Map of life expectancy at birth from Global Education Project.

Thursday, August 30, 2012

It can't happen here

Who wrote this?

[I]n the big lie there is always a certain force of credibility; because the broad masses of a nation are always more easily corrupted in the deeper strata of their emotional nature than consciously or voluntarily; and thus in the primitive simplicity of their minds they more readily fall victims to the big lie than the small lie, since they themselves often tell small lies in little matters but would be ashamed to resort to large-scale falsehoods. It would never come into their heads to fabricate colossal untruths, and they would not believe that others could have the impudence to distort the truth so infamously. Even though the facts which prove this to be so may be brought clearly to their minds, they will still doubt and waver and will continue to think that there may be some other explanation. For the grossly impudent lie always leaves traces behind it, even after it has been nailed down, a fact which is known to all expert liars in this world and to all who conspire together in the art of lying.

I proffer this for your attention because of this.

Wednesday, August 29, 2012

Religion is weird department

This is grotesque and repulsive. A priest in Italy was carrying a vial containing  blood drawn from Karol Wojtyla, better known as John Paul II, who became pope after his predecessor was murdered (or so it appears, although the church pretends otherwise), with the mission of putting the blood on public display. A couple of guys stole the blood, but it was recovered.

Presumably, people were supposed to look at the blood and be miraculously healed or have ecstatic experiences or otherwise experience its magical properties. While this is idiotic, it is no less idiotic than believing that crackers turn into the flesh of a guy who has been dead for 2,000 years if you eat them under the right circumstances. So I suppose it is to be expected of the faithful. But come on now, isn't it time we all grew up?

Tuesday, August 28, 2012

Thinking big

Our friend Ana from the land of holey cheese and tax evasion reminds me that I have been getting maybe a bit healthcare-ocentric here and may have wandered a bit from the public health beat. Fair enough. Perhaps one reason is simply frustration with the immense depth of our problems, and their apparent intractability in the current political climate.

I like to say that public health means any thinking or doing about health at the level of populations, rather than individuals. But as Rayner and Lang point out in this big picture essay (not sure it's open access, I have a magic cookie on my 'puter that gets me into most medical journals), even public health has tended to collapse into a cramped focus on individuals in the 20th Century.

In its early days, the field was largely about the physical environment, notably urban sanitation. Public health brought us sanitary sewers, clean drinking water, trash pickup, milk pasteurization, and later more extensive food quality standards, controls on air pollution, regulation of pesticides, workplace safety, all that good stuff. It had a huge impact on health and longevity, and by the way healthier people also became richer people.

Nowadays these problems are most acute in poor countries, and there is a powerful movement here in the U.S. to undo some of these regulations and neglect the public health infrastructure. You don't know what you've got till it's gone. Much emphasis here is on biomedical and social-behavioral models of public health, i.e. improving preventive medicine and trying to influence people's health related behaviors. Viz. Michelle Obama trying to get us to eat a healthier diet and exercise more. Obesity is indeed our most rapidly growing and urgent public health problem but . . .

It is not the case that obesity is explained by a sudden epidemic of individual irresponsibility, nor that the solution lies in convincing people to eat less. Obesity is, as today's featured essayists argue, an ecological problem, specifically a product of the social environment. Immensely powerful and completely amoral corporations spend more money on marketing junk food than the entire budget of  the World Health Organization, CDC, and state health departments put together. People do sedentary work, they live in neighborhoods where you can't walk to the store or work or anywhere else even if  it safe to do so, and they depend on processed and prepared foods because they don't have the time or personal social infrastructure to operate a quality kitchen.

All of our most critical problems are of this nature -- climate change, resource depletion, inequality, all contribute to poor health. And the solution to all of them requires truly radical changes in society, not campaigns about individual choices. By all means by more energy efficient light bulbs and fuel efficient cars, but that's not going to get it done. The fundamental organization of society, in which for-profit corporations acting in the interests of their wealthy executives, dominate politics, public discourse, and the economy, is fatally diseased.

