Map of life expectancy at birth from Global Education Project.

Thursday, September 29, 2011

We're mad as hell and we aren't going to take it any more

I'm not the world's biggest fan of Matthew Yglesias, but He gets my endorsement for this. This Occupy Wall Street theatrical production that's going on right now is just absurd. Yes, it's good that we're seeing some folks out protesting who are mad about some of the right things and aren't demanding that the federal government keep its hand off of Medicare.

On the other hand, even if they're ridiculous when they aren't offensive, teabagger demands actually exist. The protesters down in New York obviously don't like to see parasites suck up billions while good honest folk can't get a job. I'm with them on that. So what do they want to do about it? Maybe if they just got some giant puppets or Wavy Gravy showed up it would all make more sense. Or maybe not.

Yes, we need a movement in this country. We need people to channel their anger into political action. We need to wrestle politics away from the billionaires behind the curtain and their Jesus talking marionettes. But that means people have to come together around an agenda for real change. The only concrete demand that's come out of this action is that a New York City police inspector be investigated for gratuitously pepper spraying some people. I'm for that, but it wasn't the original problem.

Wednesday, September 28, 2011

Yet one more disappointment

You may have seen news coverage of this study which finds that saw palmetto extract is utterly useless for benign prostate enlargement. (You only get to read the abstract, but I read the whole thing. Na na na na na.)

I can tell you that this was a very high quality trial, it's got all the right randomization, blinding and assessment procedures, and the results were as negative as you can possibly get. Actually placebo turned out to appear very slightly more effective, but that's probably just chance. If you believe this, saw palmetto absolutely does not work.

What's interesting about this is that saw palmetto for benign prostate enlargement was one of the examples of a traditional herbal remedy that was believed to work, based on previous trials. (Obviously, willow bark works for pain, it's aspirin; poppy resin contains opium, which does what opium does; etc. Many drugs are derived from plants, nothing unusual about that.) However, more recent trials and meta-analyses had called that conclusion into question. One reason they did this was to clear up the confusion, and also to try a higher dose than has been used in the past to make sure they had maximum chance of finding a benefit if the stuff really does work.

So why the fairly steady trajectory from initial positive findings to this disappointing result? Actually, that's pretty common. Early trials of a compound are typically not of the highest quality, in part because there isn't a lot of money for them. People just want to get a first look, and nobody's going to put big bucks into something highly speculative. Lower quality trials are more likely to get positive results because of inadequate blinding and other design flaws, and furthermore their sponsors are usually engaged in selling the stuff. On top of that, trials with positive results are more likely to be published.

So, even with interventions that do ultimately turn out to be effective, it's common for the effect size to diminish as they are better studied. In this case, it went away completely. The universe is against us.

Fortunately, saw palmetto appears to be harmless, so it's just that men have wasted some money. My advice in general however -- don't be eager to take pills that have only been on the market (in the case of pharmaceuticals requiring FDA approval) a short time; or in the case of unregulated supplements, that have only been studied a little bit. Chances are those early encouraging results aren't going to pan out. By the way a good reason to doubt is lack of a known biological mechanism of action. Bayes theorem tells us that with a low prior probability, the positive findings aren't nearly as convincing.

Of course, this won't stop the "supplement" industry from marketing the stuff. Their claims don't have to be true.

Tuesday, September 27, 2011

Two simple words

Yesterday I blew a wheel bearing on my way home from work and wound up sitting beside Route 6 for 2 1/2 hours waiting for the wrecker. (Only 70,000 miles on the vehicle, I am not at all gruntled.) Anyway, the guy finally did show up and he was quite friendly. On the drive to the Nissan dealership he asked me what kind of work I do and I told him I'm a medical sociologist, I mostly study communication between doctors and patients. Then, as is my wont (I'm a data addict) I gave him the prompt. "Usually when I tell people that they have stories to tell me."

Did he ever. I'm don't have a lot of time today to invest in literary quality so I won't try to reproduce his voice, but here's the gist of it. Fred (let's call him) had a hernia operation a couple of years ago. It's basically day surgery, I don't even think he stayed overnight. Walking to the car with his wife he felt an excruciating pain in his abdomen. They went home anyway but from there he called the surgeon and said he was in pain.

"Why? Did you fall on the ice?" Fred took his eyes off the road long enough to beam his rage at me. "I said to him, Why the fuck would you say that? Why the fuck would you say something like that to me?" Anyway, the surgeon told him not to worry about it.

So Fred tried not worrying. But he had no appetite. He kept feeling more and more bloated, like he had gained 20 pounds, but he wasn't eating anything. A couple of days later, he vomited. "I said to my wife, shit, that's food I ate three days ago." Then he started torrential sweating and the pain became unendurable, so his wife took him to the ER.

"There was a Polish doc there, a good guy. They did a cat scan, then he said to me, You're in critical condition. We're going to have to operate. I said when, tomorrow? He said no, now. Five minutes later they had me knocked out."

