Map of life expectancy at birth from Global Education Project.

Thursday, September 30, 2010

Spinning Backwards

If you're one of those people who pays attention to the news, you have no doubt been terrorized for the past couple of days by the newsreaders' relentless respiratory distress over the horrific European terror plot. Actually here's what I gather from the facts as reported. (Duly noted that we do not in fact know exactly WTF is going on because it's all, you know, a secret.)

a) Al Qaeda consists of a few wackos hiding out somewhere in remote mountainous regions of Pakistan.
b) The CIA is listening to everything they say to each other.
c) They do not possess any unconventional or powerful weapons. In fact, they hadn't even been able to figure a way to get automatic rifles into the hands of people in Europe in order to carry out their "plot" which
d) Wasn't even a plot but just some guys idly speculating about what they might like to do.

Are you terrified yet? You should be, because more than 123,000 Americans die in a typical year from unintentional injuries, and more than 18,000 are murdered. Al Qaeda has close to nothing to do with that. We duly note the Fort Hood murders last year, and the doofus who barely managed to set his underwear on fire. This year we had another doofus load the back of his SUV with Vigoro and set off some firecrackers in the back seat. Those were unfortunate events, but driving to the grocery store should scare you a whole lot more.

If you really want a government that keeps you safe, you might want them to spend some money on protecting you from the pollution that comes out of tailpipes, which might cost a small fraction of the trillions of dollars of your money they are spending to blow up buildings and people in Pakistan and Afghanistan, just on the off chance that somebody there might persuade somebody here to set his underwear on fire again.

Site news: As I have already noted, posting may be a bit erratic because I am transitioning to a new job. You will know it has happened when my e-mail address in the sidebar changes. That may also produce some subtle changes in the overall style and spirit of Stayin' Alive, but it will stay alive.

Tuesday, September 28, 2010

Everybody talks about the weather . . .

But maybe not enough. And maybe we should do something about it. Let's start with this interesting event, entirely unnoticed, as far as I can tell, by the corporate media in the United States:

“Hurricane Igor will go down in Canada’s record books. Never before has a full-strength hurricane hit Newfoundland. The waters around Newfoundland are usually too cold for a hurricane to maintain its strength and remain tropical, but Hurricane Igor managed it. . . .

At 1,480 kilometres wide, Igor is also the largest ever Atlantic hurricane by gale force winds diameter, not just in Canada, but ever since Atlantic records have been kept. It reached that size just before striking Newfoundland. Even when just a category 1, Igor’s hurricane force winds extended outward nearly 165 kilometres from the eye! . . .

Even after it left the waters of Newfoundland and Labrador, Igor continued to produce near-hurricane conditions all the way up to Greenland, where it absorbed the remnants of Julia. The last remnants of Igor finally made landfall near southern Davis Strait, Greenland. In the process, much of south and west Greenland experienced high winds, with late September temperatures rising as high as 18 degrees Celsius right next to a glacier!”

After I posted that as a comment on Climate Progress, others weighed in. "I saw this headline in today’s on-line edition of the New York Times. “Water Use in Southwest Heads for a Day of Reckoning” Can anyone suggest a possible cause?" The commenter didn't supply a link, so here you go. Lake Mead is disappearing.

Then the commenter known as Colorado Bob noted that "The airport at Wilmington , N.C. received 10.33 inches yesterday . Needless to say , that’s a new record. But to set that record they had to beat the old one of 7.49 inches. There is one hell of a lot of water coming out of the sky right now." Meanwhile, in the Canadian west, "Residents of the Bella Coola Valley in B.C.'s Cariboo region are safe but stranded after a heavy rainstorm and floods walloped the region over the weekend. Steven Waugh, the emergency program co-ordinator for the Central Coast Regional District, said 204 millimetres of rain fell between Friday night and Saturday afternoon alone. 'It was shocking, absolutely shocking how much water has come down here in such a short period of time.' He called it "the flood of record," saying it far exceeded the last record flood in 1968." This is just part of a widespread pattern this year, as another commenter tell us: "Another weather related event that has gone un-reported in most media outside Canada is the fact that much of western Canadian farmland in the western provinces has received so much rain this past summer that many fields are still flooded. So if you think the food shortfalls from extreme weather in Russia, Pakistan can be made up from Canada you might want to re-think that."

And to the south, Mexico Landslide in Oaxaca May Have Killed as Many as 1,000, Governor Says. That's from a tropical storm, one of a series to hit Central America and the Yucatan this year. There's Pakistan, of course, still underwater; European Russia, with the hottest summer ever; oh yeah, it was 113 degrees yesterday in LA. They might as well move to Baghdad.

But does all this mean anything? Is there some unifying theme, some political issue that might be connected to all of this? Is it happening for a reason? Apparently not, at least no reason that the corporate media and political leaders have noticed. Maybe God is punishing us for gay marriage or something.

Monday, September 27, 2010

Listen to Grandma!

It's no surprise that most Americans don't eat a lot of vegetables, but I think I can offer more than Kim Severson does both to solve the problem, and scream and yell for it's importance.

First, the importance part. Eating a diet based on veggies and whole grains is the most important thing people can do to maintain a healthy weight, and prevent diabetes, strokes and heart disease. Although recent research is disappointing as far the cancer prevention potential of diet, it does help prevent colon cancer, and keeping a good weight also helps more generally. For whatever reason, supplements that contain the kinds of vitamins found in vegetables don't work -- you have to eat the real thing.

Heart disease and strokes (which are really manifestations of the same underlying disease) along with diabetes add up to by far the leading cause of death and disability in the U.S. Actually heart disease alone does it but the other two are part of the same picture. You don't want any of that, live or die. These conditions also place an enormous burden on health care resources and impose other costs from lost productivity etc. -- $503 billion a year, sayeth CDC. We could solve on hell of a lot of other problems with that kind of dough.

But wait, there's more! Mark Bittman tells us that:

[A[n estimated 30 percent of the earth’s ice-free land is directly or indirectly involved in livestock production, according to the United Nation’s Food and Agriculture Organization, which also estimates that livestock production generates nearly a fifth of the world’s greenhouse gases — more than transportation.