What we don't have right now is a well-defined alternative vision. What would a post-corporatist, humane world look like?

Monday, August 27, 2012

In the interest of full disclosure . . .

I personally have a great deal at stake in the November election. But I hope you'll agree that what's at stake for me matters to you also.

If you missed getting a Stayin' Alive post on Friday (and I know the national disappointment was palpable), it happens I was in an all day meeting. Or rather, more like a seminar. We invited colleagues from other institutions to come to the pathetically tiny state of Rhode Island for an interdisciplinary brainstorming about new approaches to the study of effective clinical communication. I'm talking computer science, psychology, sociology, mathematics -- how can we learn how doctors and patients can understand each other better and make the right decisions for each patient, from the patient's point of view.

I'm also working with a colleague at another institution, who is a pediatric oncologist, on a study of pediatric hematopoeitic stem cell transplant, more commonly known as bone marrow transplant although that's really a misnomer. These are kids with leukemia that doesn't respond to chemotherapy, or other serious blood disorders, who have their own immune systems intentionally wiped out and replaced by blood-producing stem cells from a donor. It takes six months to a year for their immune systems to reconstitute, during which time they and their families must follow impossible infection control protocols. The child can't be in crowds - no movies, no birthday parties, no shopping with Mom; the family must follow stringent kitchen hygiene and food handling protocols; no swimming; no playing in the dirt; nobody who has the sniffles can visit; no playing with the dog; no deli meat, yogurt or blue cheese, soft boiled eggs, or raw seafood; and on and on.

Believe it or not, nobody knows how families cope with these requirements or even how well they understand them. A lot of the kids die and we don't know how much failure to follow these guidelines has to do with it. So we want to study that, for the first time.

The problem is, if the Republicans get control of the government, they have promised to make drastic cuts in domestic discretionary spending. In case you think that consists largely of free money for dark-complected deadbeats, you are wrong. Try, for example, the National Institutes of Health, which already has a budget which is the lowest it has been since 2001, in constant dollars. Right now NIH is funding only about 7% of all new grant applications. Because most of its money is already committed to 2, 3 and 5 year projects, if it's budget is cut, it will be unable to make any new grants at all for at least a year, and very few after that. Ergo, I will be unable to do any of this work.

You may not care about me, but you probably do care about making medicine more efficient, and more responsive to patient needs. You probably care about really sick kids with cancer not dying. Unless, of course, you are a disciple of Ayn Rand like Rep. Paul Ryan. In which case you should vote Republican.

Thursday, August 23, 2012

The history of batshit crazy in American politics

I know, I know, it seems as though we've crossed into a new world of lunacy, what with a Texas "judge" (really a county commissioner) vowing to resist the invading UN forces should Obama be re-elected, and a New Hampshire candidate for sheriff promising, if elected, to kill doctors who perform abortions, presumably as part of his official duties.

I'm not sure this is really anything new, however. Ron Paul has been a member of Congress since I could clean and jerk 200 pounds. You may think he is sort of like your eccentric uncle, and you like his ideas about legalizing marijuana and not invading Iraq. He is, in fact, crazier than a quilt. And his inspiration, the John Birch society, a big influence on Paul, has been broadly influential in American politics for as long as I have been alive. There was no space between the Birchers and Republican presidential candidate Barry Goldwater.

Back in the 90s, before that little unpleasantness with Tim McVeigh set them back, the sovereign militia movement had numerous supporters in Congress. I'm too busy today to try to write even a summary of the history of far right conspiracy theories, eliminationist threats, and crude racism in American politics, but I shouldn't have to work to convince you. It's always been there.

Wednesday, August 22, 2012

Defining the problem correctly

Eduardo Porter, in the NYT, offers a largely correct explanation of the Medicare problem. Unfortunately, he outlines a discussion we aren't having, and apparently cannot have.

