Map of life expectancy at birth from Global Education Project.

Tuesday, July 31, 2012

An elementary fallacy

More and more middle aged and old folks are living with multiple chronic conditions, says NBC News. In fact the headline reads, "We're getting sicker."

That would seem to be really bad news. I thought modern medical science was making the world healthier, at least in the U S of A. Yet the story tells us:

The report said that in 2010, 21.3 percent of women and 20.1 percent of men between ages 45 and 64 had at least two chronic health conditions. In 2000, the rate among men was 15.2 percent, and among women it was 16.9 percent. Increases were also seen in adults older than 65, with 49 percent of men and 42.5 percent of women reporting in 2010 that they had at least two chronic health conditions. In 2000, the rates were 39.2 percent of men and 35.8 percent of women.  . . .

The increases were due mainly to rises in three conditions: hypertension, diabetes and cancer, according to the report. These increases may be due to more new cases, or due to people living longer with the conditions because of advances in medical treatments. 

Could be, could be. Or maybe something else?

The report is based on data gathered during the National Health Interview Survey, in which participants complete a detailed questionnaire about their health status and health-related behaviors. Participants reported whether a physician has diagnosed them with any of nine chronic health conditions: hypertension, heart disease, diabetes, cancer, stroke, chronic bronchitis, emphysema, current asthma and kidney disease. 
My emphasis. Guess what else happened between 2000 and 2010? The definition of diabetes and hypertension were both changed to include more people; and more and more people were screened by mammography, PSA, colonoscopy and pap smears. Hence more and more people can report that a physician has diagnosed them with one the three chronic health conditions that drive these results. Are we actually sicker? That's a completely different question.

A journalistic pathology

What's wrong with this headline? Spinal-Cord Injury Therapy OK'd by FDA Could Lead to Cures.

A: The FDA has not approved any spinal cord injury therapy.

The FDA has given the go ahead for what is called a Phase 1 clinical trial of a procedure in which Schwann cells, a type of cell that provides support and nurturance for neurons, are injected at the site of a spinal cord injury. A Phase 1 trial is intended solely to determine that an intervention is not grossly dangerous. We are still many years away from FDA approval of any therapy based on this procedure, if it ever happens.

The body of the story is less egregious than the headline, but it still does not give an appropriate sense of how much of a long-shot this is. Miracle cures are very rare -- most medical advances offer some degree of benefit for some people, with some associated adverse effects or risks. But the corporate media compulsively overhype ideas when they are at a very early stage of development.

Remember when Judah Folkman's idea about angiogenesis inhibition was going to cure cancer? (That means using compounds to impede the recruitment of a blood supply by tumors.) It turned out to have limited benefits in some specific kinds of cancer, for some patients, with side effects. And maybe even long-term harm. Somehow or other, medical reporters need to get a grip on themselves.

Sunday, July 29, 2012

Religion is weird

The MSNBC evening political yackers depend on quite a lot of B-list advertising for their daily bread, but apparently I misperceived the financial clout of one of their steady advertisers, because Christian Mingle is advertising on the Olympics as well.

In case you don't know, this is an on-line dating service. Their motto is "Find God's match for you." They claim to have tens of millions of members, which is a bad sign actually, since one would presume successful members would drop out.

That aside, do people really believe that God has a match for them, but they have to pay this company to find out who it is? What did God do about matching people before the Internet came along? Why can't He work in more mysterious ways? I mean, all religious belief is ridiculous but this has got to be a parody, right?

Thursday, July 26, 2012

The International AIDS Conference

As I promised you, more politics than science. Still, it's always a wild ride. This morning, we were greeted by cardboard cutouts of the statue of Liberty (real name: Liberty Enlightening the World. True fact) wearing a sandwich board reading "No sex workers, no drug users, no International AIDS Conference." Here's the point.

The reason the conference is taking place in DC this year, in the U.S. for the first time in
a quarter century, is that president Obama, in 2009, lifted a ban on entry of HIV positive persons into the United States imposed by Ronald Reagan in 1987. That's right, folks, Ronald Reagan wasn't a saint or a hero -- he was a shit. That was one of many idiotic, bigoted and inhumane policies enacted by Ronald Reagan. As a result of Reagan's hatefulness and depravity, it has been impossible to hold the conference in the U.S. until now.

