Map of life expectancy at birth from Global Education Project.

Monday, February 28, 2011

This time, it's personal

The Prez has proposed a slight increase in funding for the National Institutes of Health in his new budget, even as he wants to trash low income heating assistance and community service block grants. Winning the future and all that, even if we have to freeze a few folks to death in the present.

Still, from my personal point of view as a greedy sociopath -- which I believe is what it takes these days to be fashionable -- Mr. Obama has his priorities right. I depend on NIH funding but I don't get heating assistance. In fact the increase in the president's budget, after inflation, would leave NIH basically level funded and about where it was in 2000. This is despite a much larger economy than we had back then, obviously. (If you aren't feeling richer it's because the larger economy in part reflects a larger population, and the rest of the growth has gone to the super wealthy and not to you, unless the Koch's happen to be reading.)

The Republicans, however, don't even want to level-fund NIH. They want to cut it, back to the nominal dollars they got in 2008. Right now, in the face of uncertainty and with available dollars flat-funded by the continuing resolution under which the federal government is operating -- at least for this week -- NIH is not paying off any proposals that got a score from their scientific review groups above the 10th percentile. (This is scuttlebutt -- I don't know if there's an official source for it.) Due to the complexities of the NIH review process, that means that fewer than 10% of proposals are being funded. You only get to resubmit once so ultimately, fewer than 20% of all proposals to NIH will get paid off.

This has a lot of implications for the public, obviously. It means that health research will slow way down. And this is a bad time for that to happen, for several reasons. One of the most important is that we've gotten to the point where the health care system has a huge backlog of poorly absorbed biomedical knowledge. NIH has been putting major emphasis on Clinical and Translational Sciences, which means trying to get the latest knowledge and technology to actually be incorporated into clinical practice effectively. We have yet to reap the harvest from the explosion of scientific knowledge in recent decades, so that is low hanging fruit for the public good.

A related emphasis is social and behavioral science. We know that doctors don't do a lot of what they ought to be doing to practice evidence based medicine; and we know that folks don't do a lot of what they could be doing to keep themselves healthier. We can get a much bigger bang for the buck by just figuring out how to get people to stop being such screwups than by just about any other investment. Again, low hanging fruit for the public good.

And just as we're getting out in the field with the wagons, they want to puncture the tires. In the name of freedom, apparently.

Okay, here's the thing. I do translational clinical social science. That's what I do for a living. I have a proposal in right now which will be funded if Obama gets his way and will not be funded if the Republicans get theirs. I hope I can somehow keep my job and keep my program of research going either way, but in the latter case it will be a rough go. So yeah, maybe I'm not a credible advocate because of my personal stake -- but then again, neither are any of the conservative pundits, they're all rich, or the plutocrats who pay for most of the politicking and political propaganda in this country.

I like to think I do what I do because it's the right thing to do, as well as a job. But lots of people like me will be doing something else in a couple of years if the Republicans get their way. Lots of newly minted Ph.D.s will never get jobs, and post docs will never get faculty appointments. Labs and whole research institutes will collapse. We'll lose a huge investment in people and institutions, forever, and everything it might have given us one day in human knowledge and human welfare.

So do me a favor: call or write your senators and representatives, and tell them to support the National Institutes of Health.

Sunday, February 27, 2011

Morality and Reason

In "How the Mind Works" Steven Pinker writes:

Either we dispense with all morality as an unscientific superstition, or we find a way to reconcile causation (genetic or otherwise) with responsibility and free will. . . . Like many philosophers, I believe that science and ethics are two self-contained systems played out among the same entities in the world, just as poker and bridge are different games played with the same fifty-two card deck. . . . Free will is an idealization of human beings that makes the ethics game playable.

Pinker's discussion is at greater length, and he would undoubtedly claim I oversimplify, but I don't think it's entirely unfair to say that he tries to duck the challenge cognitive science poses to morality by proposing non-overlapping magisteria, as Stephen Jay Gould did to evade the conflict between science and religion. I think it's a cheap trick, and it doesn't work.

