pesticides such as malathion and diazinon. I'm talking about exposures which are routinely experienced by farm workers and exterminators, and which until fairly recently were commonly experienced by homeowners, because organophosphate pesticides were sold for use in gardens and even kitchens. Not any more, I'm happy to say, but they are still widely used commercially. Nobody pays any attention to it, but there is evidence from animal studies that sub-acute (i.e., symptom free) exposure to organophosphates causes brain damage to primates, and we've known that for 30 years or more.

Carbamate pesticides such as sevin, by the way, which are still sold to homeowners and even used in flea collars, have the same biological effect as organophosphates, although by a different mechanism. So whether this study raises any alarm about them I do not know.

Organophosphate pesticides ought to be banned.

A useful summary of the changing zeitgeist

It's subscription only, but that's probably just as well because you don't necessarily need to actually read it, but anyway Ezekiel Emanuel uses a rather strained analogy to George Carlin's famous "Seven Words You Can't Say on TV" to review changes in broad perceptions about health care over recent decades.

If you've been reading this blog, you won't find anything new here, but I agree with Emanuel that what was once considered offensive or ridiculous is now generally accepted. The three big changes are:

The U.S. has the best health care system in the world: I used to give a talk every summer out on Cape Cod. I remember denying this in my talk back in, oh, '95 or so and having some people in the audience get on me like Abu Ghraib dogs (if I may project a current metaphor into the dark backward of time). Specifically the offended ones were medical students, as I recall.

Well nowadays just about everybody who isn't faith-based, including I'd venture to say your typical medical student, knows that the United States does not have have Th' best darn health care system on the planet. Nope. We pay twice to three times as much as everybody else, we don't cover everybody, and we get worse results. It is now okay to say this on TV, and on Cape Cod.

You can't put a price on health care: Ezekiel's formulation is "Health Care is Special," but what he means by this is that it's offensive to "ration" health care and to consider cost as a factor in whether we give somebody a brain transplant in a desperate attempt to extend their life by seven minutes. Well, health care is costing so damn much nowadays that it seems the biggest worry people have about it is how to spend less, and there has been a basic cultural revolt against squandering treasure on the hopelessly terminally ill and the vegetative.

Of course religious fanatics continue to be an exception, but as the bizarre Terry Schiavo case showed, they are in a distinct minority. It is now okay to say that sometimes, it just isn't worth it, although I believe you could always say that in Wellfleet.

New is Better: As Americans, we have a profound affinity for the innovative. All an advertiser has to do to sell sugar water or a toilet cleaner is to put up


above a picture of the product. But lately, we've learned the hard way that in health care, new isn't necessarily better -- whether it be Vioxx, or drug eluting stents, or hormone replacement therapy. In fact, it is the height of wisdom to suspect that the new is worse, and even quite likely dangerous, until sufficient time has passed for it to be proven otherwise, at which point it is no longer new.

I'm not sure you can quite say that on TV yet, the idea is still too new. But soon . . .

Wednesday, May 16, 2007

Speaking Ill of the Dead

Of course I'm talking about Jerry Falwell (8/11/1933- 5/15/2007). Falwell was without question one of the most depraved and detestable human beings to achieve a position of prominence and influence in this country in the current era. It is a depressing indication of the profound division in our society that he had a large following who viewed him as a moral leader.

Falwell flacked for a God who was a malignant narcissist -- hateful, vengeful, and destructive. His was the God of Leviticus and Deuteronomy, a God who had nothing to do with the Gospels. This was a God who slaughtered thousands of innocent people -- hundreds of them not even U.S. citizens -- to punish the United States for harboring homosexuals. In case you didn't really know about Falwell's career, here's a useful backgrounder from Bob Moser at the Southern Poverty Law Center:

Falwell was plain enough about his views; in 1964, he told a local paper that the Civil Rights Act had been misnamed: "It should be considered civil wrongs rather than civil rights." His "Old Time Gospel Hour" TV program hosted prominent segregationists like Govs. Lester Maddox of Georgia and George Wallace of Alabama.

But Falwell, like other fundamentalists, worried about "tainting" his religious message by mixing it with politics.

