Map of life expectancy at birth from Global Education Project.

Tuesday, November 30, 2010


People who ought to know better are apparently unaware of the basic laws of inference. Here's a headline: Study: Drugs Linked to 1 in 5 Fatal Car Crashes. "Of the 21,798 drivers were killed on the road in the United States in 2009, about 18 percent of them had drugs in their system at the time of death, the National Highway Traffic Safety Administration says in a new report released Tuesday."

"Drugs" includes illicit and legally prescribed drugs and over-the-counter medicines.

What question did they fail to ask? (Jeopardy! music plays . . . )

What percentage of all drivers has one or more of these drugs in their system at any given time? Could it be as high as 18%? Wouldn't surprise me one bit.

Where was I?

Sorry for the no post yesterday, I had to get up at the crack of dawn to fly to Baltimore for a three hour meeting, and fly back that afternoon. Yeah yeah, bloggers who do that sort of thing usually blog from the airport but I just wasn't up for it. Apologies for the carbon emissions as well but it wasn't up to me.

Anyway, I don't subscribe or regularly read The Economist, but it is a good way to kill 3 hours so I often buy it at the airport. As I presume most readers know, this is a British magazine which is not particularly written by or for economists. It's a comprehensive review of global affairs, somewhat comparable to Time or Newsweek but far smarter and more comprehensive. It is generally considered conservative in outlook and I suppose it is, by UK standards, but by current U.S. standards it's not that far from the Daily Worker. It could be the Bernie Sanders campaign manual. That's how warped we have become.

Here's their latest page on the U.S., where they endorse the Fed's "quantitative easing" while pointing out that it's an inferior option which is only necessary because we have provided insufficient fiscal stimulus; endorse not only the DREAM act but comprehensive immigration reform while slapping Republican demagoguery about "amnesty"; and also slap the Republicans around over blocking ratification of the new START treaty, among other positions.

Every issue has a theme section and this week, it was anthropogenic global warming, which they portray as an urgent problem which we ought to be addressing by reducing carbon emissions but, since that apparently isn't going to happen, they focus on possible responses.

The Economist is also entirely free of the pervasive American trait of narcissism -- it opens up to the world and tries to free itself of a British centered perspective. Its dispatches from darn near everywhere -- Sri Lanka to Kenya to Brazil as well as the more obvious major powers and hot spots -- take the local perspective and dispassionately portray local culture and politics.

If we had conservatives like that, we would not be idiots. But we don't, and we are.

Saturday, November 27, 2010

A speciation event?

Now that I'm a part-time country boy fer sher, it's a major new experience for me and I'm going to be tempted to write a lot about my observations of the nature of nature and the idiocy or wisdom of rural life and all that. For example, today I spent the morning in my neighbor's woods harvesting firewood from the tops where he had a lot cleared and some sustainable logging done. Heating with wood is normal here, and chainsaws in the distance are background music this time of year.

Wood cut in the fall is no good till next winter, but it will be perfect then, and this is a good time to cut it. The understory has died so it's easier to see what's going on and make your way in the woods, and the leaves are off the trees so it's easier to clean up your fire logs. Loggers, in fact, prefer to work in the winter, even with snow on the ground. This time of year, it's not so cold that I didn't sweat a bit working hard, but it does feel cold when you stop. With the sun so low, it feels like it's late in the day, all day.

So, firewood forces you to be very forward looking, storing up not for this winter, but for next. Rural forms of Self-sufficiency in general tend to be like that, very obviously. What I do this fall will have a lot to do with what I can produce from the garden next summer, and from fruit trees in three or four years. I suppose that's true of any career or business one tries to build, but in these particular matters the link between current effort and future prosperity holds little mystery.

Anyway, what I'm thinking of doing is starting a new blog, to be called Windham County, where I can post all this sort of idiocy, and keep Stayin' Alive more or less on topic. Not that I'm always great about that but I'd like to keep it within limits. Let me know if you have any thoughts.

Thursday, November 25, 2010


Now that I'm spending more time in the country I'm getting to know where I live. Last night as I was drifting off to sleep a coyote got to whooping and hollering, seemingly just outside my window. It gave a complicated performance consisting of rhythmic yelps and howls that broke upward in the middle by a diminished fifth. (The Devil's interval, banned by the medieval church.) The concert lasted two or three minutes, with the pattern of yelps and howls varying throughout. Later, after midnight, presumably a different individual, or at least it was a different song, somewhat farther away, gave a brief, simple performance consisting of four howls with slight downward inflection.

They apparently do this to tell other males to stay out of their territory, and invite the females in if they are so inclined. (When I try it it doesn't seem to work.) But for a predator to announce its presence so assertively seems awfully sporting. As I say, the turkeys can fly up into the trees.

Wednesday, November 24, 2010

It's Economics 101!

Yet again. One very common conservative trope is that making people pay out of pocket for their health care will make them wise consumers and help control health care costs. This is not a finding, of course, it's an assumption, and it's an assumption based on a prior assumption that consumers have perfect information and behave "rationally" -- both of which are essential to the theory of the Free Market™.

Here is a very simple illustration of why this isn't true. When Blue Cross Blue Shield of North Carolina eliminated co-pays for generic medications, more people took their calcium channel blockers and other basic maintenance meds. These are very inexpensive medications that really do prevent strokes, heart attacks, and kidney failure, which are very expensive when they do happen.

A) People don't make a cost-benefit analysis that that tells them paying the 5 bucks for the pills is worth it, especially if they need the 5 bucks for something else; and
B) Even if they did know how to do the calculation, they might just say what the heck, I'll take the chance, it isn't really going to happen to me.