However, the U.S. still denies entry to people who have used illicit drugs or engaged in sex work in the past ten years. True, you can lie on your visa application, but that doesn't really work if you're coming to an international conference specifically as a delegate representing one of those groups. So a lot of people are unhappy that the conference is being held here despite the elimination of the HIV travel ban.

A consistent theme of this conference, year after year, is the urgent need to decriminalize drug use and possession, and prostitution. That does not mean decriminalizing human trafficking or exploitation - it means not making criminals out of victims or people who are just trying to survive however they can. And it leaves plenty of room for diversity of opinion about how exactly to regulate and manage the trade in various drugs of abuse. You don't have to agree to legalization of production and manufacture to agree to stop putting users and addicts in prison.

There is so much cultural, economic and social damage from these punitive policies that I can't even begin to summarize it all here. But for present purposes, when you drive people into the shadows, it becomes much more difficult to prevent and treat HIV infection. If we want to get a handle on this epidemic, we have to extirpate this moral idiocy from our society. And yes, the chief perpetrators of moral idiocy are preachers and their followers who lay claim to piety.

Wednesday, July 25, 2012

On the road . . .

As you know, so I'll outsource to one of my innumerable weird e-mailers.

New York, NY (July 24, 2012) - VICE today announces its latest news series, The VICE Guide to Female Fighters of Kurdistan, featuring VICE host Thomas "Baby Balls" Morton and the women guerilla soldiers of Northern Iraq. While the US military is still wringing its hands about letting women serve in combat, for the Kurds of Northern Iraq it's a no-brainer. In the series, VICE traveled to just shy of the Iranian border to hang out with the women's division of PJAK (that's the Free Life for Kurdistan Party) for a day of guerilla-style drilling, marching, AK47 practice, and—of course—line dancing, to see if they're as deadly as they are delightful to the eyes.

I assume this has something to do with another blog to which I contribute,  Today in Afghanistan, which was at one time an A-list blog called Today in Iraq, linked from Atrios and Riverbend and getting thousands of hits every day. However, nobody in the U.S. seems to give a shit about Afghanistan. I do not know why.

Tuesday, July 24, 2012

The plague

I'm heading to DC tomorrow for the International AIDS Conference. I'll only be in the Convention Center for two days, presenting a poster on Thursday and hanging out a bit on Friday.

It's only partly -- and really not very much -- a scientific meeting. It's really a politico-ideological circus. The halls are full of demonstrators, die-ins, street theater. People who don't like something a speaker has to say will march through the room chanting and carrying banners. Activists look forward to it as an opportunity to put on a show. For example, here's a bit of one e-mail I received:

The day is (almost) here!
Tomorrow is the We Can End AIDS mobilization.
Just an hour ago, two Robin-Hood-suited HIV PJA members pulled off a banner drop at the conference, right outside the Media Center as a lead up for tomorrow's event.

Meet us tomorrow to join the largest street mobilzation on HIV/AIDS this century! First we'll rally at AIDS 2012 global village booth 806, 11:15-11:30 am, then meet busloads of protesters at 9th and K streets.

Here's more information on what we are doing. See you soon! And click here if you want to volunteer at our beautiful Human Rights / Justice Zone in the FREE Global Village!
HR/HR Branch of the Massive We Can End AIDS mobilization unifies people with HIV, Occupy, and allies from around the world to “shine a spotlight”:
- illuminating heroes fighting bias, imprisonment and criminalization that fuel HIV/AIDS
- exposing those who actually profit financially from the epidemic itself
          - bringing tools to “end AIDS” to White House, risking arrest to demand change.


The fact is,  HIV is not just a virus. It seems like  a perfectly designed experiment to expose profound cultural problems and force people to respond to them. Intense political and social controversy has swarmed around it since the disease now called AIDS was first noticed among gay men in New York and Los Angeles in 1981. AIDS was absolutely devastating to gay communities, but it forced them to mobilize openly. It created organizations, solidarity, visibility, and yes, compassion on the part of many people even though it generated stigma, victim blaming, and paranoia on the part of others.

Ultimately, in spite of the terrible cost, there is a compelling historical argument to be made that without HIV, we would not have had the profound cultural transformation which has broken down the pervasive stigma and discrimination against homosexuals, brought real acceptance and progress toward equality, and is well on the way toward creating true legal equality. We sure aren't there yet but even 10, heck 5 years ago if you'd told me where we'd be today, I would have said you were nuts.

I'll let you know whatever interesting stuff I encounter at the conference.

Monday, July 23, 2012

I guess I need to say something about this . . .