The Rev. Mel White (see also A Thorn in Their Side), an evangelical writer and filmmaker who ghostwrote Falwell's autobiography, says Falwell was led to politics in part by Dr. Francis Schaeffer, a rebellious fundamentalist who had begun spreading the word about "dominion theology" and who many see as the father of the anti-abortion movement.


Schaeffer was admired by a radical group of fundamentalist thinkers called Christian Reconstructionists. Led by Orthodox Presbyterian minister R.J. Rushdoony, the Reconstructionists argued that the Second Coming couldn't occur until the faithful established a "Biblical kingdom."

Democracy, which Rushdoony called "the great love of the failures and cowards of life," would be replaced by strict Old Testament law — meaning the death penalty for homosexuality, along with a host of other "abominations," including heresy, astrology, and (for women only) "unchastity before marriage."

It was not enough for the good Reverend to lead the culture into ignorance and darkness: he helped to bring upon us the very tangible disaster of the criminal Bush administration. Falwell's moral values brought us the 1994 video, "The Clinton Chronicles," which Falwell heavily promoted in infomercials, as Murray Waas discusses here.

A conservative political organization with ties to the Rev. Jerry Falwell covertly paid more than $200,000 to individuals who made damaging allegations about President Clinton's personal conduct, Salon has learned. . . .

The drug smuggling and Vincent Foster allegations were prominently featured in "The Clinton Chronicles," a video produced by Citizens for Honest Government and co-financed, publicized and distributed by Falwell. The notorious 1994 video also insinuated that Clinton's political adversaries often met untimely and suspicious deaths. . . .

[A] direct-mail fund-raising appeal by Falwell suggests that Falwell was indeed involved with the video much earlier than he has acknowledged. The fund-raising appeal also shows that Falwell subsidized the production of the video as well. In the August 1994 direct-mail solicitation, Falwell asked supporters to "help me produce a national television documentary which will expose shocking new facts about Bill Clinton." The letter stated that Falwell was ready to make it available "as soon a I can raise approximately $40,000 needed to produce this video."

The video's commercial success is due in large part to its promotion on Falwell's "Old Time Gospel Hour," as well as in an infomercial for the video, which viewers could order through Falwell's Liberty Alliance.

During the infomercial, Falwell interviews a silhouetted individual whom he identifies only as an "investigative reporter."

"Could you please tell me and the American people why you think that your life and the lives of the others on this video are in danger?" Falwell asks the man.

"Jerry, two weeks ago we had an interview with a man who was an insider," the mystery man replies. "His plane crashed and he was killed an hour before the interview. You may say this is just a coincidence, but there was another fellow that we were also going to interview, and he was killed in a plane crash. Jerry, are these coincidences? I don't think so."

Falwell reassured the man: "Be assured, we will be praying for your safety."

During Salon's interview with Matrisciana [producer of the video], a reporter told him that his voice sounded familiar. When the reporter told Matrisciana that he sounded like the man in silhouette, Matrisciana acknowledged that he was the mystery man.

"Obviously, I'm not an investigative reporter," Matrisciana admitted, "and I doubt our lives were actually ever in any real danger. That was Jerry's idea to do that ... He thought that would be dramatic."

I doubt that Falwell actually believed most of the filth he spewed. He was nothing but a con man, whose mission in life was to steal from poor and ignorant people. But the Republican presidential candidates are falling all over each other to praise his legacy, and James Dobson gets most of Larry King's show to tell us why he was a great man. He was a nasty, greedy, dishonest, hate filled, ignorant, evil, foul and vicious man who hated Jesus more than he loved himself.

Update: I said that the Republican candidates were falling all over each other to praise the hypocritical hate monger, and indeed most of them were. However, John Aravosis has compiled the actual score, and he gives Thompson, McCain and Giuliani credit for comparatively faint praise, and Tancredo and Paul, so far, have not eulogized him. (I would not expect Ron Paul, a principled libertarian, to express admiration for Falwell.)

The rest, however -- 5 out of 9 -- are elevating him to sainthood. Credit where it's due, but of course Ron Paul is not really trying to become president.