The abolition of Cartesian dualism, and the recognition that free will is an illusion (albeit a very compelling one, which I fully embrace as my own experience), requires us to reason about morality differently than we once did, and hence to adopt a somewhat different moral stance. We understand that moral intuition is a feature shaped by the evolution of intelligent social beings. Morality makes society possible, in other words. It is inherent in our nature, though not anywhere else.

We therefore honor it as human beings, but we also recognize that the very general basic intuitions with which we are endowed -- non-maleficence, benevolence, respecting the autonomous personhood of others -- are shaped by culture and circumstance into much more specific and elaborate sets of rules that can vary enormously. We also recognize that these intuitions can be manipulated by self-interest, including the self-interest of powerful people who impose rules that may be internalized by the weak; and that what seems to make sense in one time and place may not make sense in another. Finally, we recognize that elaborations of rules are in part a response to the frequent conflicts among moral principles.

These realizations compel us to think about morality pragmatically. We sanction wrongdoing, not because God commands us to do so, or because right and wrong contend metaphysically and we are soldiers in the battle, but because it is necessary to maintain the social order. It seems to me that it is much easier to hate the sin but love the sinner when we reject religion and the ghost of free will, and understand that people do not create themselves or bring themselves to where they are. This recognition would eliminate retribution from the practice of correction, and profoundly change how we deal with crime, and the rules that we write.

I think particularly of sexual morality -- all that ought to matter is that we not coerce, hurt or betray people, and that we protect the public health -- of drug policy, obviously; and of the kind of environment we create in prisons, which ought to contain far fewer people. Also, I think of how we raise our children, interact with our peers, and govern ourselves. It seems to me that integrating science and morality, rather than proposing that they are separate realms, is the straight path to a more humane and free society.

Update: Google is getting creepy. After I posted this, it showed me the following advertisements (I deleted the links, I don't work for them):


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Thursday, February 24, 2011

One more way people are strange

We often read of these cases of compulsive animal hoarding, in which people -- women about 70% of the time it appears, often but not always elderly -- are discovered to have houses completely full of sick, starving and even dead animals, walls and floors destroyed by excrement. That's strange for sure, but it isn't rare. the ASPCA says that from 900 to 2,000 cases are discovered each year, involving millions of animals. They don't tell us where they get that info but I'll call it reasonably creditable since they are probably called in to deal with a majority of the cases themselves.

What strikes me as equally strange, given how prevalent this is, that there has been very little scientific study of the behavior. I did a Medline search and I found a recent review (subscription only but you can read the abstract) that says, yep, we don't really know much about this. It appears to be associated with attachment disorder -- personality disorders and isolation from humans are commonly associated with animal hoarding. The hoarders have no insight into their situation. They believe the animals are well cared for and that they are rescuing them from a cruel fate. Sometimes they even pose as legitimate animal rescue operations. In fact, the animals are suffering terribly, but the hoarders just cannot perceive it.

The recidivism rate is apparently close to 100%. The authorities remove the animals, they may have to condemn the house, and then they figure the problem is taken care of. But the person just does it again. Hoarders may be ordered into counseling but counselors generally have no idea how to treat them and it doesn't usually do much good.

It is particularly interesting that the features of this syndrome are so consistent. It points to something essential about us, a need for connection perhaps that takes this unfortunate term when people cannot satisfy it through human relationships. It all seems quite sad. One is tempted to think it may point to a failure of society, but sometimes family members are trying very hard to connect with the person and save them, to no avail.

Wednesday, February 23, 2011

Hang up and live!

No doubt Stayin' Alive nation is concerned about the much publicized study from Brookhaven National Laboratories that finds there is indeed an effect on brain activity from exposure to cell phone radio waves and/or low frequency electromagnetic fields. (They give off both so who knows exactly what's causing what.)

I am not an expert on the relevant biology and biophysics but it's simple enough that I feel I can summarize it for you. Unlike functional magnetic resonance imaging that you have probably heard a lot about, and which is widely overinterpreted in my view, these researchers used PET scanning to measure glucose metabolism in the brain. Their methods were quite rigorous -- for one thing, the participants didn't know when the cell phones were on and when they were off -- and the correlations they found were very strong (i.e. the response they saw was highly consistent), so despite the fairly small sample (47 people) the results strike me as compelling.