And for that matter, sometimes people don't have 5 bucks. But we still have to pay for their dialysis.

While we're on the subject, what's in that tea they're drinking anyway? The whole thing is supposed to be about cutting government spending, but the last thing in the world they will ever stand for is -- cutting government spending, specifically in this case spending on Medicare. The Patient Protection and Affordable Care Act created the Patient Centered Outcomes Research Institute, which will fund comparative effectiveness research, but the language specifically states that the institute "shall not develop or employ a dollars-per-quality- adjusted life year (or similar measure ...) as a threshold to establish what kind of health care is cost effective or recommended under Medicare." So we aren't allowed to save money because that would be "rationing." We have to cut spending, cut taxes, cut the deficit, and commit ourselves to infinite spending on Medicare. But we also can't guarantee health care for people under 65.

Makes perfect sense.

I am now headed for Windham County, which is positively infested with turkeys -- real ones, the kind the pilgrims ate, not the grotesque freaks farmers have bred with gigantic breasts and microscopic brains. Real turkeys can fly, quite well. And they're smart enough to thrive and multiply despite the harsh New England winters, and the foxes, coyotes and bob cats. If Ben Franklin had gotten his wish, and the turkey, rather than the eagle, had become our national symbol, would we be less inclined to go to war?

Tuesday, November 23, 2010

A slightly tough question

I guess. At least it seems to be to a lot of people. For reasons I cannot disclose, I've been thinking a bit lately about the placebo effect -- or possibly effects. Due to some combination of expecting to get better, and therapeutic attention, people who get treatments that have no specific biological effect tend to report that they feel better than people who get no treatment. This only works, obviously, with symptoms. There is a strong response to placebos in depression, and many people also respond who have chronic pain.

Now, this is philosophically a bit tricky to begin with. Pain and depression are more or less defined as particular ways that people feel. There could be "objectively" measurable correlates, such as range of motion in the case of pain or appetite in the case of depression, but if people say they feel better, then it seems pretty ridiculous to say the treatment wasn't really effective. Feeling better is what they want.

Accordingly, Brian Berman and colleagues raised quite a few hackles back in July when they argued in NEJM that physicians ought to refer people with idiopathic chronic low back pain (CLBP) to acupuncturists. CLBP is a real pain in the backside because most of the time, it doesn't correspond to any identifiable physical cause and it doesn't respond well to analgesics, physical therapy, or anything else. Surgeons used to do spinal fusion all the time, until it was shown that the surgery was actually a placebo. People responded just as well to fake surgery, in which they were opened and closed but nothing else was done, as they did to the real surgery.*

It turns out that people with CLBP also respond to acupuncture, even though it is well established that acupuncture is actually bogus. It doesn't matter where you insert the needles, or even whether you insert them at all. As long as people think they've had acupuncture, they often report feeling better. The same is true of homeopathy. Homeopathic 'remedies' are completely useless, but homeopathic consultations make people feel better.

So should doctors give people fake pills, or fake physical interventions such as pretending to stick needles in them? It only works, remember, if you tell the people that it will make them feel better. Actually, that's true, but it's only true because you're saying it. In other words, you're fooling them, sort of, but as long as they are fooled, it's not fooling . . . And this sentence is a lie.

Okay, here's what I think. There is no need to pay money to fake therapists for fake treatments. We can instead have real doctors who are engaged, empathetic, take time with their patients, and give them whatever treatments they can that have been shown to be more effective than placebo, along with encouragement and sound advice about coping. As Edzard Ernst writes (in the essay whose abstract is linked above):

Modern mainstream medicine seems to neglect the importance of medical core values such as empathy, sympathy, time, understanding and holism. This creates a situation where alternative practitioners tend to provide the non-specific and mainstream doctors the specific effects. Clearly this is wrong and may be one reason why patients consult alternative practitioners.

*Yes, this resulted in the famous defunding of the Agency for Health Care Policy and Research at the behest of spinal surgeons who cared more about money than they did about their patients.

Monday, November 22, 2010

Excavating my past

I don't recall whether I have mentioned it in this space, but I'm getting ready to move from my home in Boston, where I have lived for more than 20 years. I haven't sold the place yet, but I've started going through the mass quantities of paper and junk, moving what I can to my country place and deciding on what to landfill.

It turns out I have a lot of stuff I didn't know I had, and I did quite a few somewhat consequential things I hadn't thought about for a long time and had nearly forgotten. Back when I was in graduate school, for example, I paid for my crusts of bread with a consulting business. Among the projects I took on were a minority needs assessment study for the city of Fitchburg, Massachusetts; and strategic planning processes, including environmental assessments, for Boston Mobilization for Survival and Boston's Multicultural AIDS Coalition.

I found my files from these projects in a box in a spare bedroom I've been using for storage. This all happened in the early 1990s, and obviously there is no practical need to keep the papers. I ended up tossing them. But it got me to thinking about history. It consists of stories built around whatever evidence happens to have survived.

Ethnic relations in the post-industrial Merrimack Valley in the 1990s would be an interesting subject for a history dissertation. Fitchburg is a lot like Lawrence, where the famous Bread and Roses strike happened in 1912. It's a mill town where back then, immigrant workers were from Eastern and Central Europe, Ireland and French Canada. In 1994, those were the "indigenous" residents and the town was painfully absorbing a big influx of Latinos (lots of Uruguayans, for whatever reason), Hmong refugees who had been resettled there, and of course it had an African-American population from the great migration north of the Depression and war years. All of this with a scarcity of jobs, far from the big city.