Tuesday, May 15, 2007

Some talk about talking

I don't often write about my own work here, for various reasons, but today I am inspired to say a few words about some problems and issues that I see in communication between doctors and patients. Most formal research in this area is carried out in medical schools, financed by agencies that mostly fund biomedical research -- principally the National Institutes of Health -- and in fact is conducted mostly by M.D.s rather than social scientists. Inevitably, it is grounded in the physician's point of view and the problem definitions are written by physicians, mostly taking the form of "How can we get people to do what we want them to do?" These are hardly original observations but I hope they are salutary reminders.

I trust my colleagues won't mind if I refer to some ongoing research in very general terms. In a study to evaluate an intervention intended to give doctors specific, comparatively accurate information about their patients' adherence to drug regimens, we are finding that while the intervention did indeed prompt doctors to talk about adherence more, all that talk didn't have any evident effect. About midway through my own analysis of the transcripts of these conversations, I'm starting to get a pretty good idea of why that is.

The doctors scold, exhort, convince, invoke the dire consequences of non-adherence, encourage, plead, you name it. But the people already know what the instructions are, they already know what the rationale is, they already know what the doctor wants them to do. If that isn't enough for them to take the pills on schedule in the first place, it isn't going to magically become enough by repeating it.

There are reasons why the people aren't taking the pills, but these don't get talked about, and nothing gets done about them. They don't get talked about because:

1) Doctors have too much cultural authority, and the people aren't even going to mention it if they just don't agree with or believe in something the doctor is telling them. They'll just sit there and nod, and then go home and do what they think they ought to be doing. It doesn't help matters that the doctors know, beyond a shadow of a doubt, that they are right, and would meet any challenge with scorn and contempt.

2) There is a huge social difference, in many if not most cases, between doctors and patients. Doctors just do not grasp the realities of their patients lives and for the most part haven't got a clue how to help people solve problems that may interfere with health promoting behavior.

3) Doctors and patients don't necessarily have the same goals. Taking the pills, regardless of the statistical likelihood that they will have some benefit in terms of longevity or avoidance of symptoms, may just not be as important to the people as some other consideration, such as not having to think about bad stuff all the time, or more concrete considerations.

Again, there is really nothing original about these observations. To a medical sociologist, they are utterly banal. Yet we are spending I don't know how many millions of dollars every year on adherence related research with little consciousness of the basic problem, and no meaningful effort to do anything about it. Even the current superstar docs who are doing professional self-criticism, such as Jerome Groopman, aren't really looking at these basic issues. Groopman blames himself for biased thinking, but he still assumes that he should be doing all the thinking. (Props however to our friend Alan Showalter who does have an informed perspective.)

What is at issue here is the fundamental culture of medicine. Doctors have to stop telling people what to do, and learn how to form effective partnerships. Lots of people pay lip service to this simple idea, which has transformed the way people talk about medical communication, and even the conventional ethical framework for medical practice, but it's still just a lot of talk. The behavior has scarcely changed.

In coming weeks, I will present some specific case studies. As I say, nothing original here, but maybe some illustrations will get through where abstraction can't.

Monday, May 14, 2007

No, it won't be paradise . . .

If the U.S. should somehow, some day, end up with something resembling universal, comprehensive, single payer national health care, will all the sky be filled with rainbows and the trees filled with birds sweetly singing? Probably not. As Tony Blair heads for the ash heap of history, Polly Toynbee in the BMJ considers his legacy with respect to the National Health Service. (Link is to the gateway page, click again for the PDF. If you do read the article, I don't know what the photograph is all about -- Tony seems to be enjoying an afternoon stroll through beautiful downtown Baghdad with his buddy John McCain.)

Now, few in the U.S. actually advocate for a UK-style system. Rather, most sensible people who know what they are talking about think that a Canadian-style system is more feasible and appropriate for the U.S. As most readers undoubtedly know, Britain has fully socialized medicine, in which physicians are state employees. Canada has socialized health care insurance, but private medicine. Nevertheless, some of the problems both nations encounter are similar.