I'm usually reluctant to write on the topic du jour, unless I can truly claim some special expertise or insight. In this case I suppose I have just a little.

The homicide rate in the U.S. has declined by a lot over the past 30 years, believe it or not. Social scientists aren't sure of the reasons. It partly has to do with demographics -- young men are the most likely to commit homicides and they constitute a smaller proportion of the population. But that's not the whole story.

Nevertheless, we're still a particularly violent country. On average, more than 44 people are murdered in the United States every day. Every day. That means 12 extra people barely makes a blip. It's within the range of normal variation.

But, as I have discussed here many times, people's perception of the seriousness of an event or the magnitude of a risk is profoundly affected by factors that aren't necessarily part of what an insurance actuary would call rational calculus. In this case, specifically, when a bunch of casualties happen all at once, as part of the same event, we take much more notice. That's why, as I have said too many times, we pay a lot more attention to commercial airline crashes than to motor vehicle crashes, even though the latter kill anywhere from 70 or 1,000 times as many to infinitely more people in any given year.

We also don't pay a lot of attention to the everyday carnage because it usually happens for familiar reasons -- robbery, rape, revenge against specific persons. These shooting sprees that target people chosen at random are much more frightening because they are unfamiliar.

They often seem inexplicable as well. I checked in with the news on Friday only because I wanted to  know if there was any indication of motive. Thank the FSM there is no evident political motive for the crime in Colorado. That would have produced a category 4 hurricane of gasbaggery.

I think it's fine that people want to have an adult conversation about regulation of weapons but it's a waste of time -- that's just going nowhere right now so we need to worry about other problems. Sorry, just giving you the facts, just the facts.

These incidents also provoke conversations about mental health services. It is true that access to services is inadequate for many people, but in a free society, it's very problematic to force people to get services they don't want. Viz. the Virginia Tech shooter, who was apparently ordered to get treatment but didn't do it. People recognized that the Tucson shooter who attacked Rep. Giffords needed help, but there wasn't much anybody could do to make him get it. The latest wacko was evidently flying under the radar, although the entire neuroscience program at UC has clammed up, so we can't be sure. That does suggest they are afraid of being accused of inaction, but apparently the police have asked them to keep mum as well.

So what we are left with, as far as I'm concerned:

The human brain is an extremely complicated apparatus, and it can malfunction in spectacular ways. We know that traumatic and abusive childhood environments are one cause, but sometimes it happens for entirely unknown reasons. That's just the way it is, pending major advances in, ironically, neuroscience. Fortunately, events such as this are rare, but: in a society in which deadly technology is readily available to everyone, individuals who run amok can do more damage than they could in the days of the muzzle loader.

Our worries are often disproportionate to our real problems and risks.

Friday, July 20, 2012

Feeling misunderstood

Inexplicably, I am continually bombarded with e-mails from people (or some human-like entity) hawking fraudulent nostrums. The Dead Sea salt people have come around again, undeterred by the review I gave them last time. Now it seems their product is an essential component of "nasal hygeine." I'm proud to say I could not have made that up.

Next, it seems a professor at the University of Tennessee, Knoxville has come up with a pill that is the equivalent of running three miles. If the provost is reading this, you might look into revoking tenure.

Finally, a renowned hand surgeon has invented "Touchless Flatware," which saves me from the germs that lurk everywhere by not touching the table. This comes to me via "today's lifestyle and pop culture branding expert." Not surprisingly, right after that I heard from Madame Assetou Sako in Nigeria, who wants me to handle her $4 million inheritance on behalf of the poor and orphaned. I wonder if they're working together?

I wouldn't mind receiving this crap, except that it forces me to wallow in despair for my fellow humans. 


Thursday, July 19, 2012

This and that

1) Not that Prostate Specific Antigen screening needed another nail in its coffin, but this should make us think twice about a lot of issues in medical practice. It's gotten a bit of media attention, so you may already know that a large group of investigators has found no survival benefit for prostatectomy in men diagnosed with localized cancer through PSA screening. The story is a bit more complicated than that, and as always, don't rely on me or anyone else other than a physician who knows your personal situation for medical advice. The study certainly doesn't rule out that there may be a benefit of treatment for men with particularly high PSA levels, and this is only about localized, early stage cancer to begin with. But it does give pretty compelling evidence that until and unless we can do a much better job of figuring out which prostate cancers are going to cause problems and which ones aren't, surgery or other treatment for this category of cancer does more harm than good.