The early days of the HIV epidemic, as a social, political and cultural phenomenon in African American, Latino and/or Haitian communities, would make another good dissertation; as would the remnants of the New Left as the counterculture 60s (which lasted from 1964 to 1975) faded away in the 1980s and 90s.

My files would have been a good resource for any of those: lots of pertinent interviews, survey data, and minutes of meetings where highly knowledgeable key activists were debating the state of affairs and what to do about in great depth. It's possible that the relevant organizations still have some of it in their archives but I doubt it. Leadership has moved on, the times have changed, I expect that at some point they did the same file purging I did. So all that is gone.

Why didn't I hold on to the files? Basically, I consider the probability vanishingly small that anyone with an interest in these little bits of history would ever track me down and connect with my yellowing pieces of paper. I've got enough stuff to schlep and organize, I just can't keep it all because someday, some way that I can't possibly predict somebody might be interested in it. And I don't think any university library is going to want to catalog and archive my papers when I'm gone either.

How much of what we think we know about the past is a function of what documents just happened to survive? I know historians worry about such questions all the time, but it was interesting to hold some pieces of the past, not entirely insignificant, in my hands, and realize that I am part of the age old process of selective memory.

Friday, November 19, 2010

Hang up and drive!

So sayeth Ray LaHood. And he's right. As an irredeemable pedestrian, I am tired of nearly getting killed 5 times a week by idiots sailing through stop signs while steering with their knees while yelling, "So she was like, 'No way!' and I was like 'Way' and she was like 'No way' and I was like, 'Whatevah'" into their phones.

World of Illusion

I'm reading Joseph Stiglitz's book Freefall: America, Free Markets, and the Sinking of the Global Economy. (WW Norton and Company, 2010)

This isn't a review, per se -- I haven't even finished it -- but some reflections. Stiglitz is a prominent economist -- indeed a winner of the phony "Nobel Prize" that economists give each other -- so it's comforting to see him agreeing with what I have maintained here all along.

Stiglitz says, quite directly, what I have also said, that economics, as taught, practiced and promulgated, is a form of theology, not a science. This is a specialized use of the word theology, by both of us. Economists don't talk about God, but they use the methodology of theologians. Theologians begin with received truths, purported facts written down in scripture or declared by priestly authorities, and construct edifices of thought on these assumptions. Some of their effort is devoted to spinning out consequences, whether descriptive, explanatory, or prescriptive (i.e. moral) from their assumptions. Some of their effort is devoted to vindicating the assumptions in spite of the manifest failure of observable reality to correspond to them. For example, the problem of theodicy - how can God be all powerful, just and compassionate, given that the world does not exhibit justice or goodness?

Economists proceed in exactly the same manner. They make a large number of assumptions, all of which happen to be rather obviously false. They build an elaborate edifice of theory based on those assumptions. Then they forget that the assumptions are false and insist that reality corresponds to their theory, even though anyone can see that it does not. Many of the people who engage in this sort of exercise are among the most prominent academics. They receive salaries much higher than professors in other disciplines, they receive high level political appointments, and their absurd beliefs are central to much of the political and policy discourse in the United States and elsewhere in the world.

The prevailing central assertion of these theologians for many decades has been that an entity called the "Free Market" efficiently allocates resources and maximizes prosperity, is "self-correcting," i.e. it maintains itself in an "equilibrium state" from which goodness flows, and it works best when government intervenes the least. Taxes and regulations can only damage its mystic perfection.

To be sure, they admit that in exceptional circumstances, so-called "market failures" can occur. Here and there we may need to tweak things a bit. But these exceptions can best be understood in light of the prevailing truth of the God-like Free Market.

This is unalloyed, irredeemable nonsense. No such entity as this so-called "Free Market" exists, has ever existed, or ever could exist. Markets are social constructions, not forces of nature. In wealthy, technologically advanced and complex societies such as ours, markets are creatures of government, and they depend on continual, sustained and massive government action and intervention to exist and to function. They are not self-correcting, they do not allocate resources efficiently, they do not maximize prosperity, especially when regulation is minimal. The question is not whether they are regulated, but rather how -- for whose benefit.

I will say more about this in coming days. For now, I will leave us with this. We are trapped in a discourse that takes the word of these charlatans -- and I mean you, Alan Greenspan, and Greg Mankiw -- as genius. In fact, the technical term for it is bullshit. A couple of basic points. Lower taxes are not associated with higher economic growth. Reduced regulation is not associated with higher economic growth. Cutting taxes and regulation does not cause there to be more jobs or more national income. These assertions are indeed, as George W. Bush said, "Economics 101," and they are also false.

Thursday, November 18, 2010

Buddy, have you got the wrong blogger

One of the interesting perks of blogging is that I get all sorts of pitches from publicists. It's surprising how many academic physicians are paying flacks to promote their breakthrough research, that the Nobel committee has somehow overlooked. Medical device manufacturers, drug pushers and even outpatient surgery centers think I might just throw them a mention here.

Not to be.

Even weirder, I would say, or maybe not, are the woo-meisters, the purveyors of the mystic arts and the miracle cures that "They" don't want you to know about. I consider these pitches weirder because, while I'm likely to ignore the former category, I'm likely to trash the latter. As I shall now proceed to do.