Defenders of the U.S. non-system always raise massive alarms about waits for elective surgery in the UK and Canada. This sort of rationing by inconvenience (rather than by sensible judgment about what is cost effective, which is a strength of both systems) happens because of politics. Voters always want something for nothing. They want all the goodies government can offer, but they don't want to pay taxes. Politicians pander to these contradictory demands, and so publicly financed health care can end up with some resource constraints. It is particularly compelling, therefore, that even though many people believe that both the UK and Canadian systems have been chronically underfinanced, they still manage to consitently get much better results than we do.

Anyway, as Toynbee points out, but in my view doesn't succeed in explaining very well, under the Blair government financing for the National Health Service actually increased substantially, and waiting times decreased dramatically, but the public is still unhappy with the results. From what I can extract from Toynbee's essay, a big reason is that Blair's attempts to introduce market forces into the system caused distortions, in which hospitals fattened at the expense of primary care, and public health and preventive medicine suffered. This is not surprising. As I have argued here many times, the mythical "free market" does not produce efficient outcomes in medicine, whether from the standpoint of the individual consumer, or society.

Another problem, for which Blair perhaps deserves more credit than blame, is that efforts to rationalize the system created losers as well as winner, notably in efforts to close some hospitals and hospital-based services which were superfluous. When hospitals close in the U.S., there's nobody to blame, but in a publicly financed system, it's very difficult to take anything away from people. That's why we can't seem to close military bases either.

So, if we do achieve single payer national health care, la lucha continua. It will continue to be a political struggle, forever, to maintain the system at a high level of quality. Note, as a cautionary example, how the VA medical system has had its ups and downs over the years. But that's no reason not to do it. Even with all the problems we can anticipate, it will still be vastly better than what we have now.

Friday, May 11, 2007

One More Reason Why We Need . . .

Universal, Comprehensive, Single Payer National Health Care.

New Study Shows More than Half of Medicare Part D Patients Delayed in Accessing Psychiatric Medications. (PDF) Here's part of a summary of this release. (Thanks to Aunt Deb for the tip):

A new study published in the American Journal of Psychiatry (AJP) details the often devastating consequences the transition from Medicaid to Medicare Part D drug coverage had for people with both Medicare and Medicaid (dual eligibles) receiving treatment for mental illness.

The study found that coverage restrictions imposed by Part D plans in violation of guidelines for patient protection issued by the Centers for Medicare & Medicaid Services (CMS) interrupted treatments for schizophrenia and severe depression, sending scores to the emergency room and triggering suicidal behavior.

Using a survey of 1,183 psychiatrists across the country with dual-eligible patients, the study found that, during the first four months of 2006, over half of the psychiatrists’ patients experienced at least one problem getting their medications and nearly one-third were cut off from access to required refills of medicines that had been covered under Medicaid.

The primary reason for access and continuity problems, the researchers report, is that needed medicines were not on a plan’s formulary, or list of covered drugs. Two-thirds of patients had trouble getting their prescriptions, because their plans did not cover those drugs. The drugs most subject to access barriers were antipsychotics and antidepressants, even though Part D plans were required to cover all drugs in these classes.

Researchers found that about one in five patients had been clinically stable on prescribed courses of treatment prior to the transition but were required to switch to a different medication by their Part D plan. Restrictions imposed by plans to control costs that have prevented patients from getting their medications include prior authorization requirements and “step therapy” requirements that force patients to try other medicines first. The private insurance companies offering Part D imposed these restrictions, even though they were required to lift any coverage restrictions that would interrupt treatment on patients already stabilized on these medicines.

Because of these sudden barriers, almost one-quarter of affected patients stopped taking prescribed medications.

Such restrictions put patients’ lives in danger: the report found that over a fifth of dual eligibles who had problems accessing psychiatric medicines experienced an increase in suicidal behaviors. Almost 20 percent ended up in the emergency room, and over 10 percent required hospitalization.

(Summary is from the Asclepios newsletter offered by the Medicare Rights Center, and you can sign up for it here.)

Okay, let's cut through the BS and understand why this happens. It's because the (then Republican) Congress insisted that private insurance companies administer Part D, take a cut off the top in profits, and try to maximize those profits by minimizing their costs, which they do by making deals with drug companies for certain drugs and not offering other drugs to their members. The claim is that this is a "free market" solution which by some arcane alchemy is supposed to benefit consumers, but obviously it does not.