Of course, a lot of men have been through it, and many have paid the price in urinary incontinence and sexual dysfunction, as well as pain and suffering. They aren't going to want to believe it was all a waste. And the doctors who made a lot of money treating them aren't going to want to believe it either. But there have been too many of these stories.

2) On a completely different subject (or maybe not) I happened to see a new sight today -- an ambulance labeled "bariatric unit." It was double wide. Apparently this ambulance company gets enough calls for people who need special lifting equipment and extra room that they went out and made a capital investment. Not only that, but there's a factory that builds these ambulances. If we could put the money we save on not doing prostatectomies into preventing there from being so many 400 pound people, that would be a double win.

3) There is a movement going on to un-name stuff after Joe Paterno, with my employer in the vanguard. Paterno was a Brown alumnus, so when he became a famous demi-God the university naturally wanted to claim him. The football coach was officially titled the Joe Paterno Perfesser of Guys Smashing Into Each Other -- okay, not exactly, but something like that -- and the freshman athlete of the year was given the Joe Paterno award. No more. In fact all previous winners of the award have now been notified that they are now just the freshman athlete of the year, not the JPFAotY. You might think the lesson has something to do with a tragic flaw and a life of great works being undone by a single moral error. No, it doesn't. The whole Paterno mythos was always bogus. Winning big time "college" football games is not compatible with moral purity, ever.

Tuesday, July 17, 2012


A friend of mine is very upset about the U.S. Anti-Doping Agency's pursuit of Lance Armstrong, which he decries as a "witch hunt." I'm not sure about that -- not that I have any inside dope (ha!), but it seems they have substantial evidence that Armstrong used erythropoietin, a hormone that stimulates production of red blood cells and gives a boost to endurance athletes.

Howsomever . . .

This is a complicated issue. In the first place, most people, me included, are cynical enough to feel it's likely that the guys who finished in second, third, fourth and fifteenth place were probably using banned performance enhancing drugs too. Everybody knows that you can't win the Tour de France otherwise. But as Greg Downey writes in one of the PLoS blogs, the bans on certain performance enhancing drugs that are now pervasive in sports are largely arbitrary. Indeed, until the mid-20th Century, athletes and trainers openly sought chemical boosts to performance and people thought that was just fine -- admirable in fact. Of course the idea is to look for every edge you can.

The East Germans racked up astonishing Olympic achievements in the 1960s. After the collapse of East Germany, it was discovered that they had been systematically plying their athletes with androgens, and yes, shoving large quantities of male hormones into people, starting in childhood, causes major problems later on, especially for women. The most concrete and compelling argument, for most people, against allowing performance enhancing drugs is that they can be harmful to health and we don't want to encourage kids to take them.

But . . .

Many of the legal things athletes do, including just playing the sport, have long-term detrimental consequences. These include osteoarthritis, which is pretty much guaranteed for anyone who engages in high level athletic training for a long period. Athletes often spend their later years with crippling joint pain. And as you know we're learning more and more about the consequences of repeated blows to the head, even the fairly minor shocks that come from heading a soccer ball or crashing into the outfield wall. Athletes risk serious injury every time they take the field. Sometimes they die.

And, while it's clear that the kinds of massive hormone stuffing practiced by the East Germans caused devastating harm, it's not at all clear what lasting harm, if any, is caused by less aggressive practices, or hormone ingestion that starts later in life. As Downey points out, we now have lots of middle aged men taking androgens to combat ordinary aging. (Probably this is largely a scam, in my view, but that's beside the point.) And Armstrong isn't even accused of that. Erythropoietin, used to excess, does create risks for patients  undergoing dialysis or cancer chemotherapy, or with other conditions that deplete red blood cells. Too many RBCs create a risk of heart attacks and stroke. But whether Armstrong's (purported) use was dangerous, especially given his exceptional physical condition and that it was presumably episodic, is not known.

As for fairness, athletes legally use all sorts of very expensive training and coaching aids that only a lucky few have access to. They do all sorts of things to their bodies with unknown consequences, or known negative consequences. And whatever the authorities do to ban specific chemicals, people will  always be looking for, and finding, alternative chemicals that aren't banned yet, or ways of evading the tests.

So maybe this is, if not exactly a which hunt, a case of selective prosecution. Perhaps it calls for deeper thinking about the role of sports in the culture, rather than an unreflective punitive response. 