The first comes from a "manufacturer and marketer of leading natural supplements that promote optimal joint health." Well, no they don't. There was a flurry of interest a few years back in glucosamine and chondroitin, constituents of cartilage, as possible treatments for osteoarthritis. Later, more rigorous trials have been largely negative -- i.e., it doesn't work -- though perhaps equivocal in allowing some modest benefit for some people with moderate to severe joint pain. While no benefit of these supplements has been demonstrated, they probably won't hurt you, but they aren't likely to do you much good either.

So okay, selling this stuff isn't the worst scam out there. However, what is definitely a scam is the pitch this company uses. Their press release is headlined "Patients fire doctors over trust issues; PATIENTS GROWING WEARY OF DOCTOR/DRUG COMPANY RELATIONSHIPS SEEK ALTERNATIVES; More People Trust Own Instincts Rather than Endure Misleading Consultations." They cite a report in the Archives of Internal Medicine to the effect that most physicians accept items of value from drug companies. They exaggerate -- mostly we're talking the triangular plastic pen and the Post-it pad, but they go on about trips to exotic locations, speaking fees, and fancy dinners. Only a small minority of physicians nowadays get major gifts from drug companies, but it does still happen, it is corrupt, and I'm agin' it.

Nevertheless, it does not follow that you should stop consulting physicians, abandon their prescriptions, and depend on your own "instincts" to treat yourself from the snake oil aisle. In case you didn't notice, this company is itself making money by selling the stuff. So why should you trust them? Your doctor might have gotten a free pizza during his residency, but he isn't getting kickbacks from the drug companies. Probably. And he does at least have treatments available for which there is good evidence.

Worse is an "Ayurvedic M.D. and Naturopathic Physician," who is co-founder of a company that markets "ayurvedic herbs." He wants me to practice breathing exercises appropriate to my "dosha," or "natural constitution." I was once told that I'm a Pitta, meaning I "tend to run warm, get easily irritated and impatient and experience heated digestion." Fortunately I'm not a Vatta, or I would be "be anxious and absentminded and experience flatulence and constipation." As a Pitta, I'm supposed to:

1. Open your mouth to form an “O” shape. With your mouth in this position, form a funnel with your tongue and place it between your lips*

3. Slowly inhale through your tongue and feel the breath reach your heart

4. Relax the tongue and mouth, and then exhale through your mouth

5. Repeat this exercise 16 times, twice a day

* If you cannot form a funnel, bring your teeth together and inhale through your teeth instead

While the joint supplements are dodgy, this is total bullshit that the guy pulled out of his orifice of flatulence and constipation, after first getting his head out of the way. He then reinserted it. The mystery is why anybody believes this garbage.

The medical profession needs to clean up its act in many ways, not least because the ethical lapses create an opening for con artists. I hope the top docs will take this to heart.

Wednesday, November 17, 2010

The Quality of Quality

As Kathy noted on my previous post, there can be a lot to process when you're doing focus groups or any form of qualitative social research. We often hear confidences from our friends and family, have to respond to trauma in our own lives and our loved ones' lives, and live through hard times. Health care and social service providers obviously have to interact with very sick, dying and bereaved people as part of their daily routine. But there is something particular and particularly challenging about hearing tragic stories as a researcher.

I have to do my best not to influence how people present themselves, or steer the data in any direction. Normally, when it's appropriate to offer sympathy or reassurance or advice, that's what sane people do. Sociologists, however, ordinarily have to be very careful not to become a part of the real life of the people who we're trying to understand. (There are exceptions, mostly from the anthropological tradition, where investigators enter life worlds. But that's not what I was doing yesterday.)

That doesn't mean we don't care, or they're just specimens. If people really need help right away, of course we'll try to get it for them, and in a real emergency we'll step out of our role if we have to. In fact, I really have to be in the moment, I really have to empathize and understand, so I can figure out what questions to ask and where the discussion needs to go. But I also have to stay in my role of an observer and data collector. It's very taxing. Fortunately, in the situation I just worked in, the people were supportive of each other -- which is an observation -- so I didn't have to feel so stressed about it.

With the development of cheap electronic digital computing, social science, which had once been a largely descriptive discipline, became much more quantitative, and obsessed with statistical analysis and mathematical models. Qualitative methods fell out of favor. They were widely seen as intellectually inferior, not really scientific, more akin to literary art.

Fortunately we're getting past that. Fancy math is worthless if you don't understand what it is you are counting. We got to the point where our reductionism was squeezing the juice out of life. Human social interaction is different from biological processes because it has a particular kind of meaning for us, that we don't have very compelling ways of collapsing into few and definite categories that have specific, quantifiable relationships.

Because it is easy to turn survey data into mathematical models, survey methods became extremely popular in the social sciences, but as the saying goes, garbage in, garbage out. The investigator decides how to phrase the questions, and what responses to offer. Whether it makes sense to you, or means very much to you, as a respondent, is not the researcher's problem -- and we all know how annoying it can be to respond to a survey that doesn't ask the right questions, or asks them the wrong way, or doesn't let us give the answer we want to give.

On the other hand, just because I talk with some people and I see particular meaning in what they say to me, or to each other, doesn't mean you necessarily have to believe that my insights are the right or most important ones, or that those people are like others. We need ways of cogently defining units of meaning in social interactions and people's social worlds, counting them, and testing their associations with each other. It's a slow process, working back and forth between qualitative induction and quantitative deduction, and the average lay person probably doesn't think we've really gotten anywhere. But we have. A lot of what we have learned, however, people don't want to believe. But that's a problem for another day.

Monday, November 15, 2010

So what the heck do I know?

I'm involved in various forms of research based on the premise that "patient centered communication" is like, you know, good. That means that doctors encourage patients to say what's on their minds, set shared agendas, engage in shared decision making, enter patients' life worlds and understand how their values and goals intersect with biomedical understanding to shape the right choices for them, yadda yadda yadda.