It turns out the surgeon had stitched the patch to his small intestine, which stopped the peristalsis -- the waves of contractions -- that move material through the system. I had to help Fred with the technical details, which he still didn't completely understand, but this is called paralytic ileus. Food and the tiny amounts of air and saliva we continually swallow were backing up above the obstruction, while the rest of the tract below had emptied out. This situation could have killed him a couple of different ways, including peritonitis if the stitches were leaky. His intestines could have ruptured. Part of the intestine could also have died. You get the idea -- this was not good. Oh yeah -- he got a C. difficile infection, which is a common opportunistic nosocomial infection which moved in when the antibiotics they pumped him full of wiped out his normal intestinal flora. It's extremely nasty. Fred was hospitalized for 11 days.

Sooo . . . Toward the end of the ordeal he saw the nice Polish doc out in the corridor talking with Doctor Badfingers, who then came into his room. But Dr. Badfingers wouldn't admit what he had done. He hemmed and hawed and spouted some BS. "Why couldn't he just apologize?" Fred demanded. "That's all he had to do. I make mistakes working on cars, you know? He could have said it was close quarters in there, he just got a couple of stitches in the wrong place, he's sorry. But he wouldn't say that."

So I told Fred that lots of doctors have been told not to apologize because the hospital lawyers think it will count against them in a malpractice suit. In fact, this question has been researched and doctors are less likely to be sued if they apologize. Most malpractice suits have less to do with the technical screwup -- if any, although in this instance there would seem at first glance to be a good case for negligence -- than they do with the interpersonal interaction surrounding it. And Fred had indeed gotten a lawyer and was indeed looking to sue, which he said he would not have done if the guy had just apologized.

Unfortunately for Fred, he probably isn't going to get anywhere with his suit, not because this is not malpractice, but because the award he could get probably wouldn't be worth it. He doesn't have long term damage, he's back at work, he's big and robust and jolly (when he isn't thinking about this experience) and jurors just aren't going to break down and weep for him. His lawyer needs to be looking at a big enough contingency to make the whole thing worth his while and he'll probably decide it just isn't there. But I'm speculating.

The problem with the whole malpractice tort system is not that it drives up medical costs, as Republicans would have it. They are wrong about everything, of course. Malpractice awards, insurance, and resultant "defensive medicine" probably contribute around 2% to overall medical costs, and of course some part of that, maybe most of it, is perfectly legitimate. However . . .

The likelihood that a doctor will get sued has little to do with whether the doctor did in fact act negligently or incompetently. Mistakes and bad outcomes happen which are not the result of negligence, but the people who suffer from them can't get compensated, and can't even get their subsequent medical costs or other care needs resulting from the medical error or bad outcome paid for. Yet people like Fred often can't sue, which means he doesn't get compensated for his lesser harms of missed work and pain and suffering, even though he probably is the victim of negligence. Finally, people whose bad outcomes are not the result of negligence often do sue anyway, and while they don't usually win, they generate litigation costs.

What we need is a no-fault system for compensating iatrogenic harms, and a separate system for holding physicians and hospitals accountable for avoidable errors. We need to sever the two problems.

And oh yeah, Doc -- say you're sorry.

Monday, September 26, 2011

Priorities . . .

In my last post, I made a jest about spontaneous human combustion as a major public health problem, but a commenter wants me to get real. So here's my basic concept of the public health universe.

In every society, social and economic status is strongly associated with life expectancy, health status, and the prevalence of disability, even where there is universal and equal access to health care. In addition to these disparities within societies, it is now generally held that societies with more inequality tend to have worse population health than societies of comparable aggregate wealth but less inequality. Population health is also strongly affected by environmental conditions such as water and air quality; culturally and economically influenced behaviors such as tobacco and other substance abuse, diet, and physical activity patterns; and social conditions associated with psychological stress and violence.

The World Health Organization tends to view social determinants of health and resulting disparities in terms of inequities among countries, but it is also true that even after controlling for aggregate wealth, countries with less inequality have better health indicators than countries with more inequality. The United States is actually an outlier that contributes powerfully to this association -- in spite of our great wealth, we also have exceptional inequality. In fact, using one simple measure, the ratio of income between the top 10% and the bottom 10%, the U.S. is among the most unequal countries in the world -- we have greater inequality than Nepal, Ghana, Cameroon, Benin, and most of the poor countries. (Burkina Faso, anyone?) The same is true by other measures. (The Wikipedia table lets you sort by various indicators.)

And, we also have much lower life expectancy and higher infant mortality than would be predicted by our relative wealth. In fact our life expectancy at birth in 2007 was about the lowest among the wealthy countries, although obviously we're ahead of places like Ghana on that measure.

We don't completely understand the mechanisms that link social inequality to poor health. Obviously people in the poor countries are subject to severe malnutrition, contaminated water, and untreated infectious diseases which are unlikely to plague people in the U.S. (although it does happen). But even our poor people generally have clean water and enough to eat, and can get antibiotics if critically needed. Tobacco, obesity, occupational hazards, exposure to air pollution, and other measurable risks (including fire, BTW) are associated with socioeconomic status. We can figure out why these associations exist and work to ameliorate them, but of course it would be even better if everyone was better educated and more financially secure. That would be getting at root causes. And, even after we control for everything we can think of, there is still a residual, and substantial, socioeconomic gradient in health status that we can't really explain.

Basically, it hurts to be at the bottom. More justice means better health. So ultimately, that's my priority.