Monday, July 16, 2012

Feeling slightly more optimistic . . .

about November, in spite of the 70 quadrillion dollars Sheldon Adelson and the Koch Brothers are going to spend to drown the nation in lies. Here Pema Levy of TPM rounds up conservative politicians and yackers who are calling on WM Romney to release his tax returns. On the one hand, maybe they are actually naive enough to believe that there's nothing in there he really wants to hide, he's just standing on some weird principle. (Even though he hasn't actually bothered to say what that is.) But it seems to me more likely the rats are preparing to jump ship.

And, as I just said, I really don't care whether he was actively involved in Bain Capital from 1999 to 2002, but he appears really, really desperate to make sure nobody thinks he was. So there's the obvious question: If you were in fact involved in Bain Capital during those years, would that have been shameful? If so, how? Oddly, even though he spoke, on film, to reporters from five different TV networks on Friday, nobody thought to ask him that.

So, while I wish we were talking about stuff that really matters, Krugman the Magnificent points out today (can't link because I've blown my freebies for the month, even though I buy the dead trees NYT every day) that in a sense, we are. Most voters, and certainly not the persuadable ones, aren't going to study Romney's actual policy proposals or believe that the only way he could possibly pay for his massive tax cuts for the obscenely rich is to totally screw everybody else. They're just going to get the he said/she said on this from the intellectually lazy and corrupt corporate media. But, making it clear that Romney is a fat cat who made his money by screwing you tells the tale in a way that people can grasp.

I do have to give up and admit that politics is ultimately spectacle, and running for president is largely about putting on the best show. I wish it were otherwise, but I just live in this world.

Friday, July 13, 2012

Politics is horseshit

The reason not to vote for Mitt Romney is because he actually was involved in Bain Capital from 1999 to 2000? Really?

Yes, Mitt Romney lies, all the time. In fact I'm not sure he's capable of making a verifiable truth claim that isn't false. But what matters are his lies about matters of public policy and statesmanship. For example:

  • Obama has not raised taxes. In fact he has lowered them.
  • The American Recovery and Reinvestment Act ("the stimulus package") did indeed save millions of jobs.
  • Obama did not go on a world tour apologizing for America.
  • The Affordable Care Act is not a government takeover of health care, and it is indeed substantively the same as the Massachusetts health care reform Romney used to take credit for.
  • The Affordable Care Act is not a "job killer." (A CBO study estimated it might induce some people to retire earlier than they might have otherwise. That's the factoid he is distorting.)
  • Romney does not have a plan to reduce the federal deficit. On the contrary, the policies he espouses would increase it. 
  • He wants to raise taxes on low and middle income people, not cut them.

I could go on and on.  The point is, exactly when the guy stopped being actively involved in the affairs of Bain Capital is of no particular interest to me. I already know that the purpose of Bain Capital was to make profit, not to "create jobs," and that whatever Romney did or did not do there is pretty much irrelevant to the job of president anyway. Can we talk about stuff that matters?

Thursday, July 12, 2012

Okay Mr. Freeh . . .

Sorry I doubted you. I said a few days ago that I did not expect the independent investigation of the Penn State horror to be truly independent since Louis Freeh knew darn well who was paying him a million dollars. But from what I and everyone else can tell, he pulled no punches.

Alright then. What can I possibly add to the Niagara of commentary? Only this. Sometimes people -- mostly men, so far anyway -- get into positions in which their status become a far more concrete social reality than their person. Joe Paterno was an example. It was far more important for everyone associated with Penn State to protect the myth of Joe Paterno than it was for Joe Paterno to be worthy of it. And his myth was embedded in the mythology of the football program. He understood that just as well as the president and athletic director.

If his assistant coach and defensive coordinator -- the guy with the office next door -- was serially raping boys, then there was no such thing as "Joe Paterno" and "Penn State football," there was just a guy and a football team. That couldn't happen. The universe would end.

Well, now it's much worse than that.

Wednesday, July 11, 2012

Freedom -- methinks that word does not mean what you think it means

Some deep thinkers including Ezekiel Emanuel (who has been guilty of some shallow thinking lately, but that's beside the point) argue in JAMA a point I have often made here. (I think you common rabble are likely to get bounced to the first 150 words.)

To put it succinctly, the outraged claims by self-styled conservatives that requiring people to buy health insurance is an infringement of individual liberty are nonsensical. They are, as Click and Clack put it, unencumbered by the thought process.

