Map of life expectancy at birth from Global Education Project.

Friday, February 29, 2008

Would you allow this man to be a president?

Sen. McCain says, "Al Qaeda is in Iraq. It’s called ‘Al Qaeda in Iraq.’ My friends, if we left, they wouldn’t be establishing a base. They’d be taking a country, and I’m not going to allow that to happen." He's running largely on the strength of his claimed foreign policy expertise. He says -- and he reiterated yesterday -- that if the United States withdraws from Iraq, al Qaeda will take over the country.

The pundits and so-called "reporters" who work for the corporate media, including, as in the link above, the New York Times, aren't going to tell you that this is completely nuts. They treat this analysis as credible and therefore, undoubtedly, many people will believe it.

Al Qaeda is a Sunni Muslim movement. Most Kurds are Sunnis but al Qaeda in Iraq is purely an Arab phenomenon. Sunni Arabs make up about 20% of Iraq's population. The Shiite majority, rather than the U.S. occupation forces, are the principal target of al Qaeda in Iraq. Within that 20% minority, al Qaeda and religious fundamentalists in general who might be inclined to support or at least tolerate them are a further small minority. Iraq has been among the more secular and religiously tolerant Islamic societies; intermarriage between Sunnis and Shiites was common prior to the recent troubles, and many tribes have members of both sects.

The only reason al Qaeda in Iraq exists, and has any basis for continuing to exist, is because of the U.S. occupation. There is no way, no prospect, no conceivable scenario, under which al Qaeda in Iraq could take over the country, or even carve out a regional base where they could operate freely, in the absence of U.S. forces. Not only would Iraqis never allow it, neither would Iraq's neighbors.

Either McCain actually believes this, in which case he is not just ignorant, but delusional; or he is a remorseless liar. Probably both are true. But will the New York Times bother to tell you?

Thursday, February 28, 2008

It's not as if they can predict the weather . . .

But they do try to predict health care costs ten years out. You may have seen a news brief about the new prediction that health care spending will be 19.5% of GDP by 2017. Health Affairs has made this open access, so go for it if you are turned on by wonkery.

Now, there are a lot of assumptions that go into any such prediction, and it's pretty obvious that unless the McCain campaign succeeds in its increasingly transparent plan to make voters believe that Barack Obama is a secret muslim extremist who has been planted by al Qaeda to turn the country over to Islamofascist infiltrators and give Tomahawk cruise missiles to Hamas,* some of those assumptions will be overturned somehow some way, and they probably won't all work out anyway. But, for what it's worth, the broad outlines of what these perpetrators of deep wonkery expect assuming that nothing major changes are as follows.

The biggest contributor to rising health care costs will continue to be increases in medical prices. We get a bit of a break for a couple of years thanks to some SSRIs going off patent (no prediction that fewer prescriptions will be written, however), and other drugs going generic, but that isn't expected to last. Physicians' incomes have been squeezed lately, but the authors predict that Congress will top ratcheting down their Medicare reimbursements and the shortage of primary care docs is bound to push up their incomes at some point. Utilization will continue to increase -- in other words, more drugs and procedures being done to more people, but not necessarily more people having basic access -- and that's the second biggest contributor. Contrary to popular belief, the aging of the population will have a relatively very small effect, although it will start to shift more people onto Medicare from other payers by the end of the period.

Now, there is an argument swimming around in the zeitgeist from certain conservative quarters which says, so what? Over the decades, the relative share of national income spent on various categories of goods and services has changed. Food used to be a big slice of our income, now it's just a few percent. We spend more on education, housing, and stuff that never existed before like cars and computers and i-pods than we did in 1900, and that's good. If we're spending more on health care, that's because we want more of it, and aren't we lucky to have the money?

But it doesn't actually work that way. The truth is that workers' real incomes have been stagnant for decades, which means that this medical inflation is coming out of other stuff that they want and need. Since food and energy prices are also going up, it's just squeezing people's stagnant incomes more and more. And we aren't getting more for our money -- most of this is just price inflation, running ahead of overall inflation, and a lot, if not all, of the increased utilization isn't buying us better health. Again, all you have to do is make the international comparison and that flat out proves the case. If Europeans and Canadians can spend half to, at most, two thirds as much, and the gap is widening, and they are healthier than we are and more satisfied with their health care, all of which are incontrovertibly true, then there must be something good about creeping socialism after all.

We're going to have to spend the next 20 or 30 or 50 years paying for the invasion of Iraq, the tax cuts for the very rich, and the ongoing massive military buildup apparently intended to fight the Soviet Union which is going to travel from 1990 into the future and attack us in 2015 using weapons it obtained from an earlier trip to 2050. Oh yeah, we're going to have to pay for the consequences of declining world oil extraction, decaying national infrastructure, and the consequences of global climate change. We can't afford to pay 25% more for health care at the same time.

*I have it on good information that Barack Obama has fathered a black child.

Wednesday, February 27, 2008

wonk me to sleep, mommy

On the one hand I'm happy to see a presidential campaign focus on policy instead of who you'd like to have a beer with or how severe John Kerry's war injuries really were. (A lot more serious than George W. Bush's that's for sure.) But the debate last night just demonstrated, once again, the great frustration of my adult life. There is no way to talk about health care policy without getting deep into the weeds of wonkery and boring and confusing people to death.

Congrats to Hillary for getting the idea out there that you need to get everybody into the insurance pool in order to spread the cost, that a voluntary system has to mean higher premiums because young and healthy people won't be in it -- until they are hit by a bus, at which point they will be expensive too. But a) it was not possible for her to spell out all of the implications and ramifications in the available time; b) if she did spend the time, it would have resulted in a massive epidemic of narcolepsy; and c) the whole discussion came close to creating condition (b) as it was. I doubt most people really got it and it certainly didn't inspire any voters.

All that said, the whole debate is pointless anyway because it's not as though one of them is going to become president next January, say "Shazaam," and see his or her proposal become reality. Whatever happens will be processed through the K St.-Congressional sausage factory and who the hell knows what will emerge? Neither proposal really gives us what we need anyway.

Finally, if Tim Russert enters the room, I advise standing well back. The man is so full of shit, he's about to explode.

Tuesday, February 26, 2008

Prozac may finally shut up

I claim no psychic powers. I've been telling y'all for years now that antidepressants basically don't work. The drug companies have been promoting the fiction that depression is a specific disease of the brain caused by a "chemical imbalance," specifically a deficiency of the neurotransimtter serotonin, which their potions -- Prozac, Zoloft, etc. -- purportedly cure. It's all nothing but a big pile of crap.

Irving Kirsch and colleagues, in PLOS Medicine, tell us what shakes out when you look at all the RCTs that have been done on these "medications," including the ones the drug companies made sure not to publish. Naturally, the ones they didn't publish are the ones that show their products in the worst light.