To put the energy-using demand of meat production into easy-to-understand terms, Gidon Eshel, a geophysicist at the Bard Center, and Pamela A. Martin, an assistant professor of geophysics at the University of Chicago, calculated that if Americans were to reduce meat consumption by just 20 percent it would be as if we all switched from a standard sedan — a Camry, say — to the ultra-efficient Prius. Similarly, a study last year by the National Institute of Livestock and Grassland Science in Japan estimated that 2.2 pounds of beef is responsible for the equivalent amount of carbon dioxide emitted by the average European car every 155 miles, and burns enough energy to light a 100-watt bulb for nearly 20 days.

Oh, did I mention antibiotic abuse and the possibility that we will lose some of our most valuable weapons against pathogens? Eutrophication of lakes and streams, dead zones in river estuaries, and a few more things you can probably think of? I'll leave the ethical treatment of animals to your own personal feelings, but it may be very important to you.

So this perhaps unglamorous seeming issue is as important as any of the myriad crises facing humanity. It may be the single most important area where we can take meaningful action to save our sorry butts.

Severson says that people don't eat veggies because a) they are more expensive than alternatives b) people just don't like them and c) they're a pain to prepare and don't keep very long.

There are simple and powerful solutions to all of these. We can stop using your taxpayer dollars to subsidize production of animal feed, and we can also tax meat producers to capture the true social and environmental cost of meat production, e.g. all that nitrogen in the Mississippi and carbon in the atmosphere. We can use some of that money instead to encourage sustainable vegetable growing. You can even grow your own. It's fun!

Second, it's easy to make vegetables taste good, with simple techniques including healthful ingredients like olive oil, white wine (with the alcohol poached out), garlic and herbs, etc. If you really still aren't satisfied, you can add a little dairy -- which is less environmentally destructive than meat. A bit of cheese for flavor and texture goes a long way. Brown rice and legumes give you your macronutrients as we say (protein and calories). If some of the produce in your refrigerator is getting a little tired, make icebox soup, or use it up in a tomato sauce. There are all kinds of possibilities. Or, if you have trouble dealing with all that, buy frozen veggies - they keep their nutritional properties very well.

It isn't at all difficult to cook this way, people just aren't in the habit. As a matter of fact, if you're really lazy, just cut up some crudities and eat them with a little salad dressing. By the way, romaine keeps for a long time in the fridge.

This is just a matter of culture and habit -- there isn't really any truth to the excuses people make. We're accustomed to eating meat, that's all. It isn't actually any easier, or cheaper, or better tasting. That's b.s. So let's change our ways.

Update: After I wrote this I happened upon the comment to my previous post, which would have been on topic here. It's a web resource for people in India, but they actually have some recipes you might want to check out. Indian cuisine offers a lot of great ways to get major flavor into vegetable dishes.

Friday, September 24, 2010

I'm not the only one who's getting a teeny bit worried

The International Monetary Fund, which is not to be confused with the Socialist International, is also viewing with alarm.

"The labour market is in dire straits. The Great Recession has left behind a waste land of unemployment," said Dominique Strauss-Kahn, the IMF's chief, at an Oslo jobs summit with the International Labour Federation (ILO).

He said a double-dip recession remains unlikely but stressed that the world has not yet escaped a deeper social crisis. He called it a grave error to think the West was safe again after teetering so close to the abyss last year. "We are not safe," he said.

A joint IMF-ILO report said 30m jobs had been lost since the crisis, three quarters in richer economies. Global unemployment has reached 210m. "The Great Recession has left gaping wounds. High and long-lasting unemployment represents a risk to the stability of existing democracies," it said.

The IMF notes that people who can't get a foothold in the labor market in their 20s "lose faith in public institutions." It notes that the duration of unemployment has increased with each recession lately but has now risen to lengths not seen since the Great Depression. The IMF also notes that the "employment intensity of growth" has declined, i.e. production is more capital intensive and requires fewer workers.

There was a German-English guy in the 19th Century who predicted exactly this sort of thing, which he called a "crisis of capitalism." Basically the plutocrats keep so much for themselves that workers can't afford to buy the stuff they are selling. Much hilarity ensues.

Thursday, September 23, 2010

An obligatory post

Like it or not, I am required to comment on the study in the new NEJM on screening mammography in Norway. It is difficult to accurately estimate the effect of a large-scale effort like population screening because the before and after comparison is unavoidably "contaminated," as the statisticians say, by other changes over time. Specifically, it is very tricky to decide whether changes in breast cancer mortality are associated with screening, or better outcomes due to continual improvements in treatment.

Norway provided a natural experiment in that population based screening was rolled out region by region, creating side-by-side comparison groups that were temporally matched. It also has universal health care, including universal access to high quality, multidisciplinary breast cancer treatment, and a 100% breast cancer registry, so Bob's your uncle.

What the investigators found is that screening did indeed reduce breast cancer mortality for women age 50 to 69. But the difference, after more than 8 years of follow up, was 2.4 deaths per 100,000 person years. Most of the reduction in the death rate that occurred during the study period was the result of improved treatment. Indeed, women older than 69, who were not offered screening at all, had a comparable reduction in deaths from breast cancer.

In a companion essay, H. Gilbert Welch explains that if screening mammography results in a 10% reduction in the risk of death from breast cancer -- an optimistic assumption -- the difference between offering universal screening and no screening is .4 deaths from breast cancer per 1,000 women. Put another way, you would need to screen 2,500 women for 10 years to prevent one death. (Of course that woman would still have died from something else eventually, perhaps not much later.) Among the other 2,499 women, more than 1,000 would have a false positive result, and somewhere between 5 and 15 would be treated unnecessarily.

Is that worth it? Maybe, it's a matter of opinion. But it is not a matter of opinion that there would be even greater benefit in offering universal access to high quality medical care.

Wednesday, September 22, 2010

What is WRONG with you people?

As I have often discussed here, there's no use in advancing medical knowledge and discovering wonderful new drugs and all that stuff if the people won't take the pills and won't otherwise follow all that great advice the doctors give them. Yeah yeah, we've had problems with pills not turning out to be so great after all and sometimes doctors want to do too much, etc. You'll often read that first here . . .