First, clearing away a bit of underbrush, he clarifies that the reductions in Medicare spending under the Affordable Care Act are not, repeat not, cuts in benefits, contrary to the endlessly repeated and unpunished lies of WM Romney and Paul Ryan. And yes, Romney and Ryan do propose to cut Medicare benefits, while Obama does not. I won't go into those specifics yet again -- the Times has another article today, in the A section, that covers the policy issues (and quotes my old friend John McDonough).

Porter wins a Kewpie doll, however, for daring to use the word "rationing." In a world of finite resources, everything is rationed, one way or another. Unless, of course, you are Mitt Romney, in which case it would be a major problem to try to spend all your money. For the rest of us, we do without some things we might like because we can't afford them.

Why should health care be any different? Well, it can't be. Now, we could decide that we are going to continue with Medicare as it is, and not try to rein in the cost. And we could do that, for the foreseeable future, but we would have to raise taxes on the middle class, even after we got done raising taxes big time on the wealthy. (The wealthy have a lot of money, but there aren't a lot of them, you see.) At least we would if we wanted to keep spending as much on the military as we do now. But we aren't going to have that debate either.

And even if we did have that debate, we'd end up wasting a lot of money.

The way Ryan and his sidekick Romney want to limit Medicare spending is by making old people pay more out of pocket. If you don't have the money, you don't get the insurance, or at best you get cheap insurance that doesn't pay for what you need. That's rationing. By ability to pay.

Somehow that's supposed to be better than having experts and consumer advocates sit down and figure out the best way to spend a limited budget fairly and efficiently, so that everybody gets covered, everybody gets the same benefits, but we don't pay for stuff that doesn't work or costs an exorbitant amount for a tiny benefit.

Uh oh, it's that last piece that's toxic. But sorry, in a sane world -- in a libertarian world, in fact -- you don't have a claim of a million dollars on the public treasury for a shot at buying yourself two more weeks of a miserable existence. If you have a million dollars of your own, and that's how you want to spend it, go for it. But the commonwealth has to draw the line somewhere. Tell me why that's not so.

Monday, August 20, 2012

"Conservative" means "Ignorant"

Or deluded, take your pick.

Rep. Todd Akin is a member of the House Committee for Science, Space, and Technology. That's right. As you know by now, he also believes that women can't get pregnant from "legitimate" rape because of some unspecified biological mechanism that doctors know all about.

Paul Ryan is running for Vice President on a platform of fiscal responsibility. You've already read Krugman on this so I'll give you Sullivan, which I would not ordinarily do except to show that Sullivan is not a conservative, even though he likes to tell himself that he is, because he is partially reality-based. (He's also a devout gay Catholic, which makes no sense whatever, but that's for another day.) Quote:

There is no libertarian quite as convinced as a teenage libertarian. And it's the adolescent conviction of Ryan that shines so brightly.
One can call it courage or arrested development. But he is, in some ways, a pellucidly bright plant bred in the conservative movement's hydroponic greenhouse. Barely exposed to natural light, these young fertile saplings are fed with a constant drip of Koch money, sprayed with anti-liberal pesticides and brought eventually into the political marketplace with joyful children, a lovely wife and a set of abs Aaron Schock would die for (and probably has). He has no life or experience outside the greenhouse - which is why he glows with its certainties. Most important, he has that quintessential characteristic of the modern conservative - total denial of the recent past. Ryan was instrumental and supportive of the most fiscally reckless administration in modern times. He gave us a massive new unfunded entitlement, two off-budget wars and was key to ensuring that the Bowles-Simpson plan was dead-on-arrival. This alleged fire-fighter - whose credentials are perceived as impeccable in Washington - just quit being an arsonist.

Then of course there is climate change, which all conservatives are required to take an oath to consider a hoax.

What these and other conservative delusions have in common is that they are all examples of thinking backwards: reasoning from a prior conclusions to purported facts about the world. If the facts contradict your conclusions, the facts must be wrong.

It is a postulate that government regulation does more harm than good, and that the magic of the "Free Market" produces optimal outcomes. Therefore climate change must be a hoax.