However, just because something happened doesn't necessarily mean that it matters. What they saw was that the brain cells closest to the cell phone antenna got a bit more active. This degree of activation was a lot less than the differences you see naturally when the brain is engaged in particular tasks. In other words, if you are just thinking hard, or paying attention to something, there will be bigger effects on the metabolic rate of particular neurons. So there is no particular reason to think this phenomenon causes physical harm. Certainly there is no known mechanism by which it could be associated with a risk of cancer, which has been the main concern about cell phones up till now.

But, we don't know what we don't know. There could be some as yet undiscovered mechanism by which chronic stimulation of a particular brain region in this way has long-term physical effects. There could certainly be psychological effects of some kind. But that is purely speculative. You could choose to worry about anything that isn't fully understood, and I can't see any reason to worry about this in particular. We already know, for example, that exposure to ultra-fine particles from motor vehicle exhaust is very harmful, but most people pay absolutely no attention to it.

However, this does seem like a good occasion to reiterate some sensible advice. These subjects were exposed to the cell phones for a long time -- 50 minutes. A brief call probably doesn't have this effect. And there are lots of perfectly good reasons to limit cell phone use. We already know that it is very dangerous to talk on the phone while driving. That ought to be a huge worry but people do it all the time. So just stop. It can wait till you get home.

Also, people use their cell phones as a substitute for existing in the world. My brother was walking to his car a while ago and he saw this woman screaming into her phone, "Anthony, answer the %$#@ phone! Why don't you $@#@!@ answer %^&* the %^&* phone!" Then this guy ten feet away turned around and yelled at her, "What the $%^ do you want?" People are breaking up with their boyfriends over the phone on the street corner, calling their wives to say they'll be home in two minutes (apparently so the boyfriend can run out the back door), gibbering while they're paying for their groceries or eating in a restaurant. Just cut that shit out and be in the space where you are. It's very doubtful that talking on the cell phone when you actually need to, a few minutes a day (not while you're driving!) will do you any harm.

Tuesday, February 22, 2011

A thought experiment

Let us suppose there were Pakistani mercenaries, employed by that country's secret intelligence service, driving around the United States armed with semi-automatic pistols, with diplomatic immunity, hunting down extremist militants. That would mean, in the U.S., Christian dominionists, minutmen, the Michigan Militia, that sort of thing.

Or perhaps acting as agents provocateurs, or spying on the U.S. military?

Suppose this was happening with the knowledge and tacit approval of the United States government? Suppose one of them shot two U.S. citizens, and a vehicle from the Pakistani embassy, driving the wrong way down a one-way street, struck and killed a third citizen on the way to rescue him?

Obviously, we would think that was perfectly normal and acceptable. What's wrong with those wacky Pakistanis that they are upset about the identical situation? The Asiatic mind is sure obscure.

Monday, February 21, 2011

How the hell . . .

did this country go so far off the rails, so fast? Here's the state of Michigan ordering Detroit to close half its public schools, which means high school class sizes will go to 60. Unemployment is expected to stay above 9% all year and maybe be at 8.5% by election day in 2012 -- and of course it's much worse than that because a lot of people have either left the labor force or are scraping by on part-time jobs, freelancing, or whatever they can get. (If you worked 1 hour in the past week, you are counted as employed in the official statistics.) We have the greatest inequality of wealth and income since the Gilded Age, and middle class incomes have been stagnating for decades, and more and more people are living in poverty.

Roads, bridges, sewers and water systems are falling apart. Our dependence on imported petroleum is just growing deeper and deeper, while climate change threatens our food supply and the very existence of coastal communities and petroleum dependence forces our foreign and military policy into grotesque distortions.

I could go on and on but you get the idea. And what is the great political crisis the corporate media and political classes are screaming about? The need to slash public spending on social services, education, research and development (of the non-military variety only, of course), public health, food safety, environmental protection, and every other useful thing government does and can do to get us out of this mess, so that wealthy people can continue to enjoy the lowest taxes since Eisenhower was president.

Nobody even questions this, not even Barack Obama, who wants to cut low-income heating assistance in half, essentially eliminate community service block grants that support anti-poverty agencies all over the country, and who has completely given up on renewable energy development. The man simply refuses to lead. And he knows better.