But. Lots of stuff we do know works and is well worth it, but people don't do it anyway. Half the people, in fact, as a rough estimate around which many studies tend to converge in various diseases, don't take their pills the way they are prescribed. So we're always spending money testing "interventions," as we say, to encourage people to follow the advice and take the pills. In heart failure, that's particularly important because, well, it can keep you alive longer.

That's why it's a bummer that once again, a carefully designed and well conducted intervention just didn't work. In this case, people with heart failure got group based education and counseling -- plenty of it, 18 two hour meetings over a year. The control group just got tip sheets. Well, it didn't matter. Didn't do a damn thing. The people who did the group sessions were just as likely to kick the bucket as the ones who didn't. (And props to JAMA for making this open access.)

Sometimes these interventions work for a little while but the effect goes away once they stop. To get people to take their pills the way they're supposed to it seems like about the only thing you can do is have a nurse move in with them.

Listen up folks! It really matters! If you need blood pressure pills, for example, they aren't just a luxury or just a nuisance or some conspiracy by Big Pharma to take your money. They can spare you from heart attacks and strokes and disability and death. It's no joke. Why won't you do it?


Tuesday, September 21, 2010

Viewing with alarm

Here's a handy little chart that ought to give you the willies. (I didn't link to the original source, because it's embedded in a long boring PDF, but Dr. Wolff's presentation is accessible and his own discussion is worth reading, although I don't agree with it entirely.) Actually this cuts off just before the Big Plotz of 2008, which did temporarily reduce the relative incomes of the top 10% a bit because those capital gains went away, but they're coming right back.

As you can see, we are right back to the Gilded Age. But it's actually worse than that because, while we still have that extreme inequality, we also a depression-like job market. Lots of people who have already been out of work a long time are never going to get another job. Now, in the 1930s, the U.S. turned away from Gilded Age laissez faire capitalism -- an earlier form of what we today recognize as Randist libertarianism and general Republican plutocracy -- and adopted a strategy of saving capitalism by making it tolerable for the proles. You can see the pretty picture it makes in Dr. Wolff's chart. But you you already know what was going on in Germany at the same time.

In times of desperation, voters are ready for extreme solutions, and the NSDAP (National-Sozialistische Deutsche Arbeiterpartei -- National Socialist German Workers Party) exploited the situation. Skilled Nazi propagandist Joseph Goebbels launched an intensive media campaign that ceaselessly expounded a few simple notions until even the dullest voter knew Hitler's basic program. The party's program was broad and general enough to appeal to many unemployed people, farmers, white-collar workers, members of the middle class who had been hurt by the Depression or had lost status since the end of World War I, and young people eager to dedicate themselves to nationalist ideals. If voters were not drawn to some aspects of the party platform, they might agree with others. Like other right-wing groups, the party blamed the Treaty of Versailles and reparations for the developing crisis. Nazi propaganda attacked the Weimar political system, the "November criminals," Marxists, internationalists, and Jews. Besides promising a solution to the economic crisis, the NSDAP offered the German people a sense of national pride and the promise of restored order.

Draw your own conclusions.

Sunday, September 19, 2010

Playing dress up

One of the oddest things, to me, about preachers of just about all persuasions is that they have to wear bizarre, atavistic clothing. Joseph Ratzinger is making a much ballyhooed trip to the UK, wearing an elaborate ball gown and a hat modeled after a nuclear warhead.  I recently attended a funeral at a high Episcopal church and the preacher went through various rituals of donning and removing an embroidered shawl depending on whether he was passing out crackers, mumbling mumbo jumbo, or ringing bells.  Of course, the shawl also went on top of a white dress with slashes on the sleeves, sort of like a military officer from a tinpot dictatorship.  Islamic preachers also have to wear funny hats.

To me, it just makes them all look ridiculous.  But I don't purport to be the fashion police.  What I don't understand is why the heck God wants them to look silly.  If they are channeling His holy word or spiritual energy or mystic presence or whatever it is they are supposedly doing, I should think that would shine out all on its own.  I don't see how it is enhanced by a weird costume.  Maybe a believer out there can explain it to me.

Friday, September 17, 2010

I'm not a real doctor . . .

I'm a doctor of philosophy. As Dr. Ruth used to say, "I cannot advise" (although, oddly, giving advice was the entire reason for her existence). Anyhow . . .

The Brits tend to be considerably more clear-eyed than we are about the relative good and bad of doing medical type stuff, so leave it to BMJ to publish this meta-analysis from U.S. based researchers on prostate cancer screening. The money shot:

Screening was associated with an increased probability of receiving a diagnosis of prostate cancer (relative risk 1.46, 95% confidence interval 1.21 to 1.77; P less than 0.001) and stage I prostate cancer (1.95, 1.22 to 3.13; P=0.005). There was no significant effect of screening on death from prostate cancer (0.88, 0.71 to 1.09; P=0.25) or overall mortality (0.99, 0.97 to 1.01; P=0.44). All trials had one or more substantial methodological limitations. None provided data on the effects of screening on participants’ quality of life. Little information was provided about potential harms associated with screening.

Conclusions: The existing evidence from randomised controlled trials does not support the routine use of screening for prostate cancer with prostate specific antigen with or without digital rectal examination.

So here's what happens if decide to undergo prostate cancer screening:

1. The doctor may stick his finger up your ass. You may or may not like that.
2. You may be diagnosed with "prostate cancer."
3. You may spend time in a hospital, spending a lot of your own or other people's money, and undergo surgery or get yourself heavily irradiated "down there."
4. You may end up incontinent of urine, and unable to sustain an erection.
5. There is no reason to believe that you will live even a single day longer than you would had you not done all this.

So, make your own decision.

Note: As usual, if you have a family history, or if you are of African descent, or for whatever reason are at higher than usual risk, you may have a different calculation. You should talk with your doctor, but I warn you, they tend to be all for doing this, because that's just how they are. Also the urological, radiological and surgical societies won't like me for telling you this.

In the future, we hope, doctors will get better at distinguishing between dangerous and not so dangerous prostate tumors. When that day comes, all will be different.

I get some mighty weird e-mails

Since you cover religious topics, I though this national conference on the Middle East Crisis from a Biblical perspecttive [sic] might interest you:

CHICAGO, Sept. 17 /Christian Newswire/ -- On October 1-2, Chosen People Ministries is presenting the Inside The Middle East Crisis conference at The Moody Church in Chicago to critically examine the epicenter of the dramatic spiritual, geopolitical and economic events in the Middle East through a biblical lens.