Friday, September 23, 2011

An insufficiently recognized public health issue?

That would be spontaneous human combustion. It seems an Irish coroner has ruled it the official cause of death for a 76 year old man:

Michael Faherty died in his home in December 2010. His body was badly burned, but a fire in the nearby fireplace did not cause the blaze, forensic experts said. Scorch marks on the ceiling above the body and the floor below, and no trace of accelerant, led the coroner to return the controversial verdict, the first of its kind in Ireland, according to the BBC. “This fire was thoroughly investigated and I’m left with the conclusion that this fits into the category of spontaneous human combustion, for which there is no adequate explanation,” West Galway coroner Dr. Ciaran McLoughlin told a court Thursday.

Discover Magazine, which is marginally reputable, has a rundown on the subject of SHC. There is a possible explanation for some cases, which is that if an unconscious person's clothing catches fire, it could act like a wick, gradually burning the person's body fat like a candle. This process would take several hours, but it might not ignite the surroundings. The Skeptic's Dictionary is a bit less credulous, but doesn't rule it out. UK Skeptics seem to think it probably does happen.

Note, however, that the combustion is not really spontaneous. There is an ignition source, such as smoking material. And the person obviously has to be unconscious. This this is a possible explanation for some events, such as the one in Ireland; but Spontaneous Human Combustion is a misnomer.

So if this does happen, it's just an unusual way of manifesting a perfectly ordinary risk, that of falling unconscious near a source of flame. Mostly you burn the house down, sometimes you just leave a greasy soot stain. Weird, but not supernatural.

Thursday, September 22, 2011

This is probably nothing . . .

Cold fusion and all that. But ...

Puzzling results from Cern, home of the LHC, have confounded physicists - because it appears subatomic particles have exceeded the speed of light.

I post this because as far as I can tell it has yet to be reported in the U.S. If it's true, just wow.

Oppressive government regulations

As I have mentioned before, I think, I'm currently forced to commute a good distance to work so I'm OD'ing on National Pubic Radio. Yesterday I learned that our favorite country of holey cheese, global tax evasion, and giant wooden trumpets has a law prohibiting the keeping of just a single guinea pig. It seems they might get lonely, so you must have at least two. Yep, it's perfectly legal to conspire with despots to conceal the billions they have looted from their people, but you can't make a guinea pig lonely.

Believe it or not, I have a point to make here. It turns out that government regulation doesn't actually "kill jobs," at least not in this case. It has created a unique entrepreneurial niche. Consider what happens if one of your guinea pigs dies, but you don't want to make a long-term commitment to guinea pig ownership at this particular time. You have a problem if you get a second guinea pig, because you will be trapped into permanent guinea pig ownership. When the first one dies you'll be stuck with the second one so you'll need to get a third, and so on until your heirs are burdened to perpetuity.

To the rescue comes Priska Kung, who will rent you a guinea pig. When guinea pig one goes to that great Habitrail in the sky, you just send the rental back to Priska. She has no problem because she has dozens of them.

So what happens when government, for example, tells the consolidated flange factory that it can't just dump it's toxic waste into the river? The company buys water treatment equipment, that's what happens, and somebody gets a job making it. And, just as the extra guinea pig creates jobs for guinea pig feed and supply companies, the clean river provides jobs for fishing tackle and kayak manufacturers. And, we end up with fewer lonely guinea pigs and prettier and better smelling rivers. Plus less cancer and stuff like that.

Yes, it makes guinea pig ownership and flanges a bit more expensive, but they really are that expensive in the first place, it's just that now we're making the responsible parties pay for what the things really cost. That's called responsibility and fairness.

Now, maybe you don't care about lonely guinea pigs as much as you do about toxic rivers, but you know what? That's why we have democracy, so we can vote on this stuff. And if you think you're voting against "burdensome government regulations," you're really voting for dirty air and dirty rivers and fewer jobs for people who make pollution control equipment and fishing tackle, but maybe slightly cheaper flanges. So let's have an honest discussion for a change.

And that includes you, Mr. President.

Wednesday, September 21, 2011


We are in the midst of what may -- likely will -- turn out to be one of the greatest mass extinctions in earth's long history, rivaling the mass extinction that ended the cretaceous period and the reign of the dinosaurs. Most people are paying no attention, but the few who are generally tend to be unhappy about it.

At the same time, however, we are trying to eradicate some species. We've already terminated the variola virus (smallpox) and we're working on polio. Whether viruses are really species, or really alive, is questionable however. They don't have any metabolism and they don't contribute to biomass. Nothing eats them. All these particular viruses could do was make us sick and sometimes kill us, so I don't suppose anyone is sorry to see them go.

We've wiped out the dodo and the passenger pigeon and quite a few other species just by carelessness, and the U.S. government tried to exterminate the North American bison in order to starve the plains Indians (which worked), but a few survived. As far as I know, though, eradication of the Guinea worm, AKA dracunculiasis, will be the first successful, deliberate, human caused extinction of a metazoan. Former president Jimmy Carter is behind this project. The worm is now extinct in Ghana, and is hanging on only in Mali, Chad and Somalia.