The discussion of this analysis is a bit complicated for those of you who haven't studied a lot of statistics, but the bottom line is simple enough to explain. It's essentially what I have been telling you all along. There is a very large response to placebo in depression. For only a small minority of people is the response to antidepressants any better than the response to placebo, and even in those cases, generally speaking, the response is of no clinical significance. (Response is defined as how people answer a questionnaire called the Hamilton Rating Scale for Depression -- which you can like or not like as a definition of "disease.")

Kirsch et al confirm all this -- which has been widely reported in the United Kingdom but has not made it past the curtain of censorship here in the U.S. What they add to the picture is that SSRIs are of essentially no use whatsoever in people with moderate to severe depression. The small advantage only appears in people with the most severe depression as measured by the HRSD. Those are a very small minority of all people who are diagnosed with depression and who are prescribed SSRIs. The reason the drugs show some advantage with those people is because they don't respond as strongly to placebo as people with less severe depression, not because the SSRIs are more effective. The benefit, while on average above the threshold defined by the U.K.'s NICE* as clinically significant, is still pretty small.

So please ignore those TV ads. If you're feeling sad, or down, or blue, or depressed, or whatever you want to call it, one treatment which has been proven to work with many people is exercise, which is good for you anyway. If it still doesn't work, cognitive behavioral therapy has also been shown to work well for many people. That's a kind of counseling to help people redirect their thinking and behavior in more positive ways. And the outcomes are better than anti-depressants in the long run. As Kirsch et al suggest, SSRIs should be considered only in people with very severe depression, and perhaps in people with somewhat less severe depression for whom other treatments have failed. I'm convinced.

Billions of dollars are wasted every year on these worse then worthless compounds -- they can have serious side effects, and they are addictive. Instead of handing them out like lollipops, doctors should think of them as more like morphine -- only for the desperate.

*I've written about this agency many times here. One of Barack Obama's proposals for containing health care costs is to establish a U.S. equivalent -- an institute that will judge the cost-effectiveness of treatments, providing guidance to insurers on whether to cover them.

Monday, February 25, 2008

Through the Looking Glass

Suppose you knew you had a terminal illness, and the doctor told you there was a drug that cost almost $100,000 a year, that had not been shown to help people with your condition live any longer; had potentially serious side effects; and might even kill you itself. However, it did seem to slow the progression of signs of your disease such as the appearance of x-rays. Would you take it? As a taxpayer or a payer of insurance premiums, would you want the government or your insurance company to use your money to pay for it?

The FDA says yes, and yes. Avastin, a so-called angiogenesis inhibitor, was just approved for use in metastatic breast cancer, even though all of the above applies, and the relevant advisory council had voted against approval. Avastin has been shown to slow the growth of tumors, but not to confer any significant survival advantage. Again, the FDA has approved a drug on the basis of a so-called "surrogate" end point, some element of a disease process or a presumed risk factor that it affects, without any evidence that the drug actually benefits patients in any subjectively meaningful way.

Unfortunately, even those new chemotherapy agents that do show a survival advantage generally extend life by only a few months, at best, at enormous cost. Do we really want to be spending a quarter of a million dollars to give a very sick person a few weeks of existence, when we aren't even willing to spend a few hundred dollars to provide primary care to low income people? This is self-evident insanity -- but it's very profitable for the drug companies, and that, apparently, is good enough for the FDA.

I'm going to Disneyland!

No, not really. It's highly unlikely I'll end up at Disneyland, but I will be in Anaheim next week, arriving Sunday night and staying through the morning of Friday, the 7th. I'll be attending a meeting of the National Child Traumatic Stress Initiative. I hope to have some interesting things to report from there, and if any of my friends are in the area and want to connect, let me know. (E-mail is on the side bar.) Later in March I'll be at the meeting of the International Association of Physicians in AIDS Care in Jersey City, and then at the Joint Meeting on Adolescent Treatment Effectiveness in D.C. What all this will do to blogging is unclear, but I hope it will just make it bigger and better.

And now for a couple of comments about politics. It so happens I worked for Ralph Nader, in a menial capacity, back while my frontal cortex was still undergoing myelination (i.e., in my early 20s for those of you not up on the latest developments in neuroscience). Ralph was the real deal -- he lived ascetically, and plowed the money he made from his books back into the Public Citizen organization. He used to call the office on Saturdays just to see who was there, and I have to confess I answered the phone more than once.

Alas, that was during the time when his influence was starting to recede. The so-called Moral Majority (which was, of course, neither) was on the rise, Democrats were losing ground in congress, and then Ronald Reagan became president. Ralph had made a career out of opposing corporate control of government and his cause was largely lost, as Democratic politicians for the most part decided that if you can't beat 'em, join 'em, and the center of gravity in Washington moved to K Street and the national business associations.

Hence the 2000 presidential campaign. I don't think Ralph really thought that there was no difference at all between the two parties, but both were clearly beholden to big business and he wasn't interested in a mildly reformist Gore administration. Ralph figured the 2000 election would be a good one for the Democrats to lose, and he did what he could to make that happen. Indeed, he probably did siphon off enough votes in Florida to make the election stealable. He was looking for the apocalypse, and he got it.

Whatever you may feel about that strategy, it worked. So okay Ralph -- why the hell are you running again this year? You accomplished your goal. The so-called conservative movement is utterly discredited. An Obama presidency isn't going to bring about the workers' paradise but it might just stave off the collapse of civilization and/or fascism. Go play shuffleboard.

Now, turning to Mr. Obama, we are about to endure one of the most astonishing spectacles of shit slinging in the history of American politics, and that's saying a lot. Willie Horton and the pledge of allegiance are going to look like real intellectual depth and substantive, policy based campaigning. If they can't bury him in sewage, they'll try to murder him. Hang on for a rough ride the next eight months.

Friday, February 22, 2008

The Surge

Senator McCain expects to be elected president because he supported The Surge™, and it's been a great success. I guess we all have different ideas of what constitutes success.

While we ponder whether growing violence throughout the country (including continuing deaths and injuries of U.S. troops), political disintegration and now a border war between Turkey and Kurdistan constitute success, I want to draw your attention to another surge in Iraq, specifically an outbreak of measles in Anbar province -- you know, the place where we have already won, although oddly a Marine was killed there yesterday in combat? UNICEF today reported a measles outbreak there.

For those of us in the wealthy countries, measles is pretty much history, due to widespread vaccination. When I was a child, it was generally nothing more than a nuisance. But it can occasionally cause permanent disability or death, and children who are malnourished are at much higher risk. Well, while we've been busy sending over tens of thousands more troops and winning the war:

According to the United Nations Children’s Agency (UNICEF), about one in 10 children under five in Iraq are underweight and one in five are short for their age.

But this is only the tip of the iceberg, according to Claire Hajaj, Communication Officer at UNICEF Iraq Support Centre in Amman (ISCA). . . .