This is an evangelical Christian group dedicated to converting the Jews. Among the listed speakers, "The president of Chosen People Ministries, Dr. Mitch Glaser, explains God's purpose and plan for Israel and the Jewish people." I'm sure they will be very interested to hear all about it, although you might have thought God would have the common courtesy to tell the Jews directly rather than making them hear it from Dr. Mitch Glaser.

I don't know what it is about the deity, he just continues to think he needs to speak through one or another wacko. After all, being omnipotent he could just take over the TV or something. Weird.

Thursday, September 16, 2010

Pictures of my insides

. A man came for me with a wheelchair shortly after noon. Leah had given me a yellow card to hand him, with various check-offs to describe my condition. I might be "comatose," "responsive," "alert," or "combative"; "cannot walk," "walks with assistance", or "ambulatory". I told the man he would find me to be ambulatory and alert, but potentially combative. He was pleased. By the way, employees of Beth Israel Hospital came color coded. In contrast to the physicians and nurses -- but like the people with the mops and trays and changes of bedding -- this man was dark brown.

He took me down in the elevator to a windowless basement somewhere with concrete walls and exposed plumbing. He parked me in a big drafty room like the front end of a warehouse, made some markings on my yellow card, and went away. I sat. I was not alone. In a neat line on either side of me were much sicker people. A young man, tall and once handsome, sat in a wheelchair beside me staring fixedly at the floor three feet before him. He never looked at me. He weighed no more than 90 pounds. This was during the AIDS plague years, before they had ARV treatment, and I'm pretty sure that's what was happening.

On the other side of me were two women lying on gurneys, one elderly, one close to my age, I would guess. It is hard to tell people's age when their vital spark burns so low. Both women made eye contact with me, and tried to smile, but noone spoke. What would you have said? It's not a social situation we have rules for -- women lying in bed, wearing only indecent smocks, confronting strange men. We were unattended. We waited. What if one of us had vagaled?

Finally a woman came and wheeled me down a long hall. She parked me outside a big steel door marked with red warning signs. She gave me a cup of BARO-CAT and ordered me to drink it. Stupidly, like a dog-bitten sheep, I complied, though I felt sick again. There were pictures for me to look at on the wall. "Scanning with the GE-2700" read the legend. They showed slices through the human body, from the crown of the head to the soles of the feet. I studied the abdominal slices for inspiration.

Some time later, the door opened and an old woman was pushed out through it in a wheelchair. A man came out after her and pushed me in. I told him that I couldn't drink any more of the barium muck because I had ileus, and, reluctantly, disapprovingly, he let me throw it away. The CT-scanner was a big white donut with a black padded bench that rode through it on tracks. There were hooks on the ceiling for IV bags. The man held my IV bag as I climbed up onto the bench -- an easy patient, ambulatory and alert. I looked up at little portholes with bright red lights shining out of them. They had tags reading "WARNING! Laser! Do not stare directly at laser light. May cause permanent eye damage!" I wasn't too worried, since I'd seen the same sign a million times at the supermarket checkout.

Anyway, the scan was indeed painless. The bench slid through the doughnut until its central plane passed through my groin. Then man told me to hold my breath; machinery whirred and clicked; then he would tell me to relax while the bench slid me a quarter of an inch further through the device, and we would repeat the ritual. It took about twenty minutes.

A woman took me back to the holding area, where I sat for at least half an hour. A different man sat to my left now, a very old man wearing an oxygen mask, just as emaciated and even more inert than the young man before him. While I waited, an orderly came for him. The orderly disconnected the man's oxygen mask from a fitting in the wall, then he fumbled unskillfully trying to reconnect it to a portable supply on the wheelchair. Only when the oxygen supply failed did the old man register any cognizance of the world. His head lifted from his chest and his eyes filled with panic; his chest moved perceptibly in what must have been, for him, a titanic struggle for breath. But that is all; he did not move his limbs or try to speak, and he seemed unaware of the cause of his distress. The orderly never spoke. Finally the orderly managed to restore the oxygen supply, and the old man's head sank down peacefully onto his chest again. The orderly wheeled the old man away.

Remember that I still had diarrhea. It had slowed down enough that I had been able to make it through the scan alright, but now I really wanted to find a toilet. There was an official in sight: a fat man wearing a yarmulke who sat behind a counter across the warehouse floor, transacting paperwork with the orderlies. I stood up and walked over to him, pushing my wheelchair to which I was leashed by the IV. He was talking with a woman and they gabbed away for a while, ignoring me standing right there. Finally I interrupted. I pointed out that I could easily get myself back to my room and indicated that I wished to do so. "Sit down," the fat man said, "someone will be along for you soon."

Tuesday, September 14, 2010

More of my whining

As you may recall, when we last left our hero, he was suffering from severe diarrhea, ileus, fever, and a mysterious lump at the site of his surgical wound.

So, the doctors kept pumping water into my veins, but never enough. They also gave me an antibiotic that might have a discouraging effect on a particularly vicious bacteria that was hanging out in area hospitals causing diarrhea, called Clostridium difficile. (This is still a big, and actually growing, nosocomial problem. It's an opportunistic infection that moves in when antibiotics have killed the normal bowel endosymbionts, and it kills a lot of old folks.) Leah seemed contemptuous of the bacteria theory, and I got the impression there was something the doctors weren't telling me. She also let it slip that Dr. Knozall had skipped a step by authorizing a full liquid diet on Saturday. Normally, patients start with clear liquids, a category which does not include fruit juice or the luncheon menu.

I figured out that they were actually afraid the anastomosis -- the reconnection of the cut ends of my intestines -- might be leaking. The doctors told me they were leaning toward the theory of an abscessed surgical wound. They would need to do a CT scan of my abdomen. I was panicked that they might have to open me up again, but they said that was unlikely. If they saw an abscess, they could drain it with a needle. That would cure me very quickly, and I could go home. Then, on Monday, Leah came in with some news: they couldn't schedule the scan before Friday.