Thursday, February 17, 2011

Yabbut . . .

John Quiggin discusses the divorce between Republicans and reality. His explanations are credible enough, but he ends on an optimistic note that seems questionable:

Does all this hurt or help the Republicans? In short-run electoral terms, I think it helps. A base of loyal supporters who, for one or other of the reasons mentioned above, are immune to factual evidence has to help win elections. There are, however, two big costs

* First, people have noticed that Republicans have a problem with reality. That perception, which undermines the rationale for all sorts of thinking about policy, will take a while to sink in, but it will also be hard to erase once it is generally accepted. In the long run, this has to turn off a fair number of Republican-leaning independents and any remaining Republicans with a capacity for embarrassment.

* Double-think is very difficult, and people will start to act on the basis of their beliefs. If those beliefs are ludicrously false, trouble is likely to follow.

Well yes, trouble is likely to follow, but not just trouble for Republican electoral prospects -- trouble, big trouble, for everyone. Which is in fact already happening. And it's happening much faster than "Republican-leaning independents and any remaining Republicans with a capacity for embarrassment" are actually getting visibly turned off, in large part thanks to the corporate media which continues to be Fair and Balanced.

We have urgent problems to solve now, but we're just spinning our wheels deeper and deeper into the snowbank. If indeed this means the lunatics actually don't win the Senate and hold onto the House in 2012, it will already be too damn late. But hardly anybody thinks we'll even be that lucky.

Wednesday, February 16, 2011

Top Secret!

I have a little contract with the Veterans Administration for research within the VA health care system. This required me to spend more than 2 hours yesterday filling out forms including information needed for a background investigation -- just like you do to get a security clearance. I will also have to present myself personally to be fingerprinted.

In case that's not weird enough, today at the faculty meeting we heard a long lecture from the Director of International Research Administration at our university about restrictions on export of technology, which includes information as well as physical objects. That includes weapons technology, but also "dual use" technology which means stuff like computers and software that somebody could conceivably use for military applications. In order to take a laptop computer to a colleague in, say, China, I would need a license from the Commerce Department. But you don't actually have to export the technology -- you can get into big trouble for giving it to a foreign national within the United States, like, say, a visiting professor or a student.

Fines are up to a million dollars, and they can also prosecute you criminally. There are exceptions for basic research, information in the public domain, etc. You can give furriners a scientific journal or software if it's not too expensive. If it's something they might have had trouble paying for, then maybe not. If you teach a course which is listed in a published catalog, then information which is normally taught to graduate students can be taught to foreign nationals.

But still. This physics professor from the University of Tennessee has been sentenced to 4 years in the slammer for sharing information with Chinese colleagues and students. Yeah yeah, it was info from an Air Force contract and it is specifically military technology. Kind of. It's on the borderline between applied and basic science I would say. But still.

Frankly, trying to somehow keep technology and scientific information out of the hands of furriners strikes me as a largely futile, idiotic and counterproductive policy. Not that anything I do can be used to blow stuff up, as far as I know, but you could conceivably apply my software and analytic methods to interrogations or something. I was involved in a proposal to use it in China, which fortunately wasn't funded or I'd probably be looking at hard time by now.

This country is weird.

Tuesday, February 15, 2011

Get the government on the backs of the medical device manufacturers!

Props to the Archives of Internal Medicine for making this report of general public interest open access. Diana Zuckerman and friends examined recalls of medical devices from 2005 through 2009 -- you know, faulty defibrillators, flimsy hip joints, that sort of thing.

This is a slightly complicated story. As usual, I will attempt to de-obfuscate it if I can. When Congress gave the FDA responsibility for regulating medical devices in 1976, they allowed an exemption from the pre-marketing approval process for existing devices, and ones that were basically similar to them. Instead of doing studies to show they were safe and effective, and having them inspected to make sure they were well made, the companies just had to let the FDA know about them, basically. But, this was only supposed to apply to devices that didn't pose much risk -- tongue depressors, surgical gloves, that sort of thing.