It is a postulate that a zygote is morally identical to a human being, therefore abortion is precisely murder. (This postulate is really only a means to an end, which is that women who have sex for purposes other than procreation are evil and should be forced to have babies.) But since this conflicts with most people's moral intuition about pregnancy resulting from rape, that must not exist.

The "deficit" thing is more complex, but the same basic idea. Since actually eliminating the federal deficit would require doing things that we know a priori we cannot do -- raising taxes on the wealthy and reducing spending on the military -- and we know we must eliminate the deficit, it must be possible to do so by other means. And if those other means seem unacceptable to most people, they really aren't what they appear to be. It may look like we want to destroy Medicare, but we're actually the ones who are saving it. By destroying it.

Why in the Delta Quadrant of the galaxy would anybody vote for these evil lunatics?

Friday, August 17, 2012

Required Reading

More people, still not enough, are finally catching on that the past decade of American culture and politics has been utterly delusional. I could be referring to a few different delusions but today let's talk about "terrorism," as John Mueller and Mark D. Stewart invite us to do in the journal International Security.

Remember John McCain talking about the "existential threat" of terrorism in 2008? George W. Bush cruising to re-election on the premise that only he could keep us safe, while John Kerry was practically mocked out of the country for saying that terrorism was basically a law enforcement problem and that we should think of it as we do organized crime? As Mueller and Stewart recite, "trillions of dollars have been expended and tens of thousands of lives [actually more like a million -- C] have been snuffed out in distant wars in a frantic, ill-conceived effort to react to an event that, however tragic and dramatic in the first instance,should have been seen, at least after a few years had passed, to be of limited significance."

Particularly amusing is their inventory of supposed terrorist plots the feds have boasted about busting over the years.

[T]he authors of the case studies, with remarkably few exceptions, describe their subjects with such words as incompetent, ineffective, unintelligent, idiotic, ignorant, inadequate, unorganized, misguided, muddled, amateurish, dopey, unrealistic, moronic, irrational, and foolish. And in nearly all of the cases where an operative from the police or from the Federal Bureau of Investigation was at work (almost half of the total), the most appropriate descriptor would be “gullible.”

Basically, most of these plots were ginned up by agents provocateurs conning low IQ nutcases into concocting preposterous plots.

What's really sad is that we have seen basically no recognition from the Obama administration of how badly we have gone astray. In fact he has doubled down on the surveillance state and the destruction of our privacy and liberties that goes with it - all for a "threat" that is far less than the threat of drowning in your own bathtub.

Al Qaeda got lucky on Sept. 11, 2001. That's all. And with that fantastically lucky and implausible success, they had shot their wad. They were, after all, just a few deluded fanatics, who were a trivial threat to Americans and the United States.

Read the whole thing. I command you. 

Thursday, August 16, 2012

So you want to talk about Medicare?

Okay, fine. Let's go for it. First of all, if you are interested in a concise primer on the history of health care policy in the U.S., Jonathan Oberlander is kind enough to provide it in today's NEJM. This is a well-worn story here, but I'll just say that we ended up with the dysfunctional, unjust and wasteful non-system we now have through a combination of pathologies in our political culture and historical accident.

Read Oberlander for the details, but essentially, the United States failed to follow the lead of every other affluent country on the earth and create a functional system that provides universal access and reasonable efficiency by the mid-20th Century. That was the historical moment when health care took off on a path of rapid technological advance that made it both highly valuable, and increasingly expensive. Since we weren't covering everybody under a uniform, rational system, a complex of powerful, entrenched interests grew up which blocked any comprehensive reform which threatened them. Instead of a system that reconciles competing interests and serves generally accepted values -- justice, universality, efficiency -- we have people feeding off of various incomes streams who can afford to buy political influence to maintain their privileges at the expense of the common good.

So, thanks to empty suit Mitt Romney appointing the extremist Paul Ryan to define the Republican presidential campaign, we're suddenly talking about nothing else but Medicare. Since I am serious and responsible, I recognize that the cost of Medicare is increasing and that the current revenue stream that funds the Part A trust fund for hospital care won't cover projected costs some time in the 2020s. (I don't buy the false precision of the forecasts, but yeah, around 2024 or so.) The amount of general tax revenues that subsidize outpatient care and pharmaceutical costs under Medicare will also have to increase, and right now, people seem not to be inclined to raise the tax revenues needed to pay for them.