What I also haven't told you is that the weather outside was abnormally warm, but the hospital was on winter HVAC. There was no air conditioning and the atmosphere was insufferable. They were actually starting to drill evacuation. If there had been a fan working anywhere in Beth Israel hospital at that moment, the shit really would have hit it. People who know me well will tell you that I'm usually tolerant and reasonably discreet, but there is a threshold where I go through a phase change. Was I going to sit in that hospital, in unrelieved agony, paying $730 a day, for all of Tuesday, Wednesday, and Thursday, before they would get around to doing something that might very well enable them to cure me on the spot? No, I was not.

Now it might be said that I only got upset because, like the rest of us spoiled post-industrial brats, I had come to claim technological miracles as an inalienable right that I wasn't even willing to wait three days for. Remember, those folks over in Iraq were still getting their asses blown off, and they weren't getting any CAT Scans. There is some truth to that.

On the other hand, in the old days, the doctors wouldn't have had to wait for a CAT Scan, for four days or four hours. They just would have stuck a needle into that hard lump under my incision and seen if anything came out. Crude, I suppose, but just possibly effective. Nowadays, with malpractice and all that, they just can't do anything without "a diagnostic procedure being performed." Another point in my favor is the $730/day. That wasn't coming out of my pocket, but it represented social resources that were being squandered. I'll bet you anything you like that if I'd been on an HMO, they would have had me under that CAT Scanner before the vomit was dry on Dr. Huang's shirt.

A few minutes after I had expressed my feelings to Leah, the Chief Resident showed up. "I understand you're a bit unhappy about the scheduling of your CT scan," he offered. (By the way, doctors call it a "CeeTee scan"; "CAT" is evidently a vulgarism.) I explained my feelings on the subject in terms impossible to misinterpret. Less than an hour later, Leah came in to tell me my scan had been scheduled for the next day. So it pays to complain, at least if you can do it in English and sound like you mean business -- but that is prima facie evidence that most people don't do it.

It turns out there is bad news about CT scans. For a scan of the abdomen, you have to drink the most revolting, nauseating, foul, vile, filth... At about 6:00 that evening Nance came in with a little pint bottle of this stuff. It had a sprightly drawing of a pineapple and bananas. "BARO-CAT", it was labeled, "radiological contrast medium in a pleasant-tasting beverage." My first reaction was that drinking anything at all would be suicidal. Dr. Goldman stopped by and I told him, "I can't possibly drink that." He told me that I had all night to get it down if necessary, but I really needed to try my best. You can imagine how I felt about the prospect of another attack of cramps. But I was a good patient again. I started sipping.

As far as the gastronomic experience, I would compare it to a concrete slurry flavored with saccharine and petroleum distillates. But what the heck, my local Christy's probably sells 20 cases of worse stuff than that every day. The big problem was that a couple of hours after I started trying to shove that stuff down my gridlocked guts, I began to feel as though I were just about to vomit any second ... any second now ... it's just about to happen ... and I kept on feeling that way all night long. Advice: given a choice between that kind of nausea and severe pain, choose pain.

In the morning, when the torturers came on rounds, I asked if they couldn't give me something for nausea. Of course! they said, and in a moment a nurse arrived with a hypodermic containing something called reglan. Inside of ten minutes, I felt much better -- almost well enough not to throw anything when they told me I had to drink another bottle of that filth. But, why didn't they give me the reglan in the first place, instead of forcing me to beg for it after 12 hours of agony? Are they really that stupid, or careless, or sadistic?

Next: The CT Scan

Monday, September 13, 2010

FDA - Which side are you on, which side are you on?

The new BMJ features extensive discussion of the serious hoo-hah over licensing of rosiglitazone, brand name Avandia, which was recently reviewed by an FDA advisory panel. A majority of the panel recommended leaving it on the market, albeit with strengthened warnings, for reasons which most of us find inexplicable and which they have not explained very well either.

I think this review of the affair by Deborah Cohen is supposed to be available by subscription only, but as of this writing it appears to be available to the public. So get it while you can.

Without getting fussy over the details, I'll just say that there are three and a half basic issues here. (But who's counting?)

  1. Approval of new drugs based on surrogate endpoints. Rosiglitazone was first approved by the FDA on the basis that it lowers glycolated hemoglobin, which is an indicator of high blood sugar. However, there was no evidence that it reduced complications of diabetes, or mortality.
  2. As a condition of said approval, the manufacturer (whose name keeps changing during this saga but is currently Glaxo Smith Kline, was supposed to conduct post-marketing studies to determine long term safety and efficacy. It did so (often the companies don't even bother, and such orders are never enforced) but it set up a poor study design, and then interpreted the results in a tendentious way. Although the company still tries to deny it, the best available evidence indicates that the drug increases the risk of cardiovascular complications and probably death
  3. The only reason we know point 2 is because, as a result of an unrelated lawsuit, GSK was required to post results of previously secret studies to a publicly accessible web site.
  4. The most important complication of Type 2 diabetes, and the principal way it kills people, is heart disease. What earthly reason could there be to prescribe a drug to people with diabetes that increases the risk of the most important complication? Given this apparent no-brainer, what could possibly be going on in the heads of physicians who voted to leave the drug on the market?

What is going on in their heads, and in the heads of pharmaceutical regulators in general, is that they have a first duty to protect the proprietary interests of drug manufacturers, rather than the interests of the public. They seem to think it would be unfair to GSK to revoke the license without absolute proof that the drug does more harm than good and that there is no sub-group of patients for whom there might be some plausible argument for taking it. Of course any confusion about these questions results entirely from GSK's deliberately obfuscating conduct of research and efforts to withhold any negative information from public or regulatory scrutiny.

Actually, they are supposed to be on our side. As GP Iona Heath discusses in the same issue (and this is properly hidden from your view, alas), the culture of medicine, and the popular culture surrounding it, is infected by fantasies of omnipotence and rescue. There is a powerful bias to do something and to believe that what we do is for the best. Often, however, we don't have good responses to chronic diseases, but interventions that are useless or harmful are still undertaken because of an unexamined assumption that action must be better than inaction. In the case of Type 2 diabetes, trying to tightly control hyperglycemia with drugs appears to do more harm than good, at least given the drugs we have now.

Eating right (that would be vegetables), exercising, and losing weight, does work, but it isn't a miraculous heroic medical intervention. So we give up on it very early on, and start pushing pills. It just doesn't seem to change.