This is, of course, in contrast to the old idea of medical paternalism where the doctor tells us what to do and we follow orders.

So, as part of this whole program, I'm running focus groups with people with HIV to talk about their relationships and communication with their doctors about antiretroviral medication taking and other such issues of their own behavior. So what do they like? It turns out they like it when doctors scold and yell at the people who screw up. That proves the doctor really cares.

At least that's what they tend to say when I ask them. It does not follow that it works in real life, but still. The life of a social scientist is a continual carnival of surprise and wonder.

(I did two focus groups today, which is actually fairly grueling. I have to do two more tomorrow then fly back to Boston. And no, I don't get time and a half.)

Sunday, November 14, 2010

Dear Intelligent Designer

It seems to me that for whatever reason, you don't get a lot of feedback. People just seem to accept things as they are, and even give thanks for it all, without letting you know what they like and don't like. I don't see why you wouldn't appreciate a little honest, constructive criticism.

Obviously, there's plenty of good stuff, that goes without saying. You know how it is, criticism always tends to focus on the negative because there's just more to say about it. So take it as stipulated that from my point of view, at least, it's good that there's something rather than nothing. Or at least I think so -- if there weren't anything, obviously I wouldn't be here to be disappointed so that gets a little tricky philosophically and all that. And if I weren't here, then there would be nothing as far as I'm concerned, except that I wouldn't be concerned -- well let's just leave it at that. Anyway, I'm here and so are the necessary conditions for that to be true, so you're certainly doing something right. And there is stuff for me to enjoy.

But . . . First of all, you're entitled to your own interests and foibles. I don't really get the thing about the beetles but I'm okay with it. There are a lot of little things that bother me, however, which don't really make any sense, e.g. poison ivy. What the heck is the point of that? Mosquitoes don't really seem necessary, either, or bedbugs. Lots of stuff like that which I just don't get.

But then there are more serious issues, where you really could have done a better job with the design. For example, the baby's head is too big for the birth canal. This causes no end of trouble. And the lower back -- the spine has a counterproductive curvature and it just doesn't hold up very well for a lot of people. Then there's the appendix - if it does any good at all, which I doubt, it's a lot more trouble than it's worth. Also, you didn't do a very good job separating the windpipe from the esophagus. People get food stuck in the bronchi all the time and like, die. Unless there's someone around to give them the Heimlich maneuver, which I have to point out was invented by Heimlich, not you. Even if you did invent Heimlich there's no particular reason why you couldn't have revealed the maneuver a few thousand years ago, along with the commandment to kill people who pick up sticks on the sabbath.

I could go on. There isn't enough room in lot's of people mouths for all their teeth. Osteoarthritis. Alzheimer's Disease. Childhood leukemia. All totally unnecessary and the result of basic design flaws. You're supposed to be omniscient as well as omnipotent, so it seems to me you could have done a much better job if you really cared. It's not too late to make a few fixes, you know? You might find yourself better appreciated.

Friday, November 12, 2010

I had to read a European journal to learn about this

It seems that Kenny Lin, a medical officer for the U.S. Agency for Healthcare Research and Quality, has resigned his position in a controversy over recommendations for prostate cancer screening. The story is quite revealing.

The U.S. Preventive Services Task Force was scheduled to vote at a meeting on November 1-2 on recommendations concerning prostate cancer screening. (Hmm, what else was going on around that time?) It seems the PSTF had voted preliminarily last year to recommend against routine prostate cancer screening for men of all ages, but then they decided to delay the official vote until this year. Then they canceled the meeting.

As Jeanne Lenzer reminds us, writing in BMJ (it's indecent to discuss this sort of thing in the United States, don't you know), reminds us of what happened when the PSTF recommended against routine mammographic screening of women in their 40s. Specifically, the excrement hit the ventilator and and everybody from Sarah Palin to Deborah Wasserman Schultz, to her eternal discredit, started screaming about the Death Panels.

In the 1990s, the Agency for Health Care Policy and Research (now called Agency for Healthcare Research and Quality), which sponsors the USPTF, recommended against spinal fusion surgery. The spinal surgeons, who needed to hold on to their horse farms much more than they needed to provide appropriate medical care, succeeded in getting Congress to eliminate the agency entirely. Funding was eventually restored, but at a much lower level.

Prostate cancer treatment is a river of gravy for surgeons, oncologists, and radiologists. They don't want to see it slow down. AHRQ now says the meeting will happen in March, safely after the election. We'll see. But we will never get health care costs under control if we can't make these decisions based on what's good for people, not what's good for business.

Wednesday, November 10, 2010

I ask once more: What is wrong with these doctors?

Michael Rothberg and colleagues surveyed some cardiologists and their patients who had undergone so-called percutaneous coronary intervention. That basically means sticking a long tube into the femoral artery in the groin, and guiding it to the site of a blockage in a coronary artery where various implements can then be used to open the channel.

It is an absolutely accepted fact that in people with stable angina (as opposed to acute rupture of a plaque) this procedure does not reduce the risk of a future heart attack, or fatality from a heart attack. Its only benefit is that in some cases, it can relieve symptoms of angina. Get that straight folks.

It often happens that people go for a cardiac catheterization, intended to visualize any obstructions in the coronary arteries, and if one is found, they get the PCI right then and there. These investigators found that 88% of patients who underwent catheterization, and 85% of those who actually had a PCI, believed it would reduce their risk of a heart attack -- even though they all said their cardiologists has discussed the risks and benefits of the procedure with them. Some of them might have misunderstood what the doctor said, but it turns out that 37% of the doctors also believed that -- and remember, it isn't true.