If you are strongly committed to individual liberty and personal responsibility, then you ought to be a passionate supporter of the individual mandate. And here's the thought process, which is not very complicated.

Basic human ethics incorporates what is called the Rule of Rescue. This is universal -- it applies in every culture. We have an obligation to provide urgent assistance to people in dire straits. If you walk by a pond and see a child drowning, you must rescue the child. Physicians have an additional layer of professional responsibility.  When people show up in the Emergency Department with massive trauma, or anaphylactic shock, or status asthmaticus, or in labor, the personnel are required to treat them. It isn't even possible to determine if the person has insurance before acting. No matter how young and healthy you are, it is entirely possible that at some time you will require urgent care, and that the cost of that care will exceed your assets. You will therefore have imposed a burden on others -- forced them to pay, involuntarily, to meet your needs. There is nothing libertarian about that.

Zeke and friends stop there. They don't argue that people are morally obliged to buy insurance beyond a policy that will pay for situations that invoke the Rule of Rescue. That would require a step or two further in the thought process. I will just point you down that road -- you can think for yourself.

There are many costs to others when people do not receive basic health care. These include the possibility of transmitting infectious diseases; inability to care for dependents, thereby making them a burden on the state; inability to perform productive labor thereby harming the economy and shifting tax burdens to others; causing emotional distress to others who observe sick and suffering people around them. Perhaps you can think of others.

Everyone benefits when everyone has access to basic health care, and to critical care and curative care. If you can afford health insurance, but you prefer to take a chance that you won't need it, you are taking a chance that you will place burdens on others and harm all of society. That diminishes my liberty. QED.

Monday, July 09, 2012

I'll largely out-source today's post . . .

.  . . To Jackie Calmes of the NYT, who notes (as I have here previously) that the Republicans are simultaneously running against Barack Obama for "cutting Medicare," and for not cutting Medicare enough. They can get away with this, obviously, because with the apparent exception of Ms. Calmes, "reporters" nowadays can't be bother to understand the issues they report on; to point out contradictions, lies or nonsense; or even to comprehend fundamental distinctions. The politician or flack says something, and they write it down or repeat it for us. That's the basic job of a journalist in the 21st Century.

The fundamental distinction here, that the Republicans are pretending away, to which the stenographers of the press corps are oblivious, is between:

a) Spending money on Medicare (or any other health care insurance); and

b) Providing health care benefits to people.

Democrats want to do more of (b), while limiting (a). This may appear to be a contradiction of some sort, but it is not. On the contrary, you can't do (b) without doing (a) because the supply of resources in the universe is finite; and anyway a lot of money is wasted or spent on actually harmful interventions. If you want to get better health care to more people, you need to make it more efficient.

Republicans, on the contrary, want to do more of (a), and less of (b). Well, okay, their proposal would constrain Medicare spending overall, but would not constrain health care costs, so the profit to providers would be protected; and they would keep getting more and  more money from people who can find some way to scrape up the dough to pay them. People who can't scrape up the dough will be shit out of luck. That's because the Republicans'  constituents are the people who get paid the money, not the people who receive the health care. There's no contradiction there either, but there is a contradiction between the two positions.

And it is precisely that contradiction that the public does not understand, and nobody seems to be explaining to them.

Friday, July 06, 2012

Methodology 101, next installment: Case Control Studies

This new study is a twofer, because it illustrates the study design I wanted to write about next, and the finding is also right up our alley. Some folks in jolly old England were interested in whether pharmaceutical companies might be exercising subtle influence over medical journals by ordering thousands of reprints of studies they sponsor.

I realize this is a bit arcane to begin with. Traditional journals depend on two or three sources of revenue: subscriptions, reprints, and advertising. Subscriptions to medical journals nowadays can cost hundreds of dollars a year, which basically means that only libraries subscribe, with the exception of members of medical societies that publish journals. Only very widely read and influential journals attract significant advertising, and most of that, obviously, is from drug manufacturers. That sounds possibly bad, but in most cases it isn't obviously corrupting because it would look really bad for the companies to pull their ads if they didn't like the journal's content. (There have, however, been a couple of scandals.)

Reprints are another matter. Because these journals are very expensive, and it would be a violation of copyright to photocopy and distribute articles, if you want to get a paper into the hands of lots of people, you need to pay for reprints. Drug companies, obviously, have an interest in disseminating articles that support the use of their products, so they may purchase as many as 125,000 reprints. They aren't likely to purchase reprints of studies that aren't so favorable, obviously.