In 2002, in the name of getting government off the backs of the people, the soon-to-be Emperor of Mesopotamia signed legislation that ordered the FDA to use the "least burdensome" regulatory approach for all medical devices. The law still required that risky devices required clinical trials, but the FDA didn't have a sufficient budget to actually carry out that law, so the vast majority of new devices since then have been approved using the so-called 505(k) process, which does not require any clinical trials.

That's right, they didn't have to test them. At all. Of high risk devices that were recalled because they were faulty or dangerous, 80% had been approved using the 501(k) process. And yes indeed, many people have died as a result. Hundreds of people are known to have died due to faulty defibrillators. Others were blinded, or needed corneal transplants, due to faulty contact lens solution.

The FDA needs to have its budget increased so it can enforce laws that are there to protect us. You already know what the Republicans want to do to the FDA budget.

So tell me this. Why does anybody vote for these lunatics?

Monday, February 14, 2011

Cut my throat, please . . .

It's not exactly a brilliant original insight that the people who are all up in arms (often a bit too literally) to cut government spending think it's all going to those lazy, shiftless . . . well, you know. They're being taxed to death to hand their hard-earned dollars to losers of dark pigmentation.

By way of winding channels of the blogosphere, I find this chart, stolen by Bruce Bartlett from Cornell political scientist Suzanne Mettler. (Click through to page 2.) Abstract here.

These are various federal social welfare programs, and the percentage of people who actually receive these benefits who say that they have "not used a government social program." As Mettler points out, many of these programs actually tend to have an upwardly redistributive effect, (e.g., the home mortgage interest deduction) and/or they provide a lot of corporate welfare, such as student loan and savings account programs that banks make big bucks from. Sixty percent of people who take the mortgage interest deduction say they have not used a government social program. Okay, that one may be slightly hidden or taken for granted.

But what's really interesting is that 44% of people on social security, and similar percentages of recipients of veterans benefits, Pell grants, unemployment insurance, and Medicare, say the same thing. Hell, a quarter of people on food stamps say so.

This is what the Tea Party freshmen in Congress are banking on -- that their rabid constituents don't know that they themselves are the very people they resent. Will people figure this out before the government shut down? Stay tuned.

Sunday, February 13, 2011

Back of the envelope epistemology

It's no secret that I've been righteously perturbed by the recent ascendancy of unreason. That's likely what's inspired me to read Galileo's Dialogue, Bertrand Russell, Hawking, and other heavy duty jive lately. (Or, as Pogo responded, when asked to say something heavy, "Fourteen ton of bituminous coal.")

But after pondering the deep questions, I think the explanation for the unpopularity of the scientific worldview these days, and the political triumph of denialism and irrationality, is not that hard to see. Scientific knowledge has three main features that make it hard to sell.

1) As Al Gore says, it's inconvenient. It takes no account of what you want to hear. It doesn't matter whether it's comforting, whether it compels you to take difficult or unpleasant actions, whether it could undermine your profits or destroy all your dreams and plans. It is what it is. It can be inconvenient, and it can be cold.

2) It isn't easy, especially at the borders where new understanding is being mined from the hard rock of reality. Scientific conclusions depend on long, hard chains of inference. It depends on fitting together complicated structures of evidence of various kinds, from various sources. Nobody really understands more than a bit of it in depth, and even understanding a good portion of it with shallow breadth is a chore. It's just a whole lot easier to read it in an old book.

3) Scientific conclusions, again especially out toward the mine face, are not final. It's damn hard to give up your cherished beliefs, and they don't have to be religious. Witness the furor over the demotion of Pluto, and that wasn't even about facts or theories, just a label. The scientific world view requires an open mind and constant willingness to revise one's understanding. That's often uncomfortable, even for scientists, who can get dug in on an error as badly as anyone.

But right now, with the really big problems we have, it's absolutely imperative that more people meet the challenge of learning, critical thinking, and keeping an open mind. Everything that matters to us depends on it, however burdensome it may seem. And in the end, it doesn't have to be -- it's exciting and gratifying. We just have to sell it.

Friday, February 11, 2011

Cough, cough

At the recent Rhode Island Minority Health Advisory Council annual meeting, a hospital executive announced that his institution had a policy of not hiring smokers. He apparently thought he was going to win himself some luuuvvvv. Sadly, no. He got pelted with accusations of discrimination and contempt for workers.