Now suppose Congress had gone with the right system, which is to have Medicare buy drugs directly and negotiate with the drug companies on price. There would be a single, more comprehensive formulary for every Medicare beneficiary. Medicare, obviously, would follow its own rules, and make sure that nobody's treatment was interrupted. A single buyer would get a lower price for everybody, and we could easily set up an equivalent of the UK's National Institute for Clinical and Health Excellence, which would establish guidelines to make sure that every Medicare beneficiary got the most safe and effective treatments.

But no, that would cost some insurance company CEOs their $30 million a year salary and stock options. We can't have that, it's socialism.

Thursday, May 10, 2007

A lot going on today . . .

And I'm too busy to say much about it. The NYT continues its series on the drug pushers with this butt kicking expose by Gardiner Harris, Benedict Carey and Janet Roberts. Just read it, but I will tell you that the curtain opener is a 12 year old girl who wasn't eating, so a psychiatrist prescribed Risperdal, which as our long-time readers know is an anti-psychotic. As you also know, one of its many serious side effects is weight gaain, so this putative "medical doctor" prescribed it for the side effect. That worked, but unfortunately, the victim (what he would call the "patient") developed other serious, debilitating side effects.

Which is not suprising. Risperdal and other antipsychotics have no approved uses in children. None. The only people for whom it makes any sense to take them are people with schizophrenia, a terrible, disabling disorder to which the alternative of risking the often equally debilitating and sometimes deadly side effects of antipsychotics may be worth it. And that is the only approved use for them. But doctors can prescribe any FDA approved drug, to anybody, for any reason or no reason. Of course, it might just be malpractice. The doctor in this case, as it turns out, received lecture fees from Risperdal's manufacturer, otherwise known as bribes.

The doctor justifies taking the money because he only makes a salary of $196,310 a year. "Academics don't get paid very much," he says. He thinks he'd make more money if he were an entertainer.

Very entertaining.

Also, the Senate has passed FDA reform legislation. Only Bernie Sanders voted against the bill, a rare case of bipartisanship. The administration did not actively support the bill, but it appears the Decider will sign it. The bill does implement many of the NAS recommendations we have discussed here, including giving the FDA authority to compel post-marketing safety studies, but Bernie was unhappy that it did not legalize drug imports and also does not address the question of generic biotechnology drugs -- one which we will have to get to here later. Unfortunately, the legislation continues to fund FDA drug regulation mostly through user fees from drug companies, and consumer advocates remain skeptical that the FDA will really start to work for us. We'll have to see, I guess.

I'll try to catch up on the rest of the day's interesting news this evening or tomorrow morning.

Wednesday, May 09, 2007

This makes my blood boil . . .

I don't really have much to add to this fine reporting by Alex Berenson and Andrew Pollack in the NYT, except that I'm free to characterize the situation, while they must exercise reportorial discretion.

You may have seen those ads on TV for agents that stimulate erythropoiesis, that is the production of red blood cells. The ads were targeted at patients undergoing cancer chemotherapy, of which anemia is a common side effect. Lately you may have heard that there has been a controversy over Medicare reimbursing kidney dialysis centers for using high doses of these drugs (brand names Aranesp, Epogen, and Procrit), because it turns out that using too much of them can have the unfortunate side effect of killing the patients. The FDA has issued a black box warning, just two months ago:

  • Avoid serious cardiovascular and arterial and venous thromboembolic events by using the lowest dose of Aranesp, Epogen, or Procrit that will gradually raise the hemoglobin concentration to the lowest level sufficient to avoid the need for blood transfusion.
  • Aranesp, Epogen, and Procrit and other erythropoiesis-stimulating agents increased the risk for death and for serious cardiovascular events when dosed to achieve a target a hemoglobin of greater than 12 g/dL.
  • Use of erythropoiesis-stimulating agents to achieve a target hemoglobin of 12 g/dL or greater in cancer patients shortened the time to tumor progression in patients with advanced head and neck cancer receiving radiation therapy; shortened overall survival and increased deaths attributed to disease progression in patients with metastatic breast cancer receiving chemotherapy; and increased the risk of death in patients with active malignant disease not under treatment with chemotherapy or radiation therapy. Erythropoiesis-stimulating agents are not indicated for this patient population.
  • Patients treated before surgery with epoetin alfa to reduce allogenic red blood cell transfusions had a higher incidence of deep vein thrombosis. Aranesp is not approved for this indication.