“Many Iraqi children may also be suffering from ‘hidden hunger’ - deficiencies in critical vitamins and minerals that are the building blocks for children’s physical and intellectual development,” Hajaj said. “These deficiencies are hard to measure, but they make children much more vulnerable to illness and less likely to thrive at school.”

But with insecurity forcing the closure of many heath outreach centres, and hospitals and clinics lacking medicines and specialists, Iraq’s population is increasingly being cut off from access to proper health care, say officials at UNICEF and the UN Refugee Agency (UNHCR).

Children in the most restive parts of the country – such as Baghdad, Anbar, Diyala, Missan and Basra provinces - are less likely to receive critical preventative health care.

Such as measles vaccination, maybe? The WHO recently did a report on the measles vaccination campaign in Iraq. (PDF) It turns out that in "Anbar, the measles surveillance system is not working. Missan only 5 cases were notified, none was properly investigated. Babil, Muthana, Thi-Qar and Diala with some effort the measles surveillance can reach the required standard."

Now, if you're spending $275 million a day to have guys drive around and get blown up, you figure you might be able to shake loose a couple of million bucks a month or so to rebuild the public health system and get those kids vaccinated. But that would not be the Christian thing to do.

Thursday, February 21, 2008

Technical Difficulties

Apologies to my hordes of disappointed readers for the lacuna. My Intertubes were blocked on Tuesday -- or, to put it in less technical terms, our ISP had an all-day, city-wide outage. I had the chance to post from elsewhere in the evening but I said to heck with it. Yesterday, the problem was in the wetware. I think I was just so depressed and disgusted by the completely idiotic and repulsive coverage of politics on TV that my neural circuits were sputtering fecklessly. The link is to Glenn Greenwald, writing coherently.

Anyhow, both the ISP and I have rebooted, so before I do a public health post later today, let me just put in my two cents on the presidential campaign. Nothing terribly original, just the same open letter to Hillary Clinton I know you would write as well.

Dear Senator Clinton: You have already made history as the first woman to run a truly credible campaign for the presidency. You have staked out substantive positions on many issues, and your campaign has simultaneously transcended gender and championed gender equality. Good for you. The next woman to run for president will find the way smoothed by your precedent. Chris Matthews has been chastened (to some extent) and it won't be a novelty, it will just be a presidential campaign.

Alas, it appears that your campaign will not be successful. I don't think that's because you are a woman -- although your relationship with the former president Clinton was undoubtedly a mixed blessing. My mother and aunt actually lost respect for you because you didn't dump the rat. Personally I feel that was your own decision to make and says nothing about your suitability for office -- you obviously knew what you were getting into when you married him -- but it does seem to affect the attitude of some women of a certain generation. Anyhow, the bottom line is that you simply lost to a more compelling candidate. Nothing to be ashamed of, the guy has a lot going for him.

Now, you certainly owe it to your supporters to stay in it until March 4. However, in the past weeks your campaign has threatened to undo all the good you have achieved up until now. You absolutely must put a stop to tactics that portray the Democratic Party as fundamentally undemocratic; that insult and disparage Democratic voters; and that set out to damage the reputation and electability of the likely Democratic nominee for president. You must stop promulgating arguments for your candidacy based on presumptively writing off large segments of the country before November, or on assuming that voters are incompetent to make their own judgments. You must not use race to divide the electorate and you must not try to tell people that they don't understand what is in their own best interest. It's not about you, okay? Don't knock over the chess board in a fit of loser's pique.

If you can entirely repudiate these disgraceful tactics and spend the next few weeks talking about your positive ideas for the country and the reasons why people should vote for Democrats, you will bring credit to yourself and restore your place in the esteem of the party and the nation. When it is clear that the primary voters have spoken, if you are not their choice, you will consolidate your positive place in history by withdrawing, not just with grace, but with real enthusiasm for the historic transformation which lies ahead for the United States in November, and for your opportunity to contribute to it by doing everything in your power to help make it happen. If you cannot do that, you will earn our scorn.

Monday, February 18, 2008


There have been massacres throughout U.S. history, motivated by race, greed, a combination of the two as in the holocaust and dispossession of the native inhabitants of North America, political ideology or feuding. Ideologically motivated mass murder is ancient and I need not bother to list recent and current examples.

But as far as I can tell, the phenomenon of the lone individual, or occasionally a pair, who suddenly erupt into mass violence with no discernible political motive is not notable in U.S. history until after August 1, 1966, when part-time University of Texas at Austin student Charles Whitman climbed a landmark tower on the campus and killed 14 people, most of them from a sniper's perch on the observation deck. It was later discovered that he had killed his wife and mother before undertaking the massacre. There was an earlier example, the so-called Bath School Disaster in May 1927, in which farmer and school board member Andrew Kehoe, upset over a property tax levy used explosives to destroy the local school in Bath Township, Michigan, killing 45 people. However, this incident had been largely forgotten by the time of Whitman's killing spree. Unfortunately, we didn't have to wait 39 years for another.

Since then, comparable incidents have become frequent enough that they have nearly lost their capacity to shock us. The attack on Friday at Northern Illinois last Thursday was among the comparatively minor examples of the genre. Seung-Hui Cho holds the modern record with 32 killed at Virginia Tech university, but the McDonald's massacre in San Ysidro, on July 18, 1984, in which 21 were killed and 15 injured; and the Luby's Cafeteria massacre in Killeen, Texas on October of 1997, in which 23 people were killed and 20 injured, were pretty impressive as well.

Typical targets, in addition to institutions of higher education and restaurants, have been workplaces, U.S. Postal Service facilities being prominent among them; and elementary and high schools.

The perpetrators are generally young men, but there are exceptions. The Columbine killers were high school boys, and one of the most disturbing incidents was the Jonesboro, Arkansas massacre in which 13 year old Mitchell Johnson and 11 year old Andrew Golden attacked a middle school, killing 4 children and a teacher and injuring 9 children and one teacher. (By the way, under the law in effect at the time they could only be held until the age of 21 and both are now free.) Brenda Spencer, a 16 year old girl, attacked an elementary school in San Diego in January 1979, killing two adults and injuring 8 children. Her actions were immortalized in the song "I don't like Mondays," written by Bob Geldof for the Boomtown Rats. The title represents her explanation for the shooting spree. One of the soi disant disgruntled postal workers was a woman, Jennifer San Marco, who killed six employees at the San Goleta, California mail processing facility where she worked in January, 2006. Sylvia Seegrist killed three people and injured seven at a shopping mall in Springfield, Pennsylvania in 1985, just a short walk from where I was then attending college.

Wikipedia catalogs 42 American spree killers, all of them save Andrew Kehoe post-dating Charles Whitman based on my quick review. A few of these are actually serial killers, which is a somewhat different phenomenon, but most are perpetrators of one-time massacres.