It seems what his hospital is doing is all the rage, which I hadn't known at the time. As the NYT article points out, smoking is much more prevalent among less well educated and lower income people, so this policy is keeping aspiring housekeeping and transportation staff unemployed. It isn't having much effect on executives or surgeons.

Another reason it's discriminatory, which the NYT article doesn't note, is that African American and Latino neighborhoods have a much higher density of tobacco vendors and tobacco advertising. This is not necessarily a conspiracy by the tobacco companies. Well, okay, maybe it is. But it's also a function of the kinds of businesses you find in poor neighborhoods -- lots of little stores that depend on vice to get by, liquor stores and bodegas whose high profit items are booze, lottery tickets, junk food and tobacco. (Yes, yes I'm very intimately acquainted with the author of this study.) The tobacco distributors give them discounts on merchandise, free products to sell such as lighters, and store supplies such as clocks, counter mats, and display cases in exchange for putting up tobacco advertisements.

So once again, the people are getting double, triple and fourfle whammied. Every time they go to the grocery store, there are tobacco ads in the windows and on the walls, and a big pile of cigarettes is in their face behind the counter; there are more smokers among their friends and family; and they have fewer resources to help themselves quit. Now they can't get a job.

I don't want anybody to smoke. I want tobacco companies to go out of business and their executives to go to jail. They are mass murderers. But who is that gets screwed? Their victims. This is the wrong way to go about it.

Thursday, February 10, 2011

A truly sick society

I had the plumber in this morning for a minor problem. He happened to notice my musical instruments. "Oh, is that a saxophone?" Yep, it's a Beuscher Aristocrat tenor sax made in 1927. "And that's a trumpet?" Yep, and that's a cornet.

He told me he wanted to play the trumpet when he was a kid. Why didn't he? Because he would have been teased unmercifully. For playing the trumpet?

Yep, that's what Brockton High School is like. Apparently the trumpet is a faggy instrument, you have to play the guitar or something.

We have no future.

Wednesday, February 09, 2011

A follow up on TBI

I mentioned a few days ago that Rep. Giffords is fortunate to have all the indicated rehabilitation services for her traumatic brain injury paid for. Most people do not. In fact, JoNel Aleccia of MSNBC is on the case. She reports that about 2/3 of the 275,000 people hospitalized with TBI are sent home with no further medical treatment -- just like I told you, but without the quantitative estimate. And even those who do get some services don't get enough.

Of those who do receive care, it’s likely to be far less than they need — or expect. Most people with private or public health insurance assume that they’re covered for traumatic injury and the rehabilitation to recover from it — but they’re wrong, [Mark] Ashley said.

“We estimate that fewer than 4 percent of patients who need this care actually get it,” said Ashley, who is co-founder and president of the Centre for Neuro Skills, which operates centers in California and Texas. “In the last several years, more policies have been written that exclude rehabilitation altogether.”

Now this is an odd form of discrimination. Yes, it can be expensive, and long term -- but so is cancer treatment, or treatment for chronic kidney disease. We wouldn't tolerate insurance companies selling policies that don't cover cancer treatment -- or at least I don't think we would but who knows what the champions of Freedom™ who now control the house and the nightly news will do.

Living with a brain injury is awfully tough. These people deserve better.

This is the real deal, folks

As many have long suspected, a Wikileaks cable now provides strong evidence that Saudi Arabia has been grossly overstating its oil reserves, and will be unable to increase output from present levels.

The meaning of this is crystal clear: the world we have known is ending. You would think that a large faction of the corporatist regime in the U.S. would actually want to do what is necessary to defend a dynamic U.S. economy as oil prices soar and availability shrinks in the decade ahead. Instead, they are spending their tens of millions bribing politicians and deceiving the public to make sure we do nothing.

I don't get it.

Tuesday, February 08, 2011

A new mode of existence

Well, not entirely new, perhaps, but different from the old version and much more common. What I am about to say, you already know, actually, but may not really have noticed. Like other radical developments that are overtaking us, we prefer not to pay much attention.