So, what is a case control study? Basically, the researchers identified papers in high impact journals for which there had been large numbers of reprint orders -- the top 20 or top 10 in a given year. In this study design, these are called the cases. Usually, "cases" are people who have a particular diagnosis. These cases are then matched with people who don't have the diagnosis, or in this instance articles for which there were not high reprint orders. You try to find controls that are as similar as possible in other characteristics that might affect the outcome. If we're talking people, you look for controls of about the same age, same body mass index if that is relevant, whatever it may be. In this instance they found the study of the same type (e.g., randomized controlled trial, editorial, etc.) that immediately preceded the case article in the same journal.

The next step is to see if there is a difference between the cases and controls in some hypothesized causal factor. This time, it's industry funding of the study. Sure enough, high reprint articles were much more likely to have been funded by the pharmaceutical industry.

A couple of points. The statistical method used in case control studies is called logistic regression, and the output is an odds ratio, not a rate ratio. Technically, you cannot calculate the rate ratio from the odds ratio unless you know the underlying rate in the total population. Let's say 2/3 of cases have the hypothesized association and 1/3 of controls have it. The rate ratio in this case is obviously 2 - twice as many cases have the thing as controls. But the odds for the cases are actually 2:1, or 2; and for controls, 1:2, or 1/2. That means the odds ratio is not 2, but 4. (Sorry to have confused you, it isn't really important.)

Second, this doesn't prove causation. There could be something else that goes along with industry funding that actually explains the result. However, editors of traditional journals obviously have a strong financial incentive to publish studies with industry sponsorship.

Open access publishing eliminates this potential source of bias. One more reason why we're all for it.

Thursday, July 05, 2012

For those who are interested . . .

 This editorial in JAMA helps clarify the concept of the Patient Centered Medical Home and its relationship to Accountable Care Organizations. I don't have much to add to it except to tease out one important problem.

It has been shown that the PCMH model can indeed reduce overall health care costs by avoiding unnecessary hospitalizations and ER visits. The problem is, the PCMH -- which is essentially a primary care practice -- doesn't capture any of those savings. But, it costs slightly more per patient to be a PCMH.

Remember that the PCMH is a model of health services delivery based in primary care practice; whereas the ACO is a model for paying for medical care. The financial relationship between the PCMH, and hospital and specialty services is generally unspecified. The ideal is that they be included within the same ACO and that the ACO allocate sufficient funds to the PCMH to support it in successfully reducing hospitalizations, ER visits and other specialty services resulting from avoidable complications. Based on the evidence we have now, that will simultaneously result in lower overall costs, healthier patients, and happier doctors.

What's not to like? The problem is that these are all wonky arguments that most people don't understand. It's very easy for politicians to distort the issues and scream about bureaucrats and government takeovers and similar scare words. After 20 years of screaming and yelling about these issues, I despair of ever cutting through the fog and getting average folks to understand.


Wednesday, July 04, 2012

Deep and not so deep doo doo

As I noted a couple of days ago, the Penn State executives who decided not to report Jerry Sandusky to the authorities are in it deep enough they're breathing with a snorkel. They're unemployed and unemployable, two of them are facing criminal charges, and former PSU president Graham Spanier may also be prosecuted. All three of them are looking forward to being sued for their back teeth. (No surprise they aren't cooperating with the Louis Freeh investigation. Spanier is even suing to try to obstruct it. Don't expect a whitewash from Freeh, but do expect something close to it -- a pale beige at best. PSU is paying for his investigation and they aren't paying him to write a roadmap for litigants. But I digress.)

Contrast this with even wealthier and yet more evil executives at GlaxoSmithKline. They didn't just look the other way while somebody raped a couple of dozen boys. They conspired actively, elaborately, over years, to illegally foist drugs on tens of thousands of children that caused them untold harm; and they ripped off millions of adults as well by selling a drug -- which has serious side effects -- for purposes for which it is useless.

Well, the company is paying a $3 billion fine, which yeah, most people would consider a lot of money. But I expect it's less than the profit they made from the scheme -- it's just a cost of doing business. But guess what? The people who did this committed crimes more egregious than the crimes of Jerry Sandusky, by orders of magnitude, if you go by the number of people they harmed. Some likely died. Yet nobody will be prosecuted. They haven't lost their jobs either. I expect they all got bonuses.

Would love to hear the explanation. Oh I think I already know it.