The Guinea worm is, from the human viewpoint, an extraordinarily repulsive creature. Again, I can't imagine many people will be sorry to see the last of them. Still, it gives one pause. The ethics of our relationship to nature are complicated. Wolves and tigers and cougars are an economic and physical threat to us, and in the old days people were happy to try to just kill as many as possible. But we don't think that way any more. Most people think it's very important to preserve them.

But can you put your finger on precisely what is different between them and the Guinea worm?

Tuesday, September 20, 2011

I just have to say, this day is quietly amazing

Just think -- back when I was of the age to join the military, you couldn't get a security clearance if you were gay and you were likely to lose any ordinary job if you were outed. My friend Robert Belanger was the second president of the Mattachine Society, which means "mask," which was on of the earliest gay rights groups (I don't think they even had the word, they were still homosexuals) in the U.S. and which operated, our of necessity, in complete secrecy. Homosexual activity was illegal in most places and the police went out of their way to enforce the law. Obviously homosexuals were excluded from the military and it would have occurred to approximately nobody that there was something wrong with that. Just ten years ago, the horrific threat that homosexuals might get married or be allowed to serve in the military was enough to destroy Democratic chances in elections throughout the country.

Today, by law, passed by the Congress, discrimination against homosexuals in military service is illegal. If that isn't sufficiently astonishing, this has occurred with no more notice than a change in the tolls on I-93. The CNN web site right now doesn't even have a mention of it until you go 3/4 of the way down the page to a tiny text link between "Which rock killed the dinosaurs?" and "Fracking: Drilling jobs not worth it." The MSNBC front page has no mention of it whatsoever. Your local Republican member of congress is busy accusing the president of class warfare and Bill O'Reilly is threatening to stop working altogether if he doesn't get to keep at least 80% of his marginal income above $1 million, but as far as they're concerned, this just isn't happening.

It's just a normal day. Except, of course, for the people who suddenly, just like that, with no fuss at all, can lay full claim to their true identities. Wow. Just Wow.

Monday, September 19, 2011

Oh, so that's what it's all about

So the New York Times did finally cover the UN meeting on non-communicable diseases! (See my previous post.) And on page A-1 no less! Yay!

However, I had to go to the skip on page 3 to figure out that they were in fact covering the meeting. The headline reads China and India making Inroads in Biotech Drugs, and the article focuses on the patent rights of U.S. biotechnology companies. It seems the reason us 'Merkins need to know about the UN meeting is because those thieving wogs are plotting to manufacture blockbuster biotech drugs and sell them to people in poor countries who can't afford the tens of thousands of dollars those poor, victimized drug companies are charging for them.

I know, it's absolutely scandalous that somebody would try to save lives in countries where people have dark pigmentation at the expense of your stock portfolio. Don't worry, even though he's a socialist, the president has your back:

Already, the Obama administration has been trying to stop an effort by poorer nations to strike a new international bargain that would allow them to get around patent rights and import cheaper Indian and Chinese knock-off drugs for cancer and other diseases, as they did to fight AIDS. The debate turns on whether diseases like cancer can be characterized as emergencies, or “epidemics.”

Now, it might occur to you that since these folks in the southern hemisphere can't afford the patented biotech drugs anyway, it's not really going to hurt Genentech in any obvious way if they turn to some other company which does provide an affordable version -- especially since those Indian manufacturers would actually pay a licensing fee to Genentech. But hey, they might lose a couple of sales to a plutocrat somewhere, and we can't risk that, now can we?

And here I thought the UN meeting was going to be about how to give billions of people healthier, longer lives. I'm so naive. It's about how to protect corporate profits. And obviously your president knows what's really important.

Friday, September 16, 2011

If you've been reading the newspapers and watching TV, you probably don't know this . . .

but the UN is about to host a major international meeting on the prevention and control of non-communicable diseases. It evidently hasn't caught the attention of any U.S.-based journalists, but this is actually a fairly big deal around the world. The millennium development goals, which I used to write about here quite a bit, don't really include non-communicable diseases unless you want to put malnutrition and death in childbirth in that category. The focus is very much on poverty and infectious disease.

But the assumption that the most pressing health problems in the poor countries are infectious diseases and parasites is becoming obsolete. In fact most premature deaths around the world are due to heart disease, diabetes, cancer, transportation accidents and other causes that are not considered in the millennium development goals. More people have poor quality diets than literally go hungry; tobacco use is declining in the U.S. and finally becoming less chic in Europe, but the tobacco merchants have firmly set their sites on the developing world; people in the poor countries are far more affected by poor air quality and toxic exposures than are people in the wealthy countries; and hardly a day goes by that we don't read about an overcrowded ferry sinking or a train hitting a bus or a pipeline exploding or some other catastrophe in Africa or south Asia.

The UN meeting on HIV 2001 had major impact, leading to a massive international effort. That effort has fallen well short of what was needed, but it nevertheless averted a far worse disaster that one can scarcely bear to imagine. Perhaps this event will have comparable impact, but first Americans need to break out of their pathological self-obsession and take a look at the world around them. I'm hoping some of us will notice.

(BTW, of course, communicable diseases obviously haven't gone away and the prospect of multi-drug resistant staph, TB, and other pathogens is pretty damn scary. I'll stay on that case as well.)