While the phenomenon is definitely an American brand, there have been a few incidents elsewhere: the so-called Aramoana Massacre in New Zealand in which 13 people were killed; the Montreal Massacre at l'Ecole Polytechnique in March 1996, in which the killer exclusively targeted women and killed 14; and the Dunblane Massacre in Scotland in 1996, in which the killer attacked an elementary school, killing 16 children and a teacher.

From a statistical point of view, this is not a big problem. I won't bother to try to come up with numbers, since it would be tedious; the incidence obviously varies wildly and stochastically from year to year; and the definition of a conforming event is not entirely clear. Nevertheless, the average person is clearly much more likely to be killed by a current or former spouse or lover than a berserk stranger, and your biggest risk for sudden death is riding in a motor vehicle. Nevertheless, people are naturally anxious to understand why these events have become such a notable feature of modern American life.

Contrary to the stereotype -- and I don't know where it came from -- that the typical perpetrator was a quiet, polite and nerdy type and that nobody could have seen it coming, most of them were quite evidently troubled prior to their killing sprees. Many had diagnoses of major mental illness, others had histories of minor crime, violence, or disturbing behavior. Charles Whitman had a troubled childhood with an abusive father. He was court martialed as a Marine for minor offenses and did time in the brig. He was abusive to his wife. An autopsy found a small brain tumor, though it is unclear whether this contributed to his actions.

However, there are mentally ill, disturbed and strange people all over the world. Why they have a greater tendency to erupt in mass murder here in the U.S.A. is still an open question. Many people blame the easy availability of firearms, and perhaps that has something to do with it, but there are many other countries where weapons are easy to get where we see other forms of violence, but not this pattern. The Christian Right blames the theory of evolution and general godlessness, but some of the perpetrators were churchgoers: indeed, some of the targets have been the churchgoers' own congregations. Furthermore, as an atheist and firm believer in evolution, I can assure you that I have no violent impulses whatsoever, unlike the Biblical believers who want to execute adulterers and homosexuals. Finally, Europe is far more secular than the U.S. but has far fewer of these sorts of incidents. The Dunblane Massacre is the only example I can think of, in fact.

The bottom line: I don't have a good explanation. Violent movies and TV shows? Pervasive alienation, social isolation, oppressive work environments, failure of community? What do you think?

Update: Maybe Nicole Bell has a partial answer here.

In The Science of Happiness, author Stefan Klein at this phenomena [sic] and comes to some conclusions on a meta-level on what creates happiness in a society and the results might surprise you. He finds that there are three critical standards that must be met: a civic sense, social equality and control over our own lives. The more participatory the democracy, the more equal the social and income distribution among the citizens and the more self-determination (meaning not being forced to do a job you dislike because you have to pay the bills), the happier the society is.

That’s not so scary, is it?

Friday, February 15, 2008

Oh my aching back

I noted a couple of days ago that among the least intelligent features of our design is the spine. It works well enough for a while but it just isn't engineered to carry the vertical load for a whole lifespan. If you're a blasphemer, you probably think that's because it was pressed into bipedal service after having evolved as a horizontal structure in quadrupeds, but if you think that, you will be doomed to sciatica for all eternity.

Anyhow, whatever the true explanation -- evolution or a screw up in the engineering lab -- Brook Martin and a multitude, in the new JAMA, note that 26% of U.S. adults in a 2002 survey reported low back pain. In an analysis of the Medical Expenditure Panel Survey, they found that in 2005, about 15% of respondents had a medical diagnosis of a spinal problem. That's a drag, but just as big a bummer is that people with spinal problems had an average of more than $6,000 in annual medical expenditures, compared with $3,500 for people without spinal problems, after adjusting for age and sex. What is more, the average expenditure for people with spinal problems increased by almost $2,600 since 1997, which is more than the increase for people without such problems.

Biggest bummer of all -- it didn't do a damn bit of good. The prevalence of disability and functional limitations for people with spinal problems just got worse. A lot of the expenditure was on narcotics, a figure which jumped when Cox-2 inhibitors were found to be dangerous, though outpatient visits were the biggest share. Total medical spending for spinal problems in the U.S. is similar to that for arthritis, cancer and diabetes.

Since we're spending so much more on these problems, without any comcomitant improvement in symptoms or functioning, most of that increased expenditure must perforce be wasted. For those of you who have back pain, I wish I had better news, but maybe you should just try doing less about it. You might end up better off.

Thursday, February 14, 2008

Keeping us Safe

I'm so glad the valiant men and women of the Department of Homeland Security are stopping all those terrorists at the airports:

A 14-day-old infant traveling here for heart surgery died at Honolulu International Airport on Friday after he, his mother and a nurse were detained by immigration officials in a locked room, a lawyer for the boy's family said.

The Honolulu medical examiner's office yesterday identified the infant as Michael Futi of Tafuna, American Samoa's largest village, which is located on the east coast of Tutuila Island. Autopsy findings have been deferred.

According to police, the child died at 5:50 a.m. It is unknown why immigration officials detained the mother, the nurse and the child. . . .Airport paramedics were called about 6:10 a.m., he said.

No Free Lunch

And no free pass for President Obama either. As you know if you've been reading -- because I mentioned it a few days ago -- Obama's health care proposals include requiring insurers to cover preventive services, which he claims will reduce health care costs. Hillary Clinton makes some vaguer claims along the same lines, to the effect that universal coverage will end up saving money because people will get timely preventive care.

Joshua Cohen and colleagues in NEJM consider this proposition. (And you'll be pleased to know that this is one of those articles of broad public interest that the editors have made available to the rabble, so go ahead and read it.)

Alas, as a general proposition it isn't so. Screening and prevention may be worthwhile, but that isn't the same as saving money. Very few procedures actually produce a net cost saving. Cohen et al don't point it out, because it isn't really the focus of their analysis, but the really bad news is that extending people's lives actually costs money. If somebody drops dead of a heart attack, you only have to pay for the funeral. But if they live for 20 years taking beta blockers and ACE inhibitors and statins and getting angioplasties etc., you've prevented a heart attack, but spent a helluva lot of money.

Population screening for relatively uncommon conditions is very expensive. It might or might not end up saving money for the individual who tests positive -- i.e., maybe it's cheaper to find breast cancer early than to find it later -- but any cost saving is likely to be offset by the cost of the screening itself, and by the cost of treating disease in people who otherwise might never have needed treatment, either because their disease was non-progressive (some lesions called "breast cancer" may be destined to just sit there and do no harm, ditto for prostate cancer), or the people would have died of something else first.

The bottom line is that the vast waste of resources in the U.S. health care system is not traceable to a failure to provide preventive care. That's the wrong diagnosis. The truth is, the main drivers of excess cost are the enormous administrative waste created by the private insurance system; the very high profits that accrue to pharmaceutical and medical device manufacturers, and the absurdly high incomes of some medical specialists; and doing too much, spending money on interventions that are useless, cost more than they are worth, or are actually harmful. The solution to those problems is:

Universal, comprehensive, single payer national health care.