Oh yeah -- presented with two scenarios, 70% of cardiologists correctly stated that there would be no benefit of PCI, but 43% said they would do it anyway. Commenting on this mystery, the authors write:

Lin and colleagues* have attempted to explain why cardiologists continue to perform elective PCI for patients without clinically significant angina. They found that cardiologists' decisions were based on factors other than perceived benefit, such as patient expectations; medicolegal concerns; and the “oculostenotic reflex,” in which any amenable lesion receives a stent. Although cardiologists acknowledged that there was no evidence to support the practice, they believed that arteries should be opened if the procedure was technically feasible and low risk.

Shorter version: They just do it for the heck of it. And even better, they get paid!

So let's bring on the death panel, and put a stop to this. It's our money, and our hearts.

*Lin GA, Dudley RA, Redberg RF. Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. J Gen Intern Med. 2008;23:1458-63

Tuesday, November 09, 2010

Yep, this guy is actually a member of the U.S. House of Representatives

Rep. John Shimkus (R-Ill.), who will seek the Energy and Commerce Committee chairmanship maintains that we do not have to worry about climate change because God promised in the Bible not to destroy the world again after Noah’s flood. (Via Juan Cole)

I probably should be keeping up my Sunday sermons, but what the heck, Tuesday is just as good a day for one.  I don't think Shimkus is an idiot, per se; nor do I think he is insane, per se.  He is, however, religious, and I am hard pressed to tell the difference. People can hear voices in their heads commanding them to do all sorts of pointless acts, or to hold beliefs directly contrary to observable reality, and they are by definition psychotic unless they claim they are hearing the voice of the culturally endorsed God.

Now, even if Shimkus happened to be right about God and Noah, climate change is not expected to "destroy the world," it's just expected to be a really big pain in the ass, and God didn't promise to spare us that. (Nor has he.) But logic aside, you can pluck any old arbitrary bit of nonsense from the Bible to prove just about any point you want to make. Most people just concentrate on the parts they like, and pretend the rest of it isn't there. But God didn't just make a covenant with Noah. He commanded us to kill people who pick up sticks on the Sabbath, and to drive people with skin diseases into the desert to die, among other interesting ravings. And of course, according to the last book in the Bible, God did promise to destroy the world after all. So I guess you just can't depend on anything the old fart says.

Given that God is a fraud and a psychopath, I think we should just go ahead and toss him on the dust heap of history. It's time for humanity to grow up.

Monday, November 08, 2010

Kill the bastards

I've thought of saying something about the Stephen Hayes trial, but I figured I'd wait till it was over. It so happens that New England has been going through two death penalty trials, regarding fairly similar levels of depravity. The other one, which for some reason got less national attention, is wrapping up in Nashua, New Hampshire, where some zombified young men entered a rural home where they hacked a mother to death, and attempted to murder her daughter but fell short of their goal, just for the fun of it.

None of these defendants is a poster boy for abolition of the death penalty. Hayes's partner, who will go on trial in January, probably gives defense attorneys even less to work with than Hayes did. As far as I can tell, abolitionists have had little to say about these cases, probably feeling that discretion is the better part of valor.

I hereby stipulate:

  • There is absolutely no doubt of guilt in either of them. (The Nashua jury hasn't returned a verdict as I write but still . . . )
  • The depravity and moral offense of the crimes is extreme. (Yes, the scale is small; we can talk about war crimes and genocide another time.)
  • There are no substantial mitigating circumstances or factors in either case.
  • There is no issue of racism or discrimination. All the relevant parties are white and of average class background.

As many have said, if the death penalty doesn't apply here, it never applies. These are slam dunks. (Nevertheless, the Hayes jury took almost four days to decide on the sentence, and evidently some jurors started off favoring life in prison.)

So why do I wade in here, where it is perhaps best not to tread? Because here is where I feel we must take a stand. If you read the comments on news articles about both cases, you will see mobs howling for vengeance. Many commenters make a great effort, and seem to take great pride, in trying to imagine the most gruesome tortures for the guilty, striving to outdo in their own imaginations the very crimes they claim to abhor.

That is, in the end, the only justification for having the state kill these men: vengeance. It obviously will not restore anything they destroyed, will not deter anyone else -- people who do such things have no thought for the future. All it accomplishes is to bring all of us a tiny bit of the way into their moral universe. I prefer to remain outside.

Sunday, November 07, 2010

Windham County

Now that I'm really dividing my time between the city and the country, I'm getting a more intimate, personal feel for rural culture and society. As you know, politically the country folk lean much more Republican. It doesn't really make sense in terms of their interests, at least if you want my Heller School fueled policy analysis. But I do have some sense of some of the reasons.

For one thing, people experience much less in the way of obvious direct returns on their taxes. My town has no police department, and little occasion to want police services. We do pay the state for use of the state police, but they are hardly ever seen. We have no publicly funded trash pickup. We have no commercial district to speak of and so no need for enforcement of regulations on potentially obnoxious businesses, or elaborate land use planning and zoning. We pay a small fee to a district for sanitary code enforcement at our single restaurant/grocery store/bait shop, but most people are probably unaware it even happens. We have a volunteer fire company.