Sunday, September 12, 2010

The money has been followed

Although hardly anybody is paying attention. Kenneth P. Vogel and Giovanni Russonello, in Politico, of all unlikely suspects, run it down. I'm linking to page 3 because they are fair and balanced: they spend most of the first two pages on who is financing Cordoba House (not a problem, as it turns out) in order to bury the lede:

But there’s also big money behind the mosque opposition, as highlighted by the relationship between Horowitz’s Los Angeles-based nonprofit Jihad Watch — the website run by [Robert] Spencer “dedicated to bringing public attention to the role that jihad theology and ideology play in the modern world” — and Joyce Chernick, the wife of a wealthy California tech company founder.

Though it was not listed on the public tax reports filed by Horowitz’s Freedom Center, POLITICO has confirmed that the lion’s share of the $920,000 it provided over the past three years to Jihad Watch came from Chernick, whose husband, Aubrey Chernick, has a net worth of $750 million, as a result of his 2004 sale to IBM of a software company he created, and a security consulting firm he now owns.

A onetime trustee of the hawkish Washington Institute for Near East Policy, Chernick led the effort to pull together $3.5 million in venture capital to start Pajamas Media, a conservative blog network that made its name partly with hawkish pro-Israel commentary and of late has kept up a steady stream of anti-mosque postings, including one rebutting attacks by CAIR against Spencer — who Pajamas Media CEO Roger Simon called “one of the ideological point men in the global war on terror.”

So, okay, that's the money. But that's separate from the question of who the money is being used to manipulate.

Friday, September 10, 2010

The United States of Idiocy

As I understand it, we have many competing independent corporations that provide information about current events over radio, broadcast and table TV, in print, and by means of your miraculous Intertubes. Their reporters and editors are free to tell us about any subject they choose. Is this correct?

So I'm sure somebody has a perfectly good explanation of how it is that our entire political discourse can be hijacked for an entire week by a random low IQ wackjob from nowhere who has some stupid plan that he talks about stupidly.

Thursday, September 09, 2010

I don't suppose Sarah is going to start reading NEJM any time soon

They're getting max cred from me for making articles of general public interest open access, and they definitely get a dog biscuit today. Kerianne Quanstrum and Rodney Hayward tell it like it is -- the crapstorm over the Preventive Services Task Force revised recommendations on screening mammography was largely propelled by the economic interest of radiologists. They even start off with that famous Adam Smith quotation, the one Smith's libertarian fans (who have never bothered to read him) pretend doesn't exist: "People of the same trade seldom meet together . . . [without] the conversation end[ing] in a conspiracy against the public." And yep, they are talking about the American College of Radiology, in your face.

As long as Americans have it stuck in their craniums that in medicine, more is always better and the only reason people argue for less is because they want to kill your mother, we are, well, going to kill people. That's the result of squandering and misallocating limited resources, and it's even the direct result of intervening when it's likely to do more harm than good.

So let's bring on the Life Panels. Tell us what not to do. Please.

Wednesday, September 08, 2010

Oh yeah, where was I?

I was in the hospital with severe diarrhea, an unexplained fever and a lump under my incision. How can you have diarrhea when your bowels are paralyzed, you may ask? That's easy. The diarrhea was edema -- fluid leaking from the colon walls. Nothing had to move from higher up.

That was not my only problem. Every time I went into the lavatory, I had to push the IV pole in ahead of me and get it positioned correctly so I could wrestle the knee-length smock out of the way and get my pants untied. Then I had to reverse the process on the way out. Every time, the IV got yanked around inside my vein.
In the next two days, I went through four or five IVs. They would stop running completely, or the arm downstream from the needle would get painful and swollen. Now I was more dehydrated than ever. Just because I couldn't stand the thought of drinking anything didn't mean I couldn't, at the same time, feel just as thirsty as a dying man in the desert.

There was never an IV nurse after 5:00 in the afternoon. Once the IV stopped running at night and I lay there desiccating for five hours before someone came to put a new one in. She didn't know what she was doing. First she blew a vein in my left hand, then she tried to put the needle in the crook of my left elbow, in the big vein they take blood samples from, and she blew that one as well. She finally gave up. During business hours, I was considered a windfall instructional resource. The IV nurses would bring students around to jab at me, until I insisted that the butchery stop.

Once, while I was lying in bed, I looked down to see the line full of blood and then I saw that it had somehow come apart. I pushed the call button. When Nance came in, she gasped and said to me, "don't look at the floor." A man came in with a mop a few minutes later and he just said, "Oh man." I didn't look, but from the way the man worked the mop, I figured the puddle of blood must have been at least five feet in diameter.

I said to Nance, "Look, the reason this is happening is the way I have to manipulate my clothing every time I go to the toilet. I have to get this damn nightie out of the way so I can get my pants down, and it keeps getting tangled in the IV line. Can't you give me a regular short pajama shirt?" Well, they didn't have any. The long johnnie was the only upper garment in stock. But she improvised. She got me a surgeon's scrub top. Not only did that put a stop to the repeated torture of blown IVs, but it immediately gave me back a measure of dignity I hadn't had since the night I walked in. I was now the only patient in unit 7B who was not humiliated by his clothing. The scrub top had a flattering cut and was an attractive blue with tan piping; it was closed in the back; it ended appropriately at the waist. I was now dressed like an adult instead of an infant.

Believe it or not, the next morning, a physician taking residents on morning rounds called over a nurse and berated her, in my presence, for allowing a patient to wear a physicians' scrub top. If they can't humiliate and infantilize you, something is seriously wrong.

They know, but they aren't telling you

A leaked draft of a study done for the German military is getting plenty of attention everywhere but the U.S. corporate media. As reported by Stefan Schulz for Spiegel online:

According to the German report, there is "some probability that peak oil will occur around the year 2010 and that the impact on security is expected to be felt 15 to 30 years later." The Bundeswehr prediction is consistent with those of well-known scientists who assume global oil production has either already passed its peak or will do so this year. . . .