End of story.

Wednesday, February 13, 2008

Better than Human?

Roger Clemens is desperately trying to save his honored place in baseball history by denying that he ever used anabolic steroids or human growth hormone in order to improve his athletic performance. He isn't looking very credible right now, and it's a sin to tell a lie, but it is far from obvious to me why underlying allegations are so despicable.

I can think of a few reasons why people condemn the use of performance enhancing drugs. One is that it is held to give the athlete an unfair advantage. But athletes do all sorts of unnatural things to their bodies, and those who are fortunate enough to have more resources devoted to their training have an advantage over those who do not. This begins in childhood, with children of affluent families, who happen to be born in societies that invest more resources into developing athletes, or who just happen to attend the right school and have the right coaches, get advantages over all the other children. Athletic training includes systematic exercise and carefully designed nutritional regimens which produce abnormal muscle mass and endurance. Athletes use all sorts of technologies and tricks to enhance their physical capacities and skills. If you think there is something wrong with using peformance enhancing drugs, you have to explain how they are different from nutritional supplements and training regimens.

One argument that is often proposed is that they cause long-term health consequences. But so does training and playing the game. Professional athletes, and even college athletes whose careers end in their early 20s commonly end up with crippling arthritis or joint injuries. Repeated head injuries result in problems ranging from subtle personality changes to patent dementia. Enlarged hearts can result in early death. In fact the evidence for long-term damage from hormone use is quite inconclusive.

Some people make a distinction between "natural" and "unnatural" methods for improving athletic performance, but that's really a hard distinction to make. Clemens is alleged to have used hormones to speed healing of injuries and fight the decline in muscle mass associated with aging. How is that less natural than tendon replacement surgery, which many pitchers undergo? What about taking antidepressants, or pain killers, or cortisone injections, or all the other unnatural things that people do to overcome debility?

What if other means are developed to slow down or reverse the natural aging process, and the FDA decides the benefits outweight the side effects? We'll probably all want to use them -- just as women used hormone replacement therapy until it was shown that it doesn't have the promised benefits. Will it be considered unethical for athletes to use these accepted medications to extend their careers? How different would that be from what Clemens is accused of doing?

It is against the law to use prescription drugs without a prescription, but I have never heard of anyone being prosecuted for using black market Viagra, and Rush Limbaugh got off with a slap on the wrist for taking thousands of doses of Vicodin. Plenty of athletes who are in the Hall of Fame were caught at one time or another using recreational drugs, and merely served suspensions, if that.

The only issue here, as far as I can tell, is whether the Rocket's actions violated the rules. And at the time, Major League Baseball made no effort to enforce the rules in question. It's not even clear that the substances were explicitly banned. There are significant questions of personal autonomy here. If someone wants to use chemicals to enhance their physical capacities, knowing that there may be potential adverse effects, why can't they make that choice? Athletes make the same kind of choice every time they lift heavy weights, or run a marathon, or take the field.

Just something to think about.

Tuesday, February 12, 2008

Public Health Thoughts for Darwin Day

Understanding evolution is fundamental to the field of public health -- which, as I've said before, is everything. If we teach our children falsehoods, it obviously undermines their prospects to survive and succeed in the world. We aren't just battling for truth, we're battling for survival. Here are just a couple of reasons why the truth really matters.

First and most obviously, we are in a race with the evolution of pathogens, and it's a race we are losing. Heritability works differently in viruses and prokaryotes than it does in the multicellular eukaryotes, but the basic principles of Darwinian evolution apply all the same. HIV evolves to escape antiretroviral drugs and influenza viruses to overcome oseltamivir, bacteria evolve to render our antibiotics useless, and the malaria parasite (a metazoan) evolves to overcome our antimalarial agents. The day may come, and pretty soon, when the revolution in human health and longevity that occurred in the 20th Century is reversed, when we fall helplessly before common infections we thought we had conquered. It won't be any intelligent designer doing that, and praying won't do any good at all.

Understanding evolution is also essential to understanding ourselves. We're astonishingly complex and capable entities, but in many respects, our design is not very intelligent.

The baby's head is too big for the birth canal. Before we had modern obstetric techniques -- forceps and C-sections -- it was all too common for women to die in childbirth. It still is, alas, in some parts of the world.

Our teeth don't fit in our jaws. You wouldn't notice it if you hang out among affluent Americans because all the kids who needed them had extractions and braces -- unfortunately just as they were hitting puberty, which along with the zits was pretty miserable, and you can take it from me. But at least my teeth are straight now.

Our spines and lower extremities have been adapted from quadripedal ancestors, not very well, and we pay the price in disabling low back pain and ubiquitous osteoarthritis in our knees and hips in later years.

What's with that appendix? And the coccyx, whose only function is to cause excruciating pain when we fall on it? There's also that unfortunate problem that in exchange for the power of speech, we lost the mechanism that makes it impossible for the bronchi to be opened when we swallow, and we started choking to death. I remarked before on the years of helpless, vulnerable childhood. Then there's that obesity epidemic -- put a creature that evolved in a condition of chronic calorie shortage in a world of Big Macs and its doom is sealed.

And there's cancer. You can't understand cancer without understanding evolution, which explains the most basic facts about the nature of the metazoans. Same goes for the autoimmune disorders.

All of which is to say, our ills do not afflict us because our ancestors ate an apple, and if that's your preferred explanation, it's utterly useless. Evolution made us what we are, and it's only through the theory of evolution that we can understand ourselves, body and mind. Finally, only by understanding ourselves can we improve our lives.

Ignorance is not bliss. It is death.

Monday, February 11, 2008

Darwin Day

That's tomorrow, February 12. Charles Darwin and Abraham Lincoln were born on the same day in 1809. We're a long way, obviously, from having an official holiday recognizing Darwin's birth, but in my view, that might be the best way to frame the 21st Century Kulturkampf. You can read about organized efforts to celebrate Darwin Day here. Sponsors include the usual suspects -- Richard Dawkins, Steven Pinker, Daniel Dennett, and the gang -- but there's an impressive, long list, and you can join it.

What is the meaning of Darwin Day to me? The single most important is the power of inquiry -- the fundamental principle that the universe is out there to be discovered, and that our astonishing, wondrous minds and senses can journey into the unknown and find the truth. How liberating and joyous to break the chains of ancient myth and shatter the cramped, dank cell door of received belief, to walk out into the light of reason.

But it's not just the spiritual intensity of reason that makes Darwin Day special; it's necessity. We have not much time left to save ourselves from unimaginable disaster, and our only hope is fearless acceptance of truth, wherever it takes us. Let's celebrate Darwin day because it feels good, but also because we must.