Thursday, September 15, 2011

This is how bad it's gotten

Christopher C. Jennings, in NEJM, informs us that a "strange bedfellow" coalition has arisen among health care consumer advocates, states, health care providers and pharmaceutical manufacturers, all of whom are hoping that the Congressional "super committee" fails to reach an agreement and we get the automatic $1.2 trillion in spending cuts instead.

He doesn't specifically name any advocacy group or organization that has come to this conclusion, so we'll have to take his word for it. But the case he makes seems pretty sound. There is apparently no way that the Republicans on the committee will agree to any increased revenues. The legislation that set up the committee protects Medicaid from the automatic cuts and calls for only a fairly modest restraint on Medicare spending should the Committee fail to reach agreement. The likelihood is that an agreement would actually be far worse, in part because Democrats would have to give something away to get any of the president's middle income tax cuts and investment programs through.

I would add that the automatic cuts include a big whack to military spending, which I strongly favor and which also would not happen under an agreement, meaning even more would have to come out of good stuff. By the way, with no action by Congress, the Bush tax cuts will expire next year, also good, and no way that happens with a super committee agreement either.

The bad news is that medical research will get an 8% automatic cut, and that will really hurt. But you know what? Congress can just pass a bill that reverses it. A super committee agreement will require that the president and the Democrats in congress agree to some profound evil. If they just don't go there, they can keep their policy positions intact and keep on fighting. (Not that they are likely to do so, but they could in principle.)

So yes, I'm on board with failure of the super committee. We'll finally get to take a half decent slice out of the military boondoggle that is bankrupting our country, corrupting our culture, and terrorizing the planet. This is an opportunity we should embrace.

Wednesday, September 14, 2011

Holy War

Andrew Sullivan can be extremely annoying, mostly because he is committed to labeling himself a conservative but he has a really difficult time figuring out what it is about his beliefs that could justify that label. He's possibly a moderate Tory by British standards but hey Andrew, you're living in the U.S.A. and it doesn't really translate. He's smart enough to know that Barack Obama is also a moderate Tory and to be a big Obama supporter, but how does that make him "conservative" by U.S. standards? He's also a gay Catholic which is even more ridiculous.

Anyhow, he does a pretty good job here of expressing how the Republican party has left him. To slice out the pith of this essay,

the GOP, deep down, is behaving as a religious movement, not as a political party, and a radical religious movement at that. . . .That's how I explain the current GOP. It can only think in doctrines, because the alternative is living in a complicated, global, modern world they both do not understand and also despise. Taxes are therefore always bad. Government is never good. Foreign enemies must be pre-emptively attacked. Islam is not a religion. Climate change is an elite conspiracy to impoverish America. Terror suspects are terrorists. When Americans torture, it is not torture. When Christians murder, they are not Christians. And if you change your mind on any of these issues, you are a liberal, an apostate, and will be attacked. . . .Think of Michele Bachmann's wide-eyed, Stepford stare as she waits for a questioner to finish before providing another pre-cooked doctrinal nugget. My fear - and it has building for a decade and a half, because I've seen this movement up-close from within and also on the front lines of the marriage wars - is that once one party becomes a church with unchangeable doctrines, and once it has supplanted respect for institutions and civility with the radical pursuit of timeless doctrines and hatred of governing institutions, then our democracy is in grave danger.

Yes indeed, our democracy (if that's what it is in the first place) is in very grave danger. What is equally disturbing is how little awareness of the peril there seems to be on the part of sane politicians and opinion leaders. In particular, the corporate media is treating these refugees from the 12th Century with profound respect. Is it really in the long-term interest of Disney and Comcast and Time Warner to operate in an atavistic theocracy? Why don't they get wise to this?

Tuesday, September 13, 2011

Hey indeedy

I have often claimed here (and elsewhere) that economics is not a science, but a kind of theology. Economists do not set out to discover truths by studying reality. Rather they make a bunch of assumptions -- none of which are, you know, true -- and then spin out a fantasy world from the assumptions. The purpose is to tell us how we ought to behave, in particular why we should tolerate the injustices of the present day as the proper state of nature. The Free Market™, in particular, is entirely fictitious -- an elaborate delusion that never has existed and never could exist.

This somewhat arcane essay by David Graeber on the origin of money is entertaining, and concludes with the eloquence of Thoreau:

At this point, it’s easier to understand why economists feel so defensive about challenges to the Myth of Barter, and why they keep telling the same old story even though most of them know it isn’t true. If what they are really describing is not how we ‘naturally’ behave but rather how we are taught to behave by the market—well who, nowadays, is doing most of the actual teaching? Primarily, economists. The question of barter cuts to the heart of not only what an economy is—most economists still insist that an economy is essentially a vast barter system, with money a mere tool (a position all the more peculiar now that the majority of economic transactions in the world have come to consist of playing around with money in one form or another) [10]—but also, the very status of economics: is it a science that describes of how humans actually behave, or prescriptive, a way of informing them how they should? (Remember, sciences generate hypothesis about the world that can be tested against the evidence and changed or abandoned if they don’t prove to predict what’s empirically there.)