Tuesday, July 03, 2012

Maybe a tipping point?

With respect to climate change, "tipping points" are when positive feedback mechanisms start to run out of control and amplify effects, regardless of whether human emissions of greenhouse gases continue to increase. For example, as the arctic permafrost thaws it release C02 and methane; as the sea ice melts the open water absorbs heat from the sun instead of reflecting it back as ice does; as glaciers start to thaw the meltwater runs down underneath and lubricates their slide to the sea.

All of that is happening. But there does seem to be a bit of good news: The corporate media is finally starting to catch on that this is not a legitimate controversy. Until approximately now, every story that mentioned anthropogenic climate change (and they were few and far between) had to feature a he said/she said exchange between legitimate climate scientists and corporate-funded frauds; and an explicit denial that any particular weather event could be linked to climate change.

Those impregnable requirements finally seem to be disintegrating like the West Antarctic ice sheet. Even the New York times is, at long last, giving up its policy of being Fair and Balanced about this phony controversy.

Is it too much to hope that the Koch brothers billions can no longer bury the truth? Just as the effort by the North Carolina legislature to declare the sea not rising was immediately rebuked by reality, their lies are going up in flames with the Colorado forest. The legislature can't repeal the law of gravity and the Koch brothers can't buy an alternate reality. How long it might be before this matters for public policy I cannot say. But it's a start.

Monday, July 02, 2012

Sorting through the rubble . . .

. . . left by Jerry Sandusky. CNN has the latest info about deliberations among Penn State execs considering whether to report Sandusky to the authorities. This does not look good for them or for Penn State University, but I'll get to that.

There probably isn't a whole lot left to say about this case -- although I promise you a lot more will be said as more information comes out and we go down the road of years of criminal and civil litigation. But I haven't seen anyone comment on the sheer immensity of the destruction that one man could wreak. This is important, in fact, to our interpretation of history.

Obviously we have to begin with his most direct victims, the boys who he exploited for his gratification. We will never know how many there were, but the police have intimated that they are aware of somewhere north of 20. I'm sure it's many more than that.

But consider: he established a charitable organization, and helped it raise millions of dollars, for the purpose of providing himself with a continual supply of vulnerable children, fully documented with all of the information he needed to make his selections and work his methods. He even kept annotated lists of boys, provided by the organization, in his desk at home, evidently to guide his choices. Sandusky used and betrayed all of the donors and volunteers associated with the Second Mile as callously as he used the boys. The staff of the Second Mile now find themselves out of work and I can't imagine their job searches are going well. How are you going to apply for a job as an executive or director of development for a charitable organization when the last thing on your resume is the Second Mile? Good luck with that. And no, as far as any publicly available information is concerned, they had no idea.

Now consider Penn State football. Not that I particularly care about it, but thousands of young men went through the program and it meant a lot to them. They were proud of it. Linebacker Lavar Arrington has already come forward to express how betrayed he feels, and I'm sure he's just speaking for the entirety. Presumably Sandusky wasn't figuring on getting caught but he had to know it was possible.

So now we come to University. Many people have gotten up on their high horse and proclaimed that PSU needs to cough up the tens or hundreds of millions it's going to take to settle with the victims without any quibbling in order to restore the honor of the university. But PSU did not perpetrate these crimes, nor did PSU cover them up. Specific people did that -- namely Graham Spanier, Tim Curley, and Gary Schultz, and apparently Joe Paterno, based on CNN's second-hand reporting about e-mails they haven't actually seen. Okay, Paterno is dead and the other three are out of work, with at least two of them and probably all three facing prosecution. There are important lessons about the judgments they made and what it all means, which I will not belabor.

However, Penn State is not the football team, and it is not these four men. It is a major university with a mission of research and teaching. Those hundreds of millions of dollars aren't going to come out of the football program, they're going to come out of student aid, instruction, and scholarship. Where else?

I can believe that free will is an illusion and still call this man indescribably, immeasurably evil. Unfortunately that does not make him unique. But he happened to be a football coach at Penn State, instead of Ohio State; or perhaps a professor at Harvard, or an executive of the Boys and Girls Club of America, or a United States senator or the Prime Minister of England. You name it. The actions of individuals can have enormous repercussions beyond their immediate reach. Obviously that goes for the single moral choice made by Graham Spanier as well as the decades-long campaign of horror waged by Jerry Sandusky. Our lives, and everything we value, are always balancing on a knife edge. Try to do the right thing.