So what to Berenson and Pollack find? Here's the bottom line. They can't say it, but I will. The drug companies have been bribing doctors -- to the tune of hundreds of millions of dollars a year -- to give excessive doses of these agents and, uhh, kill people. That's it. Murder for gain. Tell me why it isn't.

Tuesday, May 08, 2007

On the ontological status of the psychiatric diagnoses

With all the kvetching I do here about the medicalization of the ordinary problems of being a Homo sapiens, you might think I don't really believe in mental illness. That is not correct. The concept of mental illness has its place, but for the most part, the DSM-IV diagnoses should be understood as categories of convenience, constructed for purposes such as social control, organizing systems of support and assistance, or justifying the use of empirical remedies (i.e., remedies whose mode of action is not understood) which have associated dangers and harms.

In other words, the psychiatric diagnoses -- with limited arguable exceptions -- are not facts about the world in the manner of melanoma, a staph infection, or male pattern baldness (my own sad affliction). They weren't "out there" to be discovered, like a new species of frog or an asteroid. They are categories constructed for instrumental purposes. And, while it is certainly true that distinct, clearly definable organic disease processes can occur in the human brain, as soon as such a process is identified, the disease ceases to be psychiatric and becomes neurological.

The psychiatric diagnoses are useful for several purposes. A diagnostic label is necessary in order to get insurance reimbursement for treatment. It is also needed to declare people incompetent to manage their own affairs, or to force people into institutional care or to receive services. Although nobody actually knows how most psychiatric medications work, criteria are necessary to judge whether to prescribe them. Some people violate the law in one way or another, but appear to have diminished responsibility, or it appears that some form of treatment may be more appropriate for them than prison. Some people's behavior is not illegal, but it is considered offensive or unacceptable, and we need a label in order to define their problem and guide approaches to fixing it.

In all of these cases, we can disagree about where the boundaries should be drawn, or even whether drawing one makes sense at all. (Viz. Glenn Greenwald, who wants to be free to take whatever pills he wants regardless of what his doctor thinks.) But these categories exist because of a social consensus, whether it is very broad, or only within a designated priesthood of pscyhological and psychiatric professionals. People find them useful.

Where we go wrong, however, is in reifying them -- in coming to believe that they correspond to concrete objects. They are social constructions, comparable to the generally, but not universally held opinion that Moby Dick is a great novel, or men should not wear light colored suits during the winter months. That doesn't mean I want them to go away, only that they are continually subject to criticism and reassessment, and one might object to their application in a given case, or the consequences that are attached to them in general.

Monday, May 07, 2007

A worthy penitent

The Boston Globe's Carey Goldberg tells the story of Dr.Daniel Carlat, a psychiatrist who is a self-described former drug company whore. Yup, he took the speaking fees and the fancy dinners and all that to promote psych meds -- then he was blinded by a brilliant light, fell to his knees, and was changed.

Now he publishes the monthly Carlat Report, a newsletter intended for his colleagues in psychiatry that is, miraculously, free of all drug company advertising and, he hopes, influence. (Since Dr. Carlat still inhabits in a world saturated with drug company influence, he may still be less pure than he thinks, but he's definitely trying.) He's not against psych meds, he just thinks they are overhyped, overused, understudied for safety and often too expensive, i.e. the companies push expensive pills with market exclusivity where less expensive alternatives would be just as good.

The newsletter is by subscription -- and sure, he has to pay for it and he isn't taking ads -- but he does offer a lot of information free, including some that will be of interest to consumers. I haven't had time to do my own in-depth evaluation of what he's offering, but the principle is certainly the right one, so do check it out.