Or is economics instead a technique of operating within a world that economists themselves have largely created? Or is it, as it appears for so many of the Austrians, a kind of faith, a revealed Truth embodied in the words of great prophets (such as Von Mises) who must, by definition be correct, and whose theories must be defended whatever empirical reality throws at them—even to the extent of generating imaginary unknown periods of history where something like what was originally described ‘must have’ taken place?



The Agriculture Department has issued rules banning the sale of meat contaminated with six strains of E. coli which have been found to cause severe disease in humans. You probably think that's a good idea but you're wrong, according to the American Meat Institute. (Yep, there is one.) "Imposing this new regulatory program on ground beef will cost tens of millions of federal and industry dollars — costs that likely will be borne by taxpayers and consumers. It is neither likely to yield a significant public health benefit nor is it good public policy," sayeth the purveyors of dead flesh.

It seems to me they need to hire a new PR firm. They are actually insisting on the right to sell you meat contaminated with deadly bacteria. In the name of freedom, I suppose. Do you find that comforting? If not, try eating something else.

Monday, September 12, 2011

If al Qaeda didn't exist they'd have to invent it

Actually it barely does exist any more. We were treated to breathless, wall-to-wall coverage for nearly a week leading up to last Sunday about some Pakistani guys who were supposedly going to set off truck bombs in New York and DC. The people on cable with hairpieces molded from a single piece of plastic are positively disappointed, I think, about the big fat nothing. But we do get fighter jets scrambled in order to possibly shoot down not one, but two, commercial airliners because people weren't feeling well and went to the restroom more than once.

So, if the bad scary Islamic man isn't going to kill us all, what story are they going to come up with to make us spend $600 billion a year on a useless military, give up our 1st, 4th and 5th amendment rights, and vote for Republicans? I'm not thinking of any just yet. Anybody got a nomination?

Sunday, September 11, 2011

How we let the terrorists win

The Freakonomics guys are sometimes so determined to be freaky that they are just plain wrong. However, they have this one pretty much right. The Sept. 11, 2001 terrorist attack cost almost 3,000 lives and cost quite a lot of money directly, but by far the greater damage was what we did to ourselves. They point out a lot of costs you probably have thought of and some you haven't thought so much about. But they pass very quickly over the wars in Iraq and Afghanistan, and they say nothing at all about the alienation of our liberties and the perversions of our republic to which most Americans willingly, nay eagerly, acceded.

Juan Cole has a good deal more to say about these deeper costs:

Dick Cheney, Donald Rumsfeld and George W. Bush, however, saw the attacks as “an opportunity.” They were an opportunity to assert American dominance of the oil fields of the Middle East, and therefore, they reasoned, of the energy future of the entire world, ensuring the predominance of the American superpower throughout the twenty-first century. They thus followed a successful overthrow of the Taliban in Afghanistan with a disastrous military occupation of that country. They coddled the military dictatorship of Pervez Musharraf in Pakistan. They threw international law into the trash compactor and invaded and occupied Iraq, kicking off a massive insurgency and then a civil war, and leaving the country a political basket case. They left hundreds of thousands dead and some 4 million displaced. In northern Pakistan and then in Yemen and elsewhere, a covert program of drone strikes was carried out lawlessly and with no oversight; because it is done by the CIA and is classified, our elected officials cannot even confirm that it exists, much less conduct a public debate as to its legality, constitutional validity, or wisdom. . . .

At home, our politicians, bureaucrats and even many judges actively pursued a profound betrayal of the US constitution and its bill of rights, virtually overturning the fourth amendment right to be free of unreasonable search and seizure of private correspondence and effects. Nearly a million Americans were put on a travel watch list and their travel often interfered with, most of them for no reason other than that they had attended peaceful demonstrations. The US government advocated for torture, assassination, and extra-judicial kidnapping. Via Abu Ghraib it became the world’s largest purveyor of prison pornography. A vast and labyrinthine national security state was constructed that appears to be under no one’s control, and the intelligence estimates of which are too numerous and too closely guarded for them ever to be given practical effect by our legislators.

We did this to ourselves. Sept. 11 revealed, not a powerful or even very consequential movement of radical Islamists. Al Qaeda was never anything more than a small, marginal, violent cult. What Sept. 11 revealed is the tragic immaturity of our political culture.

Thursday, September 08, 2011

Wonder where the money went?

The new issue of Health Affairs is titled "The New Urgency To Lower Costs." I'm not sure it's really all that new except that it has become a major political obsession -- not to lower costs, that is, but to dump them from the federal government onto consumers.

Health Affairs, like a lot of the cool stuff I get to read, is not available to people who don't have a faculty appointment, but all you need to get the idea is the Table of Contents and the abstracts.