Do Barack Obama and the Democrats have a plan to solve this problem? Sorta kinda, but it's likely not enough. Does Paul Ryan have a plan? No, absolutely not.

Ryan actually doesn't propose to mess with Medicare at all for ten years, as you know. He's hoping people 55 and older will be selfish enough to be reassured that they will still get Medicare and not care what happens to their younger siblings and their children. That seems dubious, but he's claiming that what he proposes is the way to save Medicare. The way I saw this described on CBS News was that when you turn 65, you get a coupon worth $15,000, which is the current annual cost of Medicare per beneficiary, which you can then use to buy insurance on the open market. If you find a plan that only costs $14,000, you get a check in the mail for $1,000 and you still have insurance.

What the "reporter" failed to tell you is that Medicare is cheaper than private insurance that provides the same benefits, ergo, you will not get the $1,000, unless the insurance companies can get away with cherry picking -- enrolling only relatively health people -- and you happen to be one of those healthy people. Which gets us into all the problems people under 65 have already. If you need insurance, you won't be able to afford it. On the other hand, if the insurance companies can't get away with that, then everybody will have to pay out of pocket to cover the difference between $15,000 and the cost of private insurance.

And it gets worse. The amount by which the voucher increases every year is less than the projected increase in health care costs. That means the out of pocket cost for beneficiaries will go up and up, and more and more people won't be able to afford it. Ryan claims the insurance companies will compete to keep costs down, but they haven't been able to do that up until now and there's no reason to think they'll do it in the future, especially because . . .

Medicare, as a single payer, has much more power to contain costs, and doesn't have to pay anything for 8 digit executive salaries, profits, marketing and underwriting. If we want to really contain costs, rather than just shifting them to old folks who can't afford them, what we need to do is stick with Medicare, but make it better. First, expand it to cover younger people, so we don't have people hitting 65 with untreated conditions that are more expensive than they have to be. (Yes, this is a significant problem now.) Second, give Medicare the power to negotiate with drug companies over price. Third, reorganize the health care system and reimbursement policies to pay for results, not for doing stuff. Fourth, establish practice guidelines based on cost-effectiveness.

The Affordable Care Act makes half-way stabs at three of these four requirements. More people under 65 will have some form of insurance, though not everyone; it finances experiments in reorganization and pay-for-results, but doesn't make any of this universal so it remains to be seen how far it goes; and it finances research into outcomes, but does not allow Medicare to take cost into account in authorizing procedures. At least it gives us something to build on, that's going approximately in the right direction.

But . . .

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

Tuesday, August 14, 2012

Sorry, I just don't get religion

As I understand it, one of the reasons why people are religious is purportedly that religion soothes our fear of death --  you and your loved ones will live on in the heavenly kingdom, or whatever the particular mumbo jumbo may be. So So why is this?

In a review of 203 cases in which doctors recommended withdrawal of life support, 17 families did not ultimately come to agreement. In 11 of these cases, their stated reasons were explicitly religious: that God would produce a miracle: "[I]ntensive care should not be stopped due to expectation of divine intervention and complete cure together with conviction that overly pessimistic medical predictions were wrong."

Now, this is doubly ridiculous because if God is going to miraculously cure the person, why does He need a respirator? But fundamentally, it is more difficult for Christians to accept death than it is for atheists. By the way there is a good deal of research on this already -- devout Christians have been shown to be much more likely to demand so-called "heroic" efforts to resurrect people in hopeless condition, by which medical ethicists mean essentially futile measures. Physicians are well aware of this.

While we're on the subject of denial, Paul Ryan and Senator Inhofe are going to have to deny this. The Millstone nuclear power plant in Connecticut, which is cooled with seawater, has been forced to shut down because the ocean is too warm. This has never happened before in the plant's 37 years of operation, that is to say the Long Island Sound has never been warmer than 75 degrees. Now it's almost 77.