The town maintains a baseball field and a couple of tennis courts, but doesn't provide any recreational programming. (The non-profit historical society and other groups sponsor activities.) The town maintains and plows some roads, and of course we pay for public education, now entirely through a district. (Our elementary school recently closed.) There is no community health center anywhere near by -- you have to drive 30 miles for a doctor. There is no public transit of any kind. Without the state college and community college system, people in rural Connecticut would have no chance at higher education, but they still have to pay more than they can afford for it and probably don't think of it as a benefit of their tax payments. You get the idea.

No wonder people have the feeling their state and federal taxes are just disappearing to who knows where; and town taxes seem bizarrely arbitrary. In addition to real estate, horses are taxed, but no other species of animal. Wagons and carriages are not taxable, but tractors are, unless you're in the farming business with revenues of at least $15,000 a year, in which case there is an exemption. Mechanics' and carpenters' tools are taxed. In other words, there's a tax on self-sufficiency and small scale enterprise, which is all the people have since there aren't any jobs to speak of nearby. It's insane, and I happen to personally resent it.

Now the fact is lots of people get disability, food stamps, and other assistance, but they don't talk about it and nobody notices. Of course lots of people get Social Security and Medicare, but they don't have much formal education and they are very easy to deceive and to scare, which is what the Republicans do. And it works. But it's not just a communication issue. We really do need to do more for the country folk.

Friday, November 05, 2010

They're always ripping me off . . .

The New York Times today writes the same editorial I wrote yesterday. (Paul Krugman also gets most of his ideas from reading Stayin' Alive. Not.)

An overwhelming majority of older voters chose Republican Congressional candidates in Tuesday’s election. They were propelled in large part, we suspect, by distorted and inflammatory attack ads claiming that President Obama’s health care reforms would “gut” their Medicare coverage and implying that a Republican-controlled Congress would somehow rescue them. . . .

Those ads may have worked, but they were also misleading or dead wrong on several counts. First, there is no way to slow the rise in Medicare costs — essential to addressing the deficit — without some changes in the Medicare program. And despite all the talk of gutting, what reform calls for is a reduction in the rate of increase in payments to health care providers, to encourage more efficiency, and a scale back in the unjustified subsidies to the private Medicare advantage programs. . . .

John Boehner, the likely next House speaker, tipped his hand in late September, telling an audience at the American Enterprise Institute that he would push to “repeal the $550 billion worth of Medicare cuts; and let’s see how many votes that bill gets in the House and Senate.”

What Mr. Boehner has yet to explain is how he would pay for that $550 billion. Those savings are a major reason why health care reform is projected to reduce the deficit over the next two decades and to extend the life of Medicare’s trust fund for hospital insurance by 12 years, thus shoring up the very program that Republicans say they want to save.

Remember, you read it here first. But it is ultimately the responsibility of politicians who sincerely want to preserve and improve Medicare -- which by definition does not include Republicans -- to explain this. If Americans want a Medicare program that will be there for them and meet their needs as they grow older, we will have to restructure so it delivers more value for less money. And yes, there is plenty of room to do that. When John Boehner and the rest of the tools of plutocracy start demagoguing about "cuts" to the program, the president and the program's true champions in the Democratic party need to already be out in front, with the clear message that cutting costs means enhancing and preserving benefits. They aren't the same thing.

If you're looking for waste, fraud and abuse in government, start with the Department of Defense, and then go to Medicare. Spending less is the only way to do more for beneficiaries. But, obviously, that means that somebody won't be slurping up all that gravy any more. Those include drug companies, medical device makers, for-profit hospitals and nursing homes, and overpaid medical specialists. That's who's bankrolling Boehner and that's who's behind those dishonest attack ads. John Boehner, believe me, doesn't give a shit about Medicare beneficiaries.

Thursday, November 04, 2010

More is still less

Among the attack ads that helped trash Democratic candidates for Congress was one that claimed [your Congressman's] vote for Obamacare cut $500 million in Medicare benefits. The proposition that Republicans are going to be more protective of Medicare benefits than Democrats is obviously absurd, but it is true that the PPACA reduces growth in Medicare spending that would otherwise have occurred through a couple of mechanisms, including eliminating giveaways to insurance companies through the Medicare Advantage Program and squeezing some provider reimbursements.

Since the Republicans claim they want to fix the long-term federal deficit problem, obviously they have to be in favor of reducing Medicare spending, but don't count on them for honesty or even the most basic rationality. Scaring people works, so that's what they do.

If you've been reading this blog, you know that spending more on health care does not equate to better health. Right now, in the U.S., the opposite is true, and here's one more piece of evidence. These investigators, writing in NEJM, find huge geographic variations in the rate at which elderly people are given inappropriate prescriptions. Some drugs basically shouldn't normally be prescribed to old folks at all, others are inappropriate for people with specific conditions such as dementia. I should know, my father was prescribed quetiapine, twice, even though my mother had given the nursing homes written orders that he should not receive it. (There is a black box warning against giving it to people with dementia.)

We'll worry about exactly WTF is wrong with physicians another time, but it turns out that in Alexandria, Louisiana, 44% of elderly Medicare beneficiaries receive high risk drugs, compared to 11% in the Bronx. Nope, no idea why.

But, inappropriate prescribing is not related to total spending on drugs, but it is more likely to happen in regions with high overall medicare spending. So higher medical spending, far from leading to higher quality prescribing, is associated with worse prescribing practices. Will older voters ever understand that Medicare spending can, and must, be reduced in a way that actually improves their health care?

Until we can get this idea across, those dishonest political ads will still run, and we'll still elect lying hypocrites to congress.

Wednesday, November 03, 2010

To elaborate . . .