September 2011; Volume 30, Issue 9
The New Urgency To Lower Costs

Desperately Seeking Savings: States Shift More Medicaid Enrollees To Managed Care
John K. Iglehart

A Decade Of Health Care Cost Growth Has Wiped Out Real Income Gains For An Average US Family
David I. Auerbach and Arthur L. Kellermann

Lower-Income Families Pay A Higher Share Of Income Toward National Health Care Spending Than Higher-Income Families Do
Patricia Ketsche, E. Kathleen Adams, Sally Wallace, Viji Diane Kannan, and Harini Kannan

Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries
Miriam J. Laugesen and Sherry A. Glied

The Growth In Cost Per Case Explains Far More Of US Health Spending Increases Than Rising Disease Prevalence
Charles S. Roehrig and David M. Rousseau

Health Care Costs Are A Key Driver Of Growth In Federal And State Assistance To Working-Age People With Disabilities
Gina Livermore, David C. Stapleton, and Meghan O'Toole

Enrolling People With Prediabetes Ages 60–64 In A Proven Weight Loss Program Could Save Medicare $7 Billion Or More
Kenneth E. Thorpe and Zhou Yang

Not that real income gains for the average U.S. family were all that much over the past 10 years -- they would have been a little over 600 bucks, but it turns out that all but 95 bucks went to health care. That's including premiums, out of pocket, and taxes. Part of the reason it costs so much here is that physicians in the U.S. -- especially outside of primary care -- get paid a lot more than physicians in other countries. You may think that's as it should be, but we're just pointing it out. And we aren't spending more and more all the time because we're getting older, or sicker: it's because we're paying more all the time to deal with similar problems. And it's busting state budgets. And we could save a lot of money just by not being so fat. That's the story you can read off of the table of contents.

News to no-one, I hope. It's fine to spend more on health care if we get more for our money and we want to pay for those better outcomes, but we're only getting a little bit more for a lot more money. Instead of kicking old folks off of Medicare and giving them vouchers that won't pay the cost of what they need, and just kicking poor folks off of Medicaid and telling them to drop dead, we can get better results and spend less money at the same time.

We need universal, comprehensive, single payer national health care.

Wednesday, September 07, 2011

Not that it really matters . . .

I can't get all that hot and bothered about anything to do with the ridiculous congressional super committee that's supposed to decide how to gut the United States like a bluefish in order to eliminate taxes on plutocrats. It obviously isn't going to come to any conclusion, and if it does, congress will just pass it and then start selectively reversing pieces of it, undoubtedly turning disaster into catastrophe.

Nevertheless, it is instructive to look at this list of contributions to committee members ranked by industry. (I hope this link takes you straight there, it's one of those interactive pages.) You'll note that lawyers and law firms are at the top of the list, with about $13.8 million, followed by "retired," which I assume mostly means AARP with $9.2 billion. I expect that "lawyers and law firms" mostly actually means lobbyists for whoever, but generically they probably don't care that much about deficit reduction. Retirees presumably want to protect Medicare and Social Security, although the AARP has weirdly wavered on this question.

However, if you add up Health Professionals (probably mostly specialist medical societies) -- $7.9 million -- plus Pharmaceuticals/Health Products -- $4.3 billion -- plus Hospitals/Nursing homes -- $2.9 million -- plus Health Services/HMOs -- $2 million -- you already have $17.1 million, which would make the medical industry the biggest contributor by far. "Insurance" contributed $6.7 billion. It doesn't break out how much of that represents health insurance but I can guess it's the biggest chunk, since other insurers have less at stake with congress.

This is why you know that nothing good can possibly come of this. Collectively, medical/industrial complex contributions are at least double those of retired people, and otherwise, I don't see any patient interests represented here at all. Oh yeah, "Republican/Conservative" weighs in at $2 million, but "Democrat/Liberal" isn't on the list.

You know the Golden Rule of politics: He who has the gold, rules.

Tuesday, September 06, 2011

Once more, more is less

It shouldn't be a surprise that oral surgeons think that 80% of people who don't have their wisdom teeth prophylactically removed will eventually end up with big trouble, but it turns out not to be true. Unless you have recurrent infections or other serious problems, you're better off just leaving them there and waiting until and unless something goes wrong to have them extracted, according to the Cochrane review, the American Public Health Association, and other disinterested parties.

Once again, if we had an equivalent of the UK's National Institute for Health and Clinical Excellence, we could spend considerably less money on medical goods and services and actually be happier and healthier. Unfortunately, the resistance to this comes not only from the lunatic "Death Panel" fringe but also from medical specialty societies and drug companies (who are probably behind the death panel lunacy in the first place). Achieving real, fundamental health care reform in this country will be extremely difficult because of the enormously powerful vested interests that stand in the way. But we really must try.

So let's collectively move the Overton Window:

We need universal, comprehensive, single payer national health care. Like those commies in Canada and Britain.

It's nice to see y'all . . .

Despite losing the occasional follower of this blog to blasphemous or otherwise intolerable posts, I've had the pleasure of seeing the number of declared followers increase since Google introduced the feature. It's great to know that people are reading, even though few ever comment. But I always wonder who you folks are, how you came across this blog, what you like about it, and what interests you. Also, is there consumer demand for anything in particular? I don't mind hearing some feedback and supplying any needs I can honorably meet.

So go ahead, introduce yourselves, let me know a bit about who I'm talking to and why you're listening. And don't be shy in the future -- conversation is always more fun than delivering a monologue.