Friday, May 04, 2007

Quote of the Day

Unfortunately, this cogent essay is behind the subscription wall, although you can read an editor's introduction here. Health Affairs at least has an excuse, since they don't take advertising.

John Lantos, a pediatrician who takes care of chronically ill children, writes:

Among all treatments for all ailments in the United States today, the most severely rationed is nonpharmacologic mental health care for poor children. For doctors on the front lines, this creates daily dilemmas. We are forced to give treatment that we know is both dangerous and suboptimal. [I.e., drugs.] The only alternative would be to turn away such patients or to refer them for treatments that I know will never actually be available. Among these immoral alternatives, we explore together, trying to find a new and more habitable world. Watching Troy and his mom walk out of clinic, I feel, just for a moment, the heartbreak. I feel frightened and depressed and, oddly, just a little exhilarated. I have to hope. What else can you do when you’re sailing toward the edge of the known world?

Lantos notes that there are two schools in Chicago that can provide appropriate education and developmental therapy for children with profound autism. They can serve a total of 150 children, but there are about 5,000 children in the area who need such services.

If you would like, you can weigh in here on what you would like to do with the $456 billion we've spent so far on invading and occupying Iraq. I have a suggestion of my own, which has to do with president Coocoo Bananas and is inappropriate for this family-oriented blog. I must say that most of the suggestions so far are not much better, so go there and raise the level of discourse.

Thursday, May 03, 2007

The Bill of Rights is a blunt instrument

Believe me, I'm all for it. I really like that first amendment, as well as the fourth, fifth, and all the rest of them including the ones most people don't know about. *

Even the second amendment is cool with me -- and all you NRA members need to go out and join the well-regulated militia, right now. It's called your state National Guard, and they could sure use you.

But, as Miriam Shuchman tells us in NEJM on-line, the current legal regime established by the Supreme Court includes commercial speech -- advertising -- under the protection of the First Amendment. Now, I'm no constitutional law scholar -- and believe me, I've learned to make that disclaimer -- but I'm allowed to have a personal opinion about what liberty means to me. And I'm not totally happy with that. It is related to the legal fiction, also imposed upon us by the SC, that corporations are persons, so that Pfizer and Monsanto have constitutional rights. That's insanity, but it proves who really rules us.

Anyway, like it or not, Shuchman informs us that a legal ban on Direct to Consumer advertising of prescription drugs would probably be found to be unconstitutional. Note that it is perfectly constitutional, and in fact is currently enforced, in numerous countries that are not generally considered to be tyrannical, including the UK, France, Sweden, Norway, Germany, Italy, Canada, etc., but if the FDA is allowed to ban Pfizer from hawking Celebrex on your TV, the Supreme Court is convinced that we'll be one step away from a situation in which the power of the President is greater than the rule of law.

Oh, wait. But I digress.

Anyway, the Institute of Medicine thinks that advertising should be banned for the first two years after a drug is approved, to allow time for post-marketing surveillance and a clearer idea about the drug's safety. Experts think that a law giving the FDA the power to implement such bans selectively, when there is more than ordinary suspicion that a drug might be risky, could be upheld. But others think that, given the current makeup of the SC, even such a limited power would be struck down.

It seems to me that drug advertisements are clearly distinguishable from political speech or social criticism, and that tough regulations, including outright bans under some circumstances, do not jeopardize our essential liberties. On the contrary, they would expand liberty by cleansing the marketplace of ideas of propagandistic clutter that has nothing to do with political and social freedom. But what do you think?

*Amendment IX

The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.

Amendment X

The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.

Suck on that, Commander Guy.

Wednesday, May 02, 2007

Some bullets

* This surprised me a bit, but a high quality trial finds that reducing salt intake over just a few years has a big impact on cardiovascular risk. I say it surprises me because I had been under the impression that only a minority of people are really salt sensitive -- but this shows a big benefit at the population level. The difficulty for those of us in the rich countries is that we get most of our salt from bread and other processed foods, not from the salt shaker. (As Francesco Cappuccio points out in an accompanying editorial.) In the category of processed foods we include staples like canned beans and vegetables, and tomato sauce. Most of literally cannot substantially reduce our salt intake unless we start baking our own bread, making all of our meals from scratch, and stop eating in restaurants. Cappuccio calls for legislation to force the food industry to reduce salt content. Not likely here in the land of the free and the home of the portable oxygen supply.