Monday, August 13, 2012

No, it's not just an ideological battle

It's a battle between truth and falsehood.

I hereby exercise my nigh supernatural powers of prognostication to proclaim that the corporate media will cover the policy differences between president Obama and presidential candidate Paul Ryan (not a typo) by quoting or paraphrasing how each of them and their spokespeople describe said policies.

This morning NPR devoted most of its program to Paul Ryan, and a pervasive them was that he is a fiscal conservative who wants to get the federal budget deficit under control. As Matt Miller of the Center for America Progress explains clearly, this is not so. Paul Ryan wants to make the federal deficit explode. However, although the linked page appears to have something to do with the Washington Post, Miller is not a WaPo columnist, they just let him post once a week on their Internet property. In the actual Washington Post, we will read about how federal deficits are unsustainable and what we need is a man with a serious plan to make the hard choices. Which is total BS.

NPR went to a Ryan rally and interviewed some fans. Waddyaknow, they were all excited because the federal budget deficit is a disaster and Paul Ryan is going to do something about it. NPR allowed those comments to stand unchallenged. And they will continue to do so. Mark my words.

Friday, August 10, 2012

You know we can't talk about anything that matters

Not if we're running for office, for Pete's sake. But maybe after the election we can have a little conversation about this: even as life expectancy in the U.S. increases, disparities by race and education won't go away. In fact, disparities related to education may have gotten worse. White women with less than 12 years of education in 2008 had lower life expectancy at birth than they did in 1990 -- by more than 5 years. Disparities between white and black Americans, adjusting for education, declined slightly but remain large.

Exactly how education drives life expectancy is not fully understood; yes, people with less formal education are more likely to smoke, be obese, etc. But the disparities remain even after adjusting for those identifiable factors.

Not everybody wants to go to college, or should. But everybody deserves a chance at meaningful work that will provide them with a decent standard of living; and education that will provide them with strong basic skills to navigate through life, including health literacy. We're literally killing people by inequality.

Wednesday, August 08, 2012

Nanny state

Here's a plug for the U.S. Department of Transportation, which is trying to get you -- and you know who you are -- to stop talking on the @#$%^& telephone while you are driving. You wanna kill yourself? Fine. You wanna kill me? Not fine. You got kids in the car? You're a schmuck.

Every single day I encounter these morons with the phone plastered to the right ear, driving with the left hand, and not noticing what the hell is going on around them. The rest of us drivers are doing our best to stay as far away from them as we can, because they obviously don't see us. Every time I walk through downtown Providence, I have to stop at an intersection because there's an idiot driving through it talking on the phone who does not see me. Almost half a million people are injured in the U.S. every year as a result of this totally irresponsible, inexcusable, stupid behavior.

While we're on the subject of public health, one third of the people in Appalachia have diabetes. This Salon article by Frank Browning highlights how difficult it is to get people to change behavior, particularly when it's deeply culturally embedded. But this is an emergency.

Tuesday, August 07, 2012

Medicine's dirty little secret

It's revealed here by Atul Gawande, although he somewhat buries the lede. Here it is:

Nobody's in charge. Every physician and surgeon is a kingdom unto himself or herself. Doctors do not have bosses, and they are essentially accountable to no-one. This remains true even as they migrate from independent or small group practices to salaried positions with large, integrated medical systems.

The result is that it takes literally decades, and sometimes forever, for evidence about best practices to be generally implemented. Even within a single hospital, as Gawande tells us, every surgeon has a particular way of doing things, even if there is good evidence that says they're all doing something wrong.

This total disorganization also extends to medical education. In medical school, each department has an inherited number of "contact hours" they get with students, and each course director uses that sinecure to teach whatever and however she or he wants to do it. The dean has nothing to say about it. In the second two years, the students are assigned to follow particular doctors around, and when they graduate, as resident they have preceptors. These people, again, teach whatever they want to teach, and model whatever practices and behaviors they happen to engage in. Nobody has anything to tell them about it.