Monday, September 05, 2011

Player Piano

For those who haven't read it (could there be such people?) Player Piano is a novel by Kurt Vonnegut Jr. It portrays a dystopian future in which automation has displaced most workers, leaving the world divided between a small technocratic class and the redundant masses. I join quite a few bloggers in recommending this essay by Harold Myerson, who summarizes our predicament:

Today, the economy that arose on manufacturing’s ashes has turned to ashes itself. The Wall Street-Wal-Mart economy of the past several decades off-shored millions of factory jobs, which it offset by creating low-paying jobs in the service and retail sectors; extending credit to consumers so they could keep consuming despite their stagnating incomes; and fueling, until it collapsed, a boom in construction.

We are only now beginning to understand the toll this economy has taken on America’s workers — and on our working men in particular. A stunning study from Michael Greenstone and Adam Looney of the Hamilton Project, published in the Milken Institute Review, reveals that the median earnings of men ages 25 to 64 declined 28 percent between 1969 and 2009. Within this age group, the median earnings of men who completed high school but didn’t go on to college fell 47 percent, while the median earnings of male college graduates also declined, if only 12 percent.

Myerson also points out that the proportion of adult men who are employed at all has also fallen sharply. He doesn't note that women's labor force participation increased over this period, which is the only reason families managed to nearly hold their own -- until recently. The employment to population ratio has now fallen sharply. New jobs are never going to come from the capitalists because they are concerned only with profit, and they have been pursuing profit by replacing workers with machines and chasing the cheapest possible labor around the globe.

Many people claim that in the long run, jobs will come because somebody has to build the machines, but that is fallacious. For a machine to be cheaper than a worker the labor embodied in its construction must be far less than the labor it replaces. In order for a share of rising productivity to go to workers, there must be a shortage of workers, and that we do not have. As long as we have a vast reserve army of the unemployed, capital can claim all the gains. Does this remind you of any particular thinker of the past?

Friday, September 02, 2011

Okay, that does it. The guy is a spy

From CBS News: Listening to the protests of Republicans and business leaders, President Obama today overruled Environmental Protection Agency chief Lisa Jackson and asked her agency to withdraw its proposal for tougher ozone standards. In a statement, the president said he decided to ask Jackson to withdraw the request after considering "the importance of reducing regulatory burdens and regulatory uncertainty, particularly as our economy continues to recover."

Note that CBS News is scientifically illiterate. The accompanying illustration of the so-called "ozone hole" over the antarctic is completely irrelevant. We want ozone in the stratosphere where it attenuates UV radiation. Where we don't want it is here on the ground where people and animals have to breathe it. The reason you don't want to breathe it is because it can kill you by triggering asthma attacks and causing or exacerbating chronic obstructive pulmonary disease, and reducing lung function over time.

What is outrageous is not only that Obama has done this, but that he has gone out of his way to justify his action in terms of conservative ideology. Our economic problems have nothing whatever to do with "regulatory burdens," and as for uncertainty, just allowing the regulations to take effect would have taken care of that. The reason we need regulations in this case is because the market does not account for the cost of ozone pollution. Therefore if we impose regulations to reduce it, we get a net economic benefit, including the jobs created by developing and installing the new technologies that will achieve the regulatory standard, as well as the value of better health and avoided medical costs, among others.

And what those might be? Ozone pollution is for all practical purpose entirely, 100%, caused by burning of fossil fuels and to a lesser extent evaporation of volatile compounds derived from fossil fuels. The people who don't want these regulations are the Koch brothers and their allies. The people who do want them are children, people with lung diseases, old people, and everyone else who at one time or another was or will be in one of these categories -- and a lot more of us will have lung diseases if we don't continue to reduce ozone pollution.

There are two possibilities. Maybe the invertebrate in chief really believes he will get credit for this from the nihilistic greedheads who run the fossil fuel lobby and they'll go easy with the attack ads next year, in which case he is an idiot. Or maybe he really believes what he says, in which case he is an even bigger idiot. Or both in which case . . .

Thursday, September 01, 2011

I'm really sorry for being a downer . . .

I won't link directly to the Financial Times column because you have to register (you can if you want, just follow the link), but via Brad DeLong, Martin Wolf sees hard times getting worse:

In neither the US nor the eurozone, does the politician supposedly in charge – Barack Obama, the US president, and Angela Merkel, Germany’s chancellor – appear to be much more than a bystander…. Obama wishes to be president of a country that does not exist. In his fantasy US, politicians bury differences in bipartisan harmony. In fact, he faces an opposition that would prefer their country to fail than their president to succeed.

The CW is all about how there cannot possibly be a double-dip recession, don't worry about it. But there are plenty of real economists, not just guys who play one on TV, who feel differently. The world desperately needs a serious fiscal stimulus right now from the only country that can deliver, but we're getting the precise opposite. Here's another headline in the FT today: Global Manufacturing Grinds to a Halt. And another: Weak Data Add to Fears of Slowing Growth.

This ought to be absolutely terrifying President Bystander, not to mention the Chamber of Commerce and the rest of us. Economic contraction at this point would be catastrophic, quite possibly leading to a ruinous deflation that would stop economic activity in its tracks and simultaneously create a real, as opposed to a fake, federal debt crisis. But all we're hearing about is a fight over which night Obama is going to make a speech in which he makes some tepid proposals about tax breaks for businesses that hire veterans and similar pussy footing around, while the Republicans get ready to shut down the highway trust fund. This is nuts folks.