The authors paint a bleak picture of the consequences resulting from a shortage of petroleum. As the transportation of goods depends on crude oil, international trade could be subject to colossal tax hikes. "Shortages in the supply of vital goods could arise" as a result, for example in food supplies. Oil is used directly or indirectly in the production of 95 percent of all industrial goods. Price shocks could therefore be seen in almost any industry and throughout all stages of the industrial supply chain. "In the medium term the global economic system and every market-oriented national economy would collapse." . . .

The Bundeswehr study also raises fears for the survival of democracy itself. Parts of the population could perceive the upheaval triggered by peak oil "as a general systemic crisis." This would create "room for ideological and extremist alternatives to existing forms of government." Fragmentation of the affected population is likely and could "in extreme cases lead to open conflict."

Note the conditional case. In fact, peak oil is not a conditional proposition. It will happen, most likely has happened already. The global recession has made the event invisible, but when demand for petroleum recovers the price will follow. Yet no world leader has stood up to say publicly that this is happening, it is an emergency, and we need to take action now to replace what will soon be a dwindling resource. Not even the disaster in the Gulf of Mexico could give Mr. Obama the courage to act in the service of humanity. What will it take?

Tuesday, September 07, 2010

The antidote to demagoguery

When it comes to health care policy, that would be Health Affairs, the new issue of which has just come out. Unfortunately, however, politicians are entitled to their own facts after all, and no amount of truth is likely to have much of an impact on our political discourse about health care. It doesn't have to be that way, reporters could be industrious, responsible and courageous, and hold politicians accountable for the truth, but as a class they are none of the above. Still, we lonely few soldier on.

There is a lot to chew on in the new issue, but today I'll just talk about malpractice litigation. Republicans have often claimed, believe it or not, that malpractice premiums and "defensive medicine" -- overuse of tests and procedures by physicians afraid of being sued -- largely account for the high cost of health care in the U.S., and that putting hard caps on awards for non-economic losses -- pain and suffering, basically -- and punitive damages will go a long way toward restraining costs.

It's actually not new news, but Michelle Mello and colleagues (including Atul Gawande of whom you have likely heard) calculate that these factors add about 2.5% to total health care costs in the U.S. More than nothing, but largely trivial in explaining why we spend twice as much as comparable nations. At the same time, they point out that there are perfectly good reasons for malpractice awards:

The system makes injured patients whole by providing compensation; it provides other forms of "corrective justice" for injured persons, which produces psychological benefits; and it reduces future injuries by signaling to health care providers that they will suffer sanctions if they practice negligently and cause injury.

They claim these benefits cannot be measured (I dispute that), but in any case that 2.5% of health care costs doesn't just go up the chimney. People who are injured do deserve compensation, and the negligent practice of medicine does need to be discouraged. But: malpractice litigation is a very crude instrument for achieving these ends. Most people who are injured by medical negligence in fact never sue, and most people who are injured by medical error don't even have grounds for a lawsuit because most errors are not negligent. Furthermore the outcome of litigation may be disputed in many instances as it depends on the quality of the counsel on each side, dueling expert testimony, various factors that tug on jurors' emotions, and the judgment of jurors who lack relevant expertise guided by instructions from judges who are often equally at sea.

There is no reason why compensation for injured persons has to be tied in any way to sanctions for negligent or incompetent health care providers. We ought simply to separate these goals.

As for compensation, universal, comprehensive health care would go a long way. Mello et al estimate that 55% of malpractice awards are for economic losses, a good chunk of which consists of future medical costs, particularly for obstetric injuries to infants. These costs should already be paid for, without regard to why they exist. A decent disability and survivors' insurance system would also help. But there would certainly be the need for additional compensation in some cases, which could be paid out of a common pool without regard to anyone's culpability. Without huge legal fees, there would be more money for people in need.

As for discouraging negligence, we need accountability through a dedicated system of tribunals which are not about making huge damage awards, but about disciplining the provider work force. I won't try to design the thing here, but the basic idea is simple enough. They should not consist entirely of physicians (since we know they always stick together) and there must be some degree of managed transparency that protects the rights and reputation of the non-culpable. Sanctions could range from a reprimand with requirements for maintaining licensure; required retraining; suspension of licensure with requirements for reinstatement; and revocation of licensure. Yes, the accused would hire lawyers but they would be paid by the hour, and wouldn't be looking to scoop up millions in contingency fees.

This is something the AMA and patient advocates might very well agree on. Trial lawyers, however, won't like it one bit, and they give a lot of money to political candidates. It so happens that they mostly give to candidates I like, so I demand major cred for being fair and balanced here. But you know, it's not going to happen.

Monday, September 06, 2010

Isn't anybody in charge here?

I could just have one of those What Digby Says blogs. I guess my fear of the slippery slope has made me reluctant to link to her. But for sure, lots of us share this sentiment:

You know, with an economy like this I would always assume this would be a tough election. Midterms always are for the majority and this one in particular was always going to be a bitch. But I don't think I ever expected anyone to lose to the collection of half educated carnival clowns, throwbacks and morons the Republicans are putting up this time. It's mind-boggling. In fact, it's so bad that now even the standard issue fascists are getting a little queasy.

It is very difficult to understand why this is happening but here's a proposal: Barack Obama has utterly, abysmally, failed to show any leadership. I am truly tempted to use the term moral cowardice. Okay, I just did.

ABC News rounds up the terrifying rise of sectarian hatred aimed at Muslims. Even George W. Bush got out in front of this sick garbage but all we've heard from Obama is a single, weak tea statement that people have a constitutional right to build mosques, followed by the next day by a baby splitting disclaimer that he really wishes they wouldn't build the Park 51 community center. Since then - not a peep, even as anti-Muslim violence, threats, and hateful rhetoric is making a mockery of U.S. claims of benevolent intentions in Afghanistan and Iraq, and yes, putting the lives of U.S. personnel at increased risk.

After almost two years, we are still expelling gay people from the military in spite of Obama's promises. The Deepwater Horizon disaster at least offered an opportunity for the president to make a forceful case for real action to end our addiction to fossil fuels and finally do something about the single greatest crisis facing humanity, but he meticulously, actively avoided making any connection. Instead he delivered a prime time speech promising to make BP pay for the damages, and nothing more.

As for the economic crisis, he has spent the past several months repeatedly claiming that it's all getting better and resolutely avoiding proposing any meaningful action. Finally, today, we get a proposal for $50 billion in infrastructure investment that comes much to late and has no chance of passing congress.