We traditionally think of medicine as being about curing disease, but obviously, once a disease is cured, it stops using up medical resources. The most important category of cure in medicine is chemicals that kill pathogens -- antibiotics, antifungals, antiparastics. Those have been around for a while now, and most diseases in those categories are now generally curable. People today have no idea what the world was like before World War II. Death was ever at hand, for everyone.

But there are a lot of diseases that medicine can't cure, but instead converts from quickly fatal (or perhaps completely unnoticed most of the time and occasionally fatal or crippling) to chronic. Type 1 diabetes was the original example, but now we also have many other autoimmune diseases, HIV, chronic kidney disease, Type 2 diabetes, hypertension, many cases of cancer that are never cured but only controlled for a long time, and many others. Sooner or later, just about everybody has a chronic disease diagnosis, unless you die young.

This has created a very large class of people whose social status includes one or more permanent diagnostic labels, and who have a once unheard of task of taking medications continually, for the rest of their lives. At the lowest impact end of the spectrum, where I currently happen to reside, there's uncomplicated hypertension. I take cheap generic drugs, with no side effects, and it's not a big deal. But people with chronic kidney disease may be taking 20 drugs, going regularly for dialysis in the end stage, and find their lives entirely ruled by their medical regimen.

This is one reason -- a very important reason, as a matter of fact -- why health care costs keep rising. Instead of dying, we are being converted into permanent patients. Sure, that's better than the alternative, but one thing about dying that you can't deny is that it saves a lot of money. And as we learn to manage more diseases we learn how to manage, without curing them, the trend will continue. (By the way, drug companies are much more interested in developing drugs that control diseases, than in developing drugs that cure them, for obvious reasons.)

It also creates a whole new set of economic, psychological, and instrumental problems for a large portion of the population. We acquire disease labels as part of our identities. We have to think about the logistics of taking pills in connection with travel or anything we want to do that changes our daily routine. We have more medical visits, more to worry about, a major set of conversational topics with which to bore our friends and family.

This is the world we live in, where everybody is diseased. We're living longer, for sure, and our diseases don't necessarily make us feel sick, or at least not very sick. It's a continuum. But most of us are on it somewhere, and moving along it. Abnormal is the new normal.

Monday, February 07, 2011

Another open door crashed through

This is kind of in the "well,duhhh" department, but it reinforces an important enough point that I'll subject you to it. As you probably know, Canada is a totalitarian dungeon where everybody gets health care. David Alter and colleagues, in the new Health Affairs, followed a cohort for 10 years to untangle the associations among health care utilization, socio-economic status, and health. (You're just common rabble so you only get to read the abstract.) While there are some details I won't go into, the main point is that lower income, and less educated people tended to be less healthy at baseline; they had more primary care visits and more specialist visits; they got more CABGs; and they were more likely to develop heart disease and diabetes, and to die.

Specific risk factors -- you know, smoking and what not -- could explain some of the effect of income, but interestingly, not much of the effect of education.

In other words, as we already knew, universal access to health care, while it's the right thing to do on numerous grounds, doesn't do a whole lot to make up for all the bad stuff that happens to people that damages their health -- and poor people and less well educated people have a lot more of that bad stuff happen. They're also more likely to be depressed, by the way.

So if we're going to invest in universal health care, we would be very well advised to invest even more in public health, and that means a more just and humane society. The fashion nowadays in the U.S. is that we owe no obligation to each other and them that's got should just get more and to hell with the losers. Sociopathy is the new morality. We can debate that but if you're a libertarian or a teabagger, that's what you believe. At least be clear about it.

Also in the new HA, it seems that newly minted female doctors are paid a lot less than newly minted male doctors in the same specialties. No idea why. Hmm.

Saturday, February 05, 2011


The big story -- actually just about the only story -- on the local news last night in Connecticut was buildings collapsing. As far as I know, nobody has been seriously injured. They usually give you a clue when they're about to come down, such as walls cracking or loud popping noises. But two horses were killed in a barn collapse. Numerous businesses have been destroyed, schools and apartment buildings evacuated. An elementary school just over the border in Rhode Island did come down, fortunately nobody was inside. One town called out the national guard to get snow off the roof of the high school.