As a result, my colleagues and I who study health services policy and practice, and clinical researchers who learn all the latest and best ways of treating disease, can publish as much compelling research as we can possibly produce, but if anybody pays attention to it we're lucky, and we're luckier still if it changes the way anybody does anything. We figure it will get out there gradually, like a bucket of paint diffusing in a lake, but that's all we can hope for.

Gawande envisions a day when medicine is organized like a business, with protocols that are enforced by people who are actually in charge. You'd think this would maybe appeal to conservatives, because he isn't saying the government should do it. He's saying big companies should swallow up lots of hospitals and practices and put their managers in charge. The government will just keep 'em honest. This may well be a good idea but it's going to set off a serious shit storm. We'll see.

Monday, August 06, 2012

Just in case you still give to Susan G. Komen . . .

. . . one more reason to send your money elsewhere. This is from Steven Woloshin and Lisa Schwartz at Dartmouth, who review Komen's advertising urging women to get screening mammograms. "Komen's public advertising gives women no sense that screening is a close call. Instead, it simply tells women to be screened, overstates the benefits of mammography, and ignores harms altogether."

They specifically critique an ad that claims that "early detection saves lives. The 5-year survival rate for breast cancer when caught early is 98%. When it's not? 23%."

I know my readers are smart enough to see right away what is wrong with this assertion. It's called lead time bias. Suppose you could has a time machine, and you first  identified a group of 100 women who died of breast cancer at age 70. Then you went back in time and gave half of them a mammogram at age 65. The other half would have been diagnosed later, when their tumor became palpable. The ones who got screened would have five year survival of 100%; the ones who did not, would have five year survival of 0%. That's a big difference, but it's completely meaningless, except that the screened women had three or four years more to be sick and undergoing surgery and chemotherapy.

The best available estimate we have now is that mammographic screening reduces the chance that a women in her 50s will die of breast cancer within 10 years from .53% to .46%. When I do the math, that tells me that 7 women out of 10,000 will will avoid this fate.

For each of them, anywhere from 2 to 10 women will be overdiagnosed -- will be diagnosed with a condition that, if left untreated, would never have harmed them. They will undergo surgery, radiation, and/or chemotherapy, which does them no good, and only harms them.

So why does the Komen Foundation lie to women? I'm going to take a guess -- some of their big donors profit from cancer treatment. If they want to argue with me, my e-mail is in the side bar.

Friday, August 03, 2012

A Rorschach tragedy

Sorry, there will be a bit of a long lead up to get to the point of this post -- skip down if you like.

When a shocking event like the Batman massacre happens, everybody comes along and tries to grind their own ax on it. (Is that grammatically correct?) No, it didn't happen because of teaching evolution, or violent movies and video games, or demonic possession (yup, a Catholic priest came up with that one), or because all men are scum. There's a legitimate argument to be made about regulation of the sale of weapons and ammunition, but tightening up on background checks wouldn't have helped because the perpetrator didn't have any relevant public record.

What happened is, of course, that he had an onset of psychosis at just the age when it usually happens. Advocates for the mentally ill are universally claiming, and getting reporters to include the statement in their stories, that mentally ill people are not any more likely to commit violent acts. I'm afraid that is not exactly true. The truth is that most people diagnosed with schizophrenia are not in any way dangerous, but some are. Many studies have found that severe mental illness is associated with an increased risk of violent offending.

So, this could have been a story about inadequate mental health services and limited access. Except it isn't, because it turns out the perpetrator was seeing a psychiatrist. Everybody has clammed up about this, for two good reasons. He's obviously going to put on an insanity defense, and there's pretty much only one target that victims can sue, and that's the University of Colorado and the psychiatrist.

So now to the point. It has leaked out that the psychiatrist was concerned enough about the possibility that her patient would commit violence that she initiated the university's internal process for evaluating and addressing such situations. When he withdrew from the university, all that evidently stopped. So, did the psychiatrist screw up? Did she fail to take appropriate action, thereby endangering the public?