Yes, the polls show that the Park 51 project is unpopular, and so is a carbon tax, and the Republicans are guaranteed to screech about deficits and socialism every time he proposes spending money, and while public opinion on homosexuality is shifting it's still going to cost him some cred with religious conservatives who don't like him anyway to eliminate discrimination in the military and change course in support of same sex marriage but . . .

People want leadership. He can redefine these issues and move public opinion if he will step up and speak forcefully and passionately, which we know he can do. People aren't planning to vote for Democrats because Democrats don't appear to stand for anything. That's my view.

Sunday, September 05, 2010

Hard cases

As readers in the northeast will likely know (I don't know how prominently the story has played elsewhere) Connecticut is scheduled to start a death penalty trial in a few days that makes opponents of capital punishment -- including me -- feel lonely and maybe a little defensive. Briefly, in July 2007, two parolees with long histories of non-violent crime invaded the home of an affluent family in a leafy suburb, held and tortured them for hours, and now are charged with sexually assaulting the mother and 11 year old daughter, and killing both of them along with an older daughter. Only the father, a prominent endocrinologist named William Petit, survived.

The attorneys and principals have been under a gag order in the case since shortly after the event, and the police have also shut up, so details which were reported early on have not been repeated. I will not recount them here because the reported actions were so depraved that it would be pointlessly disturbing. Suffice it to say that what the jurors are likely to hear presents a very daunting challenge to the defense. Of course I have no idea what sort of a case the defense will present, but the facts of the crime are not in question. The defense might actually have a slightly better chance of arguing diminished capacity with the other defendant, Joshua Komisarjevsky, who goes on trial later.

The case has generated several controversies. One Brian McDonald published a book about the crime, featuring a jailhouse interview with Komisarjevsky. Dr. Petit vociferously objected and he had public opinion overwhelmingly on his side. This is not such a hard case, however. Under our constitution Mr. McDonald is guaranteed the right to publish his book, however objectionable one might find it. In my view, there will have to be one or more books about these events, but the right time is after the trial when all of the facts are known and the various ethical and policy questions have played out. However, Komisarjevsky evidently violated the gag order by talking with him, which raises the question of the free speech implications of the gag order. These are common in high profile proceedings, but they are a barrier to the public learning the truth.

It won't surprise you that these events did not generate an outpouring of public support for parole policies in Connecticut. Governor Rell responded by suspending parole for all persons convicted of violent offenses, never mind that this would have had no effect in this case. The Governor set up a commission (natch) to review criminal justice policies in the aftermath of the crime, and the only real result was equally irrelevant to the case. The state eliminated furloughs for prisoners who were scheduled for parole. (Hayes and Komisarjevsky were not on furlough; they had been paroled.) But shortly thereafter, facing a budget crisis, lawmakers and the governor agreed to reinstate furloughs. Now the governor is closing a prison, which will inevitably result in more, not fewer, paroles.

Dr. Petit has been publicly advocating for the death penalty in this case, drawing the ire of Hayes's defense attorney. "Ullmann said Petit and other relatives were giving daily press conferences and trying to sway jurors outside of court. He said he should have the right to respond."

Hayes tried to commit suicide in prison and managed to hoard enough prescription meds that he nearly succeeded. It has also been reported that his lawyer has blocked him from confessing.

But with all of this fodder for vexing arguments about conflicting rights, the greatest difficulty of the case is the most basic. Both defendants have offered to plead guilty in exchange for sentences of life without possibility of parole, but prosecutors have refused. The public wants the death penalty and that's what the state is determined to give them.

I can only make the same old arguments. Killing these guys won't undo their crimes. It will make killers of the prosecutors, jurors, prison warden, guards and executioners. It forces us to make choices about who lives and who dies and no matter how confident you feel about it in this particular case, there will always be cases that aren't clear. Neither of these individuals created themselves, and who knows what you would be if your life had been different? To allow them to live is to demonstrate the respect for humanity that they did not have. The prospect of the death penalty obviously did not deter them; it only forces Dr. Petit and the rest of us to observe a trial at which the horrific events of that day will be repeated in every horrific detail. It gives Hayes and Komisarjevsky the easy way out, the way accused "Craigslist killer" Philip Markoff chose for himself. So it does no good for anyone and only does harm. Dr. Petit thinks it's what he wants but I can pretty much guarantee one thing: he will feel no better after these men are executed.

Friday, September 03, 2010

Just so you know . . .

I'm in the process of moving to a new university, in a different city; completing construction of a new home in yet a third location; and doing a couple of family obligations. Hence none of the deeply informative, cleverly written and emotionally moving posts to which you have grown accustomed will occur today or tomorrow, but don't give up on Sunday, it might happen then.

Meanwhile, if anyone who knows me personally is interested in the details, you know how to reach me.

Thursday, September 02, 2010

I wish I had the energy right now to get up a proper rant

NYT's Duff Wilson gets down home and personal about the epidemic of prescribing psychmeds to little kids. On a good day, I would go postal on this, but hey, I've already done that and this is a good piece of journalism that covers the issues well.

What I will say, in calm and measured tones, is that the vast majority of the time, when a young child has serious behavioral problems, the reason is that something is wrong in the child's nurturing environment. The mother of the poster child in Wilson's story says it herself: "Ms. Warren conceded that she resorted to medicating Kyle because she was unprepared for parenthood at age 22, living in difficult circumstances, sometimes distracted. 'It was complicated,' she said. 'Very tense.'”

Kyle was ultimately drugged into a stupor, using powerful antipsychotics. He's was lucky enough to get into a program to get him off the drugs, and he's fine now. He isn't psychotic, he isn't autistic -- as a matter of fact there is no such thing as a psychotic child. Schizophrenia manifests in late adolescence or early adulthood. But according to Wilson's story, there are actually instances of antipsychotics being given to infants.

This is the most outrageous child abuse. It is perpetrated by the confluence of greedy, psychopathic drug company executives; improperly trained, overwhelmed primary care physicians; psychiatrists seduced by a depraved ideology that views human beings as vats of chemicals; and a selfish political culture that refuses to provide needy families and damaged children with the resources they actually need.

Giving antipsychotics to children, under any circumstances, should be a crime. No exceptions.