Sunday, February 10, 2008

A rational view of irrationality

I headed into my neighborhood watering hole yesterday after a hard day working in the woods, on a mission to get some food, and got talking with the bartender, who is a young woman recently graduated from college. I guess I'm more avuncular than I realized, because she started confiding in me, and of course with bartenders it's supposed to be the other way around. Anyway, she majored in international relations, and now she somewhat regrets it, because she knows too much about what's going on in the world and it's depressing. She'd rather be a happy idiot. I told her that happiness isn't everything.

Anyway, however depressed I may already have been about the state of our species, it didn't lift my spirits to open the paper this morning and read that American creationists are carrying their cause to Europe, with some success. AP reporter Gregory Katz quotes a British cabdriver who has joined the movement: "Evolution is a lie, and it's being taught in schools as fact, and it's leading our kids in the wrong direction. But now people like Ken Ham are tearing evolution to pieces." Ham, of course, is the founder of Answers in Genesis. His British lieutenant, Monty White, says "People are looking for spirituality. I think they are fed up with not finding true happiness."

This of course begs the question: why is True Happiness to be found in creationism? It certainly doesn't work for me, but I think I have some understanding of what this is all about. The universe we have discovered in the past 150 years or so is, obviously, radically different from the stories people had been telling each other since they first learned how to speak. Those stories were made up, and that's a huge advantage over the truth. The made up stories that made people feel good were the ones that got repeated and believed in.

Isn't it nice to think that a being of awesome power and grandeur not only created us, but that we are his main concern and preoccupation? Even if he's only good to us some of the time, that means we're important, and those of us who don't feel very important here in the real world can take comfort in knowing that they are, after all, extremely important to the almighty and by believing the right stories and saying the right mumbo jumbo, they can play an equal part in the central story of creation with the mightiest potentates, and be elevated to the same state of eternal glory as any of the grandest princes.

The truth about the universe just isn't very satisfying to the individual ego. It doesn't seem to mean anything, this bursting of infinite heat and density out of nothingness, expansion and cooling and condensation over billions of years, until some chemical reactions in a layer of slime on a dust mote in the infinite cold and dark make us wake up and feel joy and pain, unnoticed and alone. How comforting to be an ignorant idiot, like Ham and White wish for us all to be.

But my young friend behind the bar can't put her own genie of knowledge back in the bottle, and I don't think she really wants to. She hasn't decided what she wants to do next, which is why she's tending bar -- maybe be a schoolteacher, maybe the foreign service -- and there's no particular hurry. But whatever she chooses, her life is going to be deeper and richer and more interesting lived in the hard light of truth. The narcotic of ignorance may be awfully tempting, but the bliss of morpheus is far less rewarding than the battle to know the truth. It will never be over, but it's the meaning of life.

Friday, February 08, 2008

Medical Ethics

Long time readers know that I have at times been unkind to Robert Jarvik, inventor of the useless and now forgotten artificial heart, for going on TV and trying to convince you to buy an expensive statin when there are generics available that do precisely the same thing for less than 1/10th of the cost.

Well, the awesome power of Stayin' Alive is once again revealed as Rep. John Dingell has taken up our cause. I already told you that Jarvik is not a cardiologist and has never practiced medicine, but what I did not know is that he also has never rowed a boat -- that guy sculling across the pristine lake is an impostor. I also didn't know that Pfizer is paying the clown $1.35 million over two years to con you.

The drug companies claim, of course, that consumers benefit from advertising which supposedly "educates" them about pharmaceutical products, but that is transparent nonsense. The purpose of the ads is to get you to buy the pills. A properly educated consumer would never take Lipitor, but rather Zocor or another generic. It never occurred to Pfizer to start advertising until Zocor went off patent and it faced competition from a cheap alternative. Furthermore, of course, a properly educated consumer would discuss the risks and benefits of statins with his or her physician and make an informed choice about whether or not to take them. Dr. Jarvik's opinion should have nothing to do with it.

Unfortunately, an outright ban on Direct-to-Consumer advertising of drugs in the U.S. is probably not possible, because of the way in which the courts interpret the First Amendment. The rest of the civilized world, with the curious exception of New Zealand, has banned it, without any evident crisis created by uninformed medical consumers. While we're probably stuck with some amount of DTC advertising, once we have a president who has some concern for the public interest she or he can work with the Congress to give the FDA both power and an affirmative charge to put strict limits on it. There are many regulatory approaches, which should be fully constitutional, which would be sufficiently discouraging to the thieves who run the pharmaceutical industry that we would see minimal, and largely harmless, DTC ads.

But don't hold your breath. The pharmaceutical industry can bribe Democrats just as well as it can bribe Republicans.

Thursday, February 07, 2008

In case you think you're confused . . .

I was as confused as hell today when I first read this in the New York Times, then I checked out this week's NEJM and read this (abstract only for you uncredentialed scum).

Item One:

For decades, researchers believed that if people with diabetes lowered their blood sugar to normal levels, they would no longer be at high risk of dying from heart disease. But a major federal study of more than 10,000 middle-aged and older people with Type 2 diabetes has found that lowering blood sugar actually increased their risk of death, researchers reported Wednesday. . . .

Among the study participants who were randomly assigned to get their blood sugar levels to nearly normal, there were 54 more deaths than in the group whose levels were less rigidly controlled. The patients were in the study for an average of four years when investigators called a halt to the intensive blood sugar lowering and put all of them on the less intense regimen.

Item Two:

Methods In the Steno-2 Study, we randomly assigned 160 patients with type 2 diabetes and persistent microalbuminuria to receive either intensive therapy or conventional therapy; the mean treatment period was 7.8 years. Patients were subsequently followed observationally for a mean of 5.5 years, until December 31, 2006. The primary end point at 13.3 years of follow-up was the time to death from any cause.

Results Twenty-four patients in the intensive-therapy group died, as compared with 40 in the conventional-therapy group (hazard ratio, 0.54; 95% confidence interval [CI], 0.32 to 0.89; P=0.02). Intensive therapy was associated with a lower risk of death from cardiovascular causes (hazard ratio, 0.43; 95% CI, 0.19 to 0.94; P=0.04) and of cardiovascular events (hazard ratio, 0.41; 95% CI, 0.25 to 0.67; P<0.001). One patient in the intensive-therapy group had progression to end-stage renal disease, as compared with six patients in the conventional-therapy group (P=0.04). Fewer patients in the intensive-therapy group required retinal photocoagulation (relative risk, 0.45; 95% CI, 0.23 to 0.86; P=0.02). Few major side effects were reported.

Conclusions In at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from cardiovascular causes.

Before we retire to bedlam, I should note that there were differences between the two interventions. Although I don't have access to full information about the study that was suspended, it appears that the people in the intensive intervention group regularly injected insulin; the people in the steno-2 study did not. Maybe that had something to do with it. Also, the steno-2 study didn't make a fetish out of achieving a particular glycemic control target.