It's not really that most people are idiots, but most voters don't really understand much of anything about public policy. In particular, right now, they don't understand why they can't find a decent job, or maybe any job at all; why their savings evaporated if they ever had any; why their kids can't afford to go to college; why their house isn't worth anything; and why it just doesn't seem to get any better.

Now, to be sure, when voters try to explain what they think is going on or why they vote as they do it often sounds pretty goddamn stupid. "Keep your government hands off my Medicare" was a famous quotation from the summer of teabaggery. NPR interviewed an elderly woman yesterday who said, "I have to live on a budget, the government needs to do the same." Ahh, her budget almost certainly comes 100% from the federal government, which is the most important reason why government spending is increasing over time. People are furious about the Wall Street bailout, which was enthusiastically endorsed by John McCain and signed into law by George W. Bush, so they voted for Republicans.

Right now, the only thing that's going to get them a job is increased government spending, to supply the demand that's missing from the economy; and the only way their grandkids will have a shot at a better future is if we hurry up right now and spend a whole lot on renewable energy, efficient transportation, and other technologies of the future that private investment isn't creating.

But Democrats didn't tell them any of that. They were too chicken shit to make the case for saving the country from the disaster which will come upon us if the greedy psychopaths behind the modern conservative movement have their way. It's too damn bad.

The American people have spoken, and the message is clear.

We are idiots.

Tuesday, November 02, 2010

Religion and morality

I deleted it immediately, but I recently had a commenter making death threats against PZ Myers on behalf of Jesus. (I thought about leaving it up for a while on the principle of res ipsa loquitur but I decided it was just too vile.)

I find it interesting that many apologists for religion claim that faith is the only possible source of morality. I have never heard of atheists threatening or wishing for violence against believers; whereas it is quite common for believers to perpetrate violence in the name of their God, threaten violence, call for God to smite the infidels, and/or predict that God will do so. What does that tell you about religion and morality?

I have to be very careful . . .

. . . about what I say here. I am a member of an NIH Scientific Review Group (SRG) -- these are the peer review panels that score proposals for NIH-funded research -- that will meet at the end of this month. That is a matter of public record -- the rosters of all SRGs are posted openly on the NIH web site. The text of the so-called Funding Opportunity Announcement that we will be reviewing -- in this case, a so-called PO1 or research program announcement -- is also posted for all to see. It's called RFA-AT-10-002, and it is issued by the National Center for Complementary and Alternative Medicine (NCCAM). Beyond that, however, I am pledged to absolute secrecy about the content of the proposals, my own critiques, and the SRG's discussions about them.

I doubt that Orac would be happy if he knew I was doing this. He, and many other advocates for science-based medicine, do not feel that the NCCAM should exist. They argue that there is essentially no such thing as "complementary" or "alternative" medicine. If an intervention is shown to work by convincing evidence, then it's medicine, i.e. doctors will use it and insurers will pay for it. It's only "alternative" if it hasn't been shown to work, and that's a pretty silly kind of alternative.

And indeed, NCCAM has spent a lot of money over the years evaluating "alternative" medicine and it has not found a single thing that actually works. You may say that's fine, people are spending money on all that jive, so if we show that it doesn't work, maybe they'll stop. Unfortunately, that doesn't happen. The snake oil salesmen going on selling, and the people go on buying.

However, I figure these funds are going to be awarded, so somebody might as well review the proposals on their scientific merit. In other words, it's dirty work, but somebody has to do it. And there may be some merit in this particular effort, to fund "Centers of Excellence for Research on CAM for Pain." Chronic pain often has no detectable physical cause; and people report benefit from techniques such as acupuncture, meditation, chiropractic, etc. Maybe these are so-called placebo effects, but okay, something about them seems to work, so we might as well try to figure out what that is.

Is that the best use of limited NIH dollars? I may not think so but Congress has decided that it is -- NCCAM is specifically funded by its own line item. So I will read with a critical eye and judge whether the proposed research is good science, and whether it can answer important questions. I hope that all the SRG members will do the same and that the proposers assigned to me are not disadvantaged by catching a skeptical reader. Am I doing the right thing?

Monday, November 01, 2010

Take that shot with a grain of salt

No doubt you have heard or read about the new "study" that finds alcohol is more harmful than heroin or crack. Wellllll .. .

It's not really a study. Dr. Nutt -- who was fired as head of a UK government advisory commission on drug abuse for saying that cannabis is less harmful than legal drugs -- basically got a bunch of people together, and they sat around and ranked drugs on the basis of various criteria of harm. Once they added up all the votes, alcohol won.

I'm not saying this is a useless exercise, but presumably, if they had recruited a different group of experts, they might have gotten a different result. Also, you might weight the criteria differently. And, uhh, one reason why alcohol is particularly harmful is because more people use it than any of the other drugs. Finally, they divided harms into those to the user, and those to others and "society." Tobacco gets off easy on the latter, in large part because it's legal. A lot of the harm done by many of the drugs stems from their illegality, whereas alcohol's harm profile is greatly enhanced by its acceptability and ready availability. Meth is down the list, even though it is extremely destructive to users, largely because it isn't very popular in the UK. So as a guide to public policy, this is pretty confusing.

I have my own opinions, obviously. Had I been on the panel, the whole thing might have come out differently, or I might have decided that the criteria are too vague and/or inappropriate. But, the basic idea that prohibition and other policy responses to drug use and abuse doesn't make any sense is one I totally accept.

Well I'll be hornswoggled

I read this whole thing and I thought,"well, at least they're up front about it." Then somebody told me The Onion is actually satirical. Who knew?