Naturally, people are getting anxious. All the chatter in the checkout line at the grocery store this morning was about where to buy roof rakes. Home Depot and Lowe's are sold out and can't get any. Typical houses, with their fairly steep roofs and not a whole lot of surface area, aren't likely to come down but I've seen a few old shacks along route 14 that are definitely sagging. There's probably some old person in there who can't do anything about it. Let's hope for the best.

As with flood, earthquake and volcanoes, people build with little regard for events they don't expect to happen in 100 years. That's not so wise, especially today when 100 year and even 500 year floods are starting to happen routinely. Now, just maybe, we'll have to expect that seasonal snowfalls never seen in recorded history will become commonplace. No doubt we can adjust, but this is just the beginning.

New Windham County post, for all you Bambi fans.

Thursday, February 03, 2011

Consumer Sovereignty

As I believe I may have mentioned a few days back, I had a little thing on my tongue. This morning I had it biopsied -- or really, removed. First the surgeon punched out a sample, then she took a scalpel and dug out the whole thing. Yes, it's as unpleasant as you imagine.

Sure, we let doctors do incredibly painful and repulsive things to us, on the faith that it's worthwhile. And I use the word faith advisedly. I accept that evolution and anthropogenic global warming are for real because I have studied the evidence well enough to be convinced. Even if I hadn't, there is such a powerful consensus of experts in both cases that I would be willing to take that as evidence.

However, if you ask me whether I really needed to have that thing biopsied I would have no good answer. It didn't seem like anything dangerous -- just a little smooth spot, basically. It wasn't growing, wasn't painful. The specialist even told me that it didn't look overtly suspicious, but she wanted to take it out anyway.

There's no consensus of experts who have deeply studied my case here -- just one individual who gets paid a handsome fee to do what she advised me to have her do. She doesn't have to suffer the pain. On the other hand, I have very good insurance and this only cost me a $10 co-pay.

So here's where I'm really going. Republicans say we can control health care costs, and make everybody free at the same time, by giving regular folks crappy insurance, or none at all if they can't qualify or afford it, and making us pay more out of pocket. If I'd had to pay for the procedure and the pathological examination, there's no doubt, I would have been less inclined to go through with it. But . . .

Suppose the doctor knew that the chance of the thing being, or potentially becoming malignant was non-trivial -- which I presume was indeed her sincere belief -- and suppose I happened to be on the wrong side of that bet? Would my decision have ended up saving money? Yes, I suppose it might have if I died quickly enough and never made it to Medicare. Otherwise no.

So raising co-pays and deductibles is not the way to create a more efficient health care system, and giving everybody good, comprehensive insurance is not the cause of waste. Just look around the world and you will see that is obviously true. What we are buying from physicians is expertise. Making me decide what to do based on my out of pocket cost defeats the entire purpose of the enterprise. This is just trivially obvious.

Tuesday, February 01, 2011

You probably don't want to read the whole thing . . .

But the executive summary of the new nanny state guide on what to eat is here. (If you do want to read the whole thing, go here.)

Finally, finally, at long last, they've managed to get decent protection from the offensive line and keep the "food" manufacturers way from the quarterback long enough to get off an accurate throw. They also manage to put the key messages in simple terms that people can actually understand and act on. They don't have the stupid pyramid any more -- they tell you to cover half your plate with fruits and vegetables, eat whole grains, and for proteins they include lean meat but on an exactly equal level with legumes, nuts and soy products. They tell you to consume very little salt and yep, stay away from sugar, refined flour, and solid fats. That means non-fat dairy, and vegetable oils instead of animal fats. Trans fats are out. And don't eat too much.

People can understand that, and do it, but the "grocery manufacturers" aren't going to like it. (Neither are the Iron Chefs, who can't live without bacon and duck fat.) My pumpkin has been seriously frosted of late by deeply offensive advertising harping on teabagger themes to oppose what they call "food taxes," which means proposed taxes on massive amounts of sugar dissolved in water, otherwise known as soda, with which the protagonist is filling her shopping cart as she ostensibly buys "food" for her family. It's too expensive already, you see, and now they want to tax "food" -- another 2 liters of sugar water goes in the cart -- because they're socialists who hate America.

Lady, that isn't food. If you don't want to pay the tax, don't buy it. Your family will thank you.