Anyway, even if we're left confused about how to manage Type 2 diabetes, we can draw an important lesson here: never depend on surrogate end points.

The false logic was that the definition of diabetes is high blood sugar, ergo, eliminate the high blood sugar and you eliminate the bad stuff that diabetes causes. Not necessarily so, it turns out. And this is the case with many drugs that are widely prescribed, that have received FDA approval not because they are shown to improve health or longevity, but because they influence some metabolic pathway or the level of some substance in the blood which is believed to be associated with a disease. We need a radical change in FDA policy to make approval of drugs based on surrogate endpoints much more difficult.

And, if you have diabetes, don't be terribly confused. It is still true, and absolutely supported and not controverted by anything we learned today, that losing weight, excercising more, and eating right will save your eyesight, your kidneys, your lower extremities, and your life. That is 100% operative.

Update -- Some Clarity: The intensive arm of the steno-2 study didn't just focus on blood sugar, it focused on blood pressure and cholesterol as well. The bad news: they weren't successful in getting people to make those all-important "lifestyle" changes, which undoubtedly would have benefited them even more. My main point -- that the surrogate endpoint of glycemic control turns out not to be a good marker of successful diabetes management -- is just reinforced by this analysis.

Wednesday, February 06, 2008

Uninformed Consent

It turns out that Heath Ledger's death is what we in the biz call an iatrogenic event, i.e. "caused by healing." [sic] He had taken a lethal combination of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine. Now, I have no reason to believe his death was not an accident, but if you wanted to kill yourself, that would be a good way to go.

He had prescriptions for two opioids, three benzos -- two of which are marketed as tranquilizers, and one as a sleeping pill, but they're similar -- and an antihistamine that makes you drowsy as what used to be a side effect, but is now the reason it is prescribed. He had apparently complained of difficulty sleeping, but I don't know why he had the scrips for the junk and the tranks. What I do know is that you sure as hell aren't supposed to take them all at the same time, for reasons which should now be obvious.

It is possible to buy most of that shit -- I don't know about the doxylamine -- on certain street corners, but if a doctor gives it to you, there is a doctrine called informed consent, which means that the physician is supposed to tell the patient about the benefits and risks of the drug. There is also a doctrine called, in the technical language of medical ethics, "don't kill your patients," which means you are supposed to know what other prescriptions they have and warn them not to take combinations of drugs that can produce the medical condition known as "you ain't got no red corpuscles, Jack you dead." Apparently Mr. Ledger's doctor or doctors failed to follow these guidelines.

I wish I could say this was outrageous and egregious, but unfortunately it is completely standard medical practice. Studies have shown that when physicians write prescriptions, they do not, in the large majority of cases, warn patients about side effects or drug interactions. There are a couple of reasons for this, of varying degrees of defensibility. It's a huge but unquantified, underrecognized, understudied problem. As a matter of fact doctors often don't even know very much about the side effects or counterindications for the medications they prescribe. They're busy ordering unnecessary CT Scans to avoid highly unlikely malpractice suits, even as they are handing out powerful toxins without telling people about the bad things that can happen if the people go ahead and take them.

Any time you are given a prescription, you need to read the FDA label. Now, don't get all hypochondriacal and start imagining that you're having the horrific side effects listed as occurring rarely. One reason doctors don't like to mention them is because they know that's exactly what you'll do. But do pay attention to the warnings, interactions, and counterindications, and do pay attention to what your body is telling you, without getting too bent out of shape about it. Most common side effects, like an upset tummy or a headache, will go away after a short time. But you need to know what you're getting into.

Can we find ways to get doctors to do a better job of informing their patients, and preventing tragedies like the death of Heath Ledger? I hope so. We're working on it. But meanwhile, caveat emptor.

Tuesday, February 05, 2008

Stupor Tuesday

Digby, (who has turned off commenting apparently because it bugs her when people figuratively yell at each other by hurling photons down fiber optic cables) gives this account of the battle for California's Democratic voters -- Obama reaching past the cerebral cortex to forge a mystic connection with the lizard brain, Clinton's generals meticulously marshalling the troops. Note that in neither case is the election about public policy.

And of course it cannot be. Elections are about very expensive theater, as edited and repackaged by a corporate media with its own bizarre obssessions that have no discernible relationship to any definition of the national interest or the interests of any definable group within society except for their own self adoring selves; and as transmitted directly by the campaigns to the extent they can pay for advertising. Secondarily, once sufficient brains have been rewired by the dramaturgy, the zombies have to be marched to the polls, which is where the military-style organization comes in.

All of this costs immense amounts of money, so that's where it all begins. And that's our form of government -- a moneyocracy.

Now, it does matter whether we have a Democratic or Republican president come January 20. They build their theater around contrasting rhetoric and plot lines, and depend on different categories of people to pay for it, which does mean they have somewhat contrasting broad agendas. It's got to be obvious by now that Ralph Nader was basically wrong about that. The differences are bounded, but they do matter. But while I did vote in the Massachusetts primary, it wasn't a big deal to me. My main motivation was just to increase the recorded Democratic primary turnout.

Election campaigns, and particularly presidential campaigns, are not where issues get decided such as whether or not there will be an individual mandate for health care insurance. I can have an opinion about that but it would be ridiculous for me to choose Hillary or Obama on that basis.

The main point of all this is that I hope nobody thinks they've done their civic duty by voting. Being a citizen means you've absolutely got to work much harder than that -- and not necessarily in electoral campaigns, either. Don't waste time in blathering on the Internet, organize.

Monday, February 04, 2008

Ahh, so that's what they meant by The Surge.

Or, $10 billion a month just won't stretch very far these days.

Sewage backup in Baghdad is creating a lake that can be seen on Google Earth:

AFP: Baghdad is drowning in sewage, thirsty for water and largely powerless, an Iraqi official said in a grim assessment of services in the capital five years after the US-led invasion.

One of three sewage treatment plants is out of commission, one is working at stuttering capacity while a pipe blockage in the third means sewage is forming a foul lake so large it can be seen "as a big black spot on Google Earth," said Tahseen Sheikhly, civilian spokesman for the Baghdad security plan.

Sheikhly told a news conference in the capital that water pipes, where they exist, are so old that it is not possible to pump water at a sufficient rate to meet demands -- leaving many neighbourhoods parched.

A sharp deficit of 3,000 megawatts of electricity adds to the woes of residents, who are forced to rely on neighbourhood generators to light up their lives and heat their homes.

Sheikly goes on to say that they are going to rebuild now, but of course they've been saying that since April 2003. This same article also features happy talk from a U.S. general about new schools and clinics -- which seems an odd category of investment, since Iraq had plenty of school buildings and a well-functioning health care system before the invasion. Today, the health care system doesn't lack buildings, it lacks physicians, drugs, and electricity.