I can't, obviously, speak to the specifics of this case. But I can tell you that we can't really predict who is going to commit acts of violence. The linked review, in the new BMJ, tells us that the best systematic screening tools will overpredict -- that is, less than half the people identified as high risk will actually offend. And they are expensive and difficult to implement, usually requiring that the person already be in custody.

Just plan clinical judgment, which was all that was available in the Colorado case, is pretty much useless. Psychiatrists, in Colorado as elsewhere, can get a court to commit a person involuntarily but they are obviously reluctant to do this because most of the time, they'll be depriving a person of liberty without good cause.

Every time a criminal on parole commits a serious crime, we get a huge outcry. This just happened in Connecticut, when a guy on parole murdered a gas station owner for a few bucks. But let's face it -- criminals, until they actually do something like murder a gas station owner, will get out of jail eventually. If we could predict which ones would commit violence, maybe we could deny them parole, but a) we can't and b) it's actually better to release people on parole, where at least they get some supervision and conceivably even services, than just to dump them on the street.

So that's it folks. When people do their best in these situations, it isn't always good enough. 

Thursday, August 02, 2012

Zombie lies eat my brain

Andrew Sullivan, who is an inexplicable stew of wisdom and folly, in discussing tax policy, writes the following: ". . . even though lower tax rates are obviously better than higher ones for growth, if you can afford them."

I responded as follows:

This is simply false -- as the history you discuss in the very same post proves. [I.e. poor economic performance under GW Bush]. It is what is called a truism -- conservatives have repeated it so many times, and the corporate media have swallowed the meme so wholly, that most people have come to believe it.

The truth is that there is no correlation between growth rates in developed countries and the marginal tax rate. As you know perfectly well, federal income tax rates in the U.S. were higher under Dwight Eisenhower than they are today, and indeed higher than they were under Ronald Reagan. Growth in the U.S. was much higher under Clinton than it was after the Bush tax cuts. It is not a question of whether one can "afford" the taxes - it's a question of what you do with them. When government collects taxes, the wealth represented by the funds is not destroyed -- government spends the money. It is recycled. If it is spent wisely, on public investments that support long term prosperity, then we are better off than we would be had the taxes not been collected.

Conversely, when people are not taxed, they do not necessarily spend or invest the money in ways which promote long term growth. They may invest it abroad, invest it unwisely or even counterproductively, squander it on drugs, you name it. Whether taxes are "affordable" or not is purely a question of judgment - do you want to pay for what the government buys with them, or not? If you don't want to educate children, maintain highways, enforce the law, invest in the creation of knowledge and technology, or take care of the sick and old, then you don't think we can afford the taxes needed to do those things. If you do wish to do them, then you think we can afford it.

It is simply not the case that government is necessarily a worse steward of wealth than Sheldon Adelson. Once you notice that, the entire argument about lower taxes and economic growth dissolves like a snowflake in May.

Wednesday, August 01, 2012

This has actually been known for some time

But for whatever reason, the corporate media has decided to cover this (not new) analysis from the Brookings Institution that states the obvious:

This paper examines the tradeoffs among three competing goals that are inherent in a revenue-neutral income tax reform—maintaining tax revenues, ensuring a progressive tax system, and lowering marginal tax rates—drawing on the example of the tax policies advanced in presidential candidate Mitt Romney’s tax plan. Our major conclusion is that any revenue-neutral individual income tax change that incorporates the features Governor Romney has proposed would provide large tax cuts to high-income households, and increase the tax burdens on middle- and/or lower-income taxpayers.

You can find summaries and discussion here and here with the headline "Study: Romney tax plan would shift burden to poor," no less.

But guess what? It doesn't matter! Romney will keep saying that Obama wants to raise your taxes, and the stenographers will just write it down, and people will continue to believe that Republicans cut their taxes and Democrats raise them, because that's just the way it is.

I know this because I already know that it doesn't make any difference what lies Romney tells. There is no penalty for lying. He'll just keep doing it, and it will continue to work. There's no sense even pointing it out.