* Updating my previous posts about abstinence only sex education, here, and here, in which I described it as a case of "thinking backwards" from the conclusion to the justification, we now have the thinking forward version of the truth, starting with the evidence and following it where e'er it will take us. (Scroll down a bit and it's the top publication on the left. I didn't want to give you the direct link to the PDF because it's a big file.) A long-term, prospective study of more than 2,500 students, starting at age 11 or 12 and following them for up to six years, found that abstinence only sex education does not result in abstinence. It does not cause a delay in sexual activity, or a reduction in the number of sexual partners. So, whether you think teenagers should have sex or not, if you support abstinence only sex education, you support wasting taxpayer dollars. That may be faith based, but it's also stupid.

* Remember the Canadian Medical Association firing the editors of its journals because they published a study that upset its pharmacist sponsors? Revenge is a dish best served cold. More than a year later, the former staff have started an open access journal called, appropriately enough, Open Medicine. So take that, CMA, drug companies, corruption and elitism. Knowledge is power, and open access publishing is power to the people. And guess what? There's already news you can use in the first issue, about DTC advertising, and prostate cancer screening, and medical reporting. So go there and give them a high five. And of course, they're going on the sidebar here.

Tuesday, May 01, 2007

Weird Side Effects

An issue we have touched on from time to time is the growing perplexity in the zeitgeist over the problems of free will and moral responsibility, as the science of mind continues to develop. The Virginia Tech massacre helped to illuminate this cultural conundrum, as the cable networks struggled to fill air time with increasingly desperate and inane attempts to account for Cho Seung-hui's actions in political terms (he was corrupted by campus liberalism, contaminated by Islam, or a Marxist, or this proves we shouldn't let so many immigrants into the country); or as an examplar of cultural depravity (he was warped by violent video games, or horror movies, or the removal of God from the classroom).

Everybody finally realized that there is no such lesson to be drawn from this tragedy, that the young man was simply insane. There was something wrong with his brain, somehow the neurons got hooked up wrong or the wrong chemicals were sloshing around in the wrong places. We no longer have theories of demonic possession to provide a morallly meaningful account of such events -- that an underlying cosmic struggle between the benevolent deity and his satanic rival is contested in the souls of individuals. Cho's disease was a physical phenomenon, exactly what we don't know, but our minds, and our behaviors, are produced by the physical substrate of our wetware, that 4 1/2 pounds of gray and white glop inside our heads, and his just went haywire.

This realization starts to get quite problematic when you step down from such extreme cases to the minor virtures and sins of everyday life. It's bad when people gamble away their kid's college tuition, their retirement savings, or their next mortgage payment. I know of people who have done that, it's actually a growing problem around here since they built those casinos in southeastern Connecticut. Those people are irresponsible, they betrayed their families, and they rightly deserve the scorn of the community.

But did you know that pathological gambling can be a side effect of drugs called dopamine agonists, which are prescribed for Parkinson's disease? It's true, and it's actually astonishingly common. According to Sui Wong and Malcolm Steiger in BMJ (April 21, subscription only), citing a study by Voon, et al in Neurology, in the UK 7.2% of people taking dompamine agonists develop gambling problems. The pervasive availability of gambling opportunities on the Internet, and at the corner grocery store and the newsstand, as well as in the enticing fantasy world of the casino, no doubt interacts with the bad chemicals to make the problem all the more common.

So, it's not much of a stretch to suppose that some people who aren't taking dopaminergic drugs happen to just naturally have the wrong amount of dopamine in the wrong place -- which can lead not only to gambling problems but to compulsive shopping, hypersexuality, and who knows what other harmful or socially disapproved behaviors. Maybe they'll invent pills one day to cure people who shop too much, or talk too much, or goof off at work, or aren't good listeners, or don't spend quality time with their children. Of course, these pills will have unanticipated side effects. Maybe the pill that makes you appropriately thrifty will turn out to make people talk with their mouths full. Meanwhile, what is happening to good and evil?