The truth is that dozens of Iraqis are still dying in political violence every day -- on good days -- there is no sign of political reconciliation whatsoever, and the main contribution the United States makes to Iraq continues to be to pump in, not drinking water, but more and more weapons. The current path is insanity, for both Americans and Iraqis. Is it really going to change next year? I doubt it.

Sunday, February 03, 2008

Not a hard decision after all

People keep asking me who I'm planning to vote for Tuesday and I didn't have an answer -- it was a very tough call. Then I saw an ad last night in which Robert Kennedy Jr. endorses Hillary, and that sealed the deal.

I'm voting for Obama.

Saturday, February 02, 2008

Wonk On!

Readers are begging for more about the Massachusetts health care reform legislation. Okay, not begging, but they have expressed mild interest. You can get a one page overview here, and the authority responsible for administering the law, called (weirdly) The Connector, provides links to the actual legislation and associated regulations here.

Unfortunately, in my view, this legislation has become the model for the leading Democratic national proposals. To answer Kathy A.'s question, the law provides sliding scale subsidies for low and moderate income people to purchase insurance. To answer Roger's question, it provides for fairly stiff fines for individuals who don't get insurance, although less than the cost of actually buying it.

For low income people, it's definitely a good deal -- they pay little or nothing and get pretty good, comprehensive insurance. For middle income people whose employers don't provide insurance, it's more problematic. Insurers are required to offer a so-called "affordable plan" for those people, but the plans are either not very affordable or pretty crappy, with high deductibles and co-pays. Also, the premiums are age rated. This puts people in their 50s and early 60s in a tough spot.

I wish it were possible to talk about health insurance without being long winded and boring. I've been trying my entire career to find a way to do it, and I just can't. So here goes. In addition to squeezing some of our citizens, the law squeezes the hell out of the state, which is going to have a hard time coming up with the financing to make it work. As the cost of health care keeps going up, it's just going to get harder and harder.

And there's the rub (whatever that means). The legislation does nothing to control costs. The forces which relentlessly drive up the cost of health care are untouched. There are two essential issues in health care, and unfortunately, progressive politicians only focus on one of them. The first is the people without health care insurance. Hillary and Obama (and she prefers to be called by her first name and he by his last, based on their campaign signs, so I'm not being sexist) want to do something about that problem. But they won't take on the second issue, which is the grossly disprortionate share of society's resources that go to health care. Obama gives lip service to that, but he doesn't offer any real solution.

The real solution is that we need a way to say no. We need to provide the services to everyone that really are worth the money, that really will improve their quality of life and worthwhile years of longevity -- and some years of longevity are not worthwhile, as we all know. And we need to not spend money on drugs and procedures that just aren't worth it. The only way to achieve that is to set a budget. Figure out how much is worth spending on health care, and allocate it in the most effective way. The word for that is rationing, and people don't want to hear it. But it's the only way to solve this problem. There is such a thing as enough, and there is such a thing as too much.

Friday, February 01, 2008

Wonking us to sleep

As I have said before, I'm not going to be all over the health care proposals of the presidential candidates because whatever they are saying now is not miraculously going to become reality after January 20. It's all going to get processed through the Congressional/K Street/Moronic Corporate Media meat grinder anyway, and who knows what vile offal might emerge?

But, the debate last night has no doubt raised questions in people's minds regarding what that was all about with the mandates and the amputations and what not. Let me say, first of all, that the debate as a whole was extremely heartening. It was largely substantive, we've got two capable candidates who both demonstrated a willingness to submerge their competing personal ambitions for the good of the nation, and it would be absolutely shocking if one of them doesn't become president. Whoever it is will spend the next few years shoveling out a shitpile that makes the Augean stables seem like your cat took a dump on the rug, but maybe they'll get something done on health care.

So, you can go to the respective web sites and read it all for yourselves, but here's my executive summary.

Both posted plans are largely qualitative. They are short on numbers and dollars, which makes it very hard, nay impossible, to judge how things would really work out. I suppose that's inevitable. If they put the numbers up there people would start crunching them and yelling about a $100 billion tax increase and what not. But, for what it's worth --

They both start by letting anyone who wants to buy into the health insurance program for federal employees, called the FEHB. One very important issue that they're both a little bit vague about is what's called "rating." They are clear that nobody can be denied this coverage due to pre-existing conditions, but it is not 100% clear that everybody will pay the same price regardless of age or health status. This is important because of the way health insurance markets work. Both Clinton and Obama propose tighter regulation over private insurance, but Obama is explicit that private insurers could adjust premium levels based on risk, although he doesn't say how much. The problem, if we stop short of requiring national community rating (i.e., everybody pays the same price), is that the FEHB would end up soaking up all the higher risk people and families that private insurers don't want, leaving them to "cream" the lower-cost beneficiaries. This potentially makes the national insurance program unsustainable.

They both say there will be subsidies for low and moderate income families that aren't eligible for Medicaid, to buy into private insurance or the national plan, but they don't quantify these. They'll limit the cost to some percentage of income, but they don't say how much. They will tax employers who don't offer coverage, but again they don't say how much.

The big difference that they argued about last night is the mandate. Clinton would require everyone to have insurance, as in Massachusetts. Obama is afraid that this will force some people to buy insurance they can't afford, but that would seem to undermine his other claims about his plan. Assuming the subsidies and premium caps are adequate, the issue about the mandate is not affordability at all. Its those healthy young people in their 20s who would rather spend the money on an X-Box and a steak dinner at Smith and Wollensky's because they figure they don't need insurance. Getting them into the pool is important because it helps to subsidize the expensive older folks with diabetes, to put it crudely.

Both of them talk about investments to make the system more efficient, suchas electronic medical records -- which may or may not turn out all they're cracked up to be -- but Obama has a great deal more to say about this. Again, it's qualitative and often a bit vague. He wants to require insurers to cover disease management programs, which is definitely a good idea. Right now, they won't pay for intensive supports for people with, say, diabetes, to help them manage their condition and avoid complications down the road. The reason, although Obama doesn't say so, is that by the time you need your amputations or your kidney dialysis, you probably won't be on their plan any more -- either because you turned 65 and went onto Medicare, or you lost your job -- so why should they pay now to avoid those costs later on? (That's where his remark last night about amputations comes from, BTW.) Society would save in the long run if they did, but they don't care about that, they aren't in business for their health.

Obama also wants to establish an equivalent of the British National Institute for Clinical and Health Excellence, to recommend evidence based practices and discourage wasteful interventions. Good idea, especially if the recommendations are somehow enforceable. He also talks a lot about public health but without mentioning any dollar amounts.

Bottom line, though? This kind of piecemeal, half-assed reform doesn't work in the long run, because it doesn't get everybody into a single pool and doesn't ultimately get a cap on costs. We need universal, comprehensive, single payer national health care. But maybe these baby steps will have the virtue of making that obvious.