Map of life expectancy at birth from Global Education Project.

Saturday, November 30, 2013

One of life's enduring mysteries

Yesterday one of the headlines on CNN was "Mike Tyson tells Piers Obamacare is bad."

Yup, if I have one go-to person on health care policy, it's Mike Tyson. Nobody has a more distinguished career in policy analysis than Iron Mike, and there's nobody I'd rather have bite my ear off.

So, what explains the utter, screaming stupidity of the corporate media? Do they give candidates for editorial positions an IQ test and if it exceeds room temperature, toss out their resumes?

Alternatively, are they not actually blithering idiots, but on a mission to degrade the public discourse and stupefy the population? If so, why? Whose idea is it to replace the brains of the U.S. population with mush? What is the ultimate goal of the conspiracy?

Just wondering.

Wednesday, November 27, 2013

I basically have respect for the medical profession but this is ridiculous

Using data from the National Ambulatory Medical Care surveys (there are two because on covers outpatient practices and the other ambulatory care delivered in hospitals, mostly EDs), Drs. Barnett and Linder (no link because you need a subscription to JAMA Internal Medicine) give us some disturbing news.

Only 10% of people with sore throats have an infection that is treatable by antibiotics. And almost all of them have group A streptococcus. Good news about good ol' group A strep -- it's not antibiotic resistant, in fact it's 100% susceptible to good ol' penicillin, which by now isn't good for much else, and is also very cheap.

So most people presenting with a sore throat shouldn't get any antibiotics, and those who do, should get penicillin. Guess what? About 60% of people get antibiotics, and the vast majority of them do not get penicillin but other, more expensive antibiotics. This is ridiculous.

It's not only that this contributes to resistant bacteria. Taking antibiotics is bad for you! You should only take them if you really need them because a) there can be side effects of the antibiotics themselves and b) they wipe out your beneficial endosymbionts, in other words all that good stuff living in your digestive tract and elsewhere. You can wind up with diarrhea, and opportunistic infections such as thrush or something really nasty like C. dificile. (I had it when I was hospitalized, and believe me, es muy difĂ­cil.) We're learning more and more now about the importance of our microbiome, as it's called. Having your good bugs trashed can cause all kind of previously unsuspected bad results, including obesity. And it's wasting hundreds of millions of dollars every year.

Why do doctors do this? Beats the hell out of me. How hard is it to tell somebody, sorry, antibiotics won't do you any good, go with the chicken soup? Aaaarrrggh.

Tuesday, November 26, 2013

Sometimes there just aren't any reasons

As a Connecticutian (or whatever we're supposed to be called) I can't help but feel affected by the Sandy Hook disaster. And that's the word I purposefully chose for it. The State's Attorney yesterday released his report on the shooting, with this report in the Hartford Courant conveying the gist of it.

Sadly, and I know this is probably adding to the pain of parents and others who knew and loved the victims, there doesn't seem to be much we can take away from this as far as practical lessons or philosophical consolation. Yes, Adam Lanza's mother didn't have her head screwed on right, in failing to aggressively get him the help be obviously needed and probably more strangely, by making it her personal mission to make sure he had access to guns and target practice. But it's hard to think of any public policy or change in the law that would usefully address such a situation -- which is extremely rare in any case.

The report makes it clear that Lanza was deeply disturbed even as a young child, his head full of violent fantasies. Over the years he drew more and more inward, in his solitary world constantly gnawing on anger and imagining ultimate revenge on -- what? We'll never know. There is no known history of abuse or trauma. His brain just failed to wire correctly.

I've said before that the wetware is extremely powerful, unimaginably complex, and when it goes wrong, it can go spectacularly wrong. I think we make a category error by trying to classify this event in moral terms. It was the equivalent of a meteorite hitting the school. Perhaps some will feel a bit of satisfaction by casting blame on the deceased Ms. Lanza, but even there I am inclined just to say that she didn't grasp what was happening. The gun thing was a desperate attempt to connect with her son around the one thing they seemed to have in common.

And she could not imagine, let alone know, what was happening inside his cranium. It made no sense, it had no explicable cause, it didn't mean anything. It was just neurons that somehow got hooked up in a way that produced the awful result. Sadly, that's about all I can say.

Monday, November 25, 2013

The ruling narrative vs.the truth

Usually a huge disconnect there, whatever the subject. Let's consider the Affordable Care Act, shall we? You know,the trainwreck that has cost Barack Obama the trust and affection of the American people?

You might consider this a bit of self-pleading; it's from the president's Council of Economic Advisers. But hey, reporters are supposed to pay attention to them as well as to Republican senators, right? The sustainability picture for health care really is improving.

Health care cost inflation is the lowest in 50 years. The CBO has reduced its forecast of Medicare and Medicaid costs in 2020 by 10%. And a lot of this has to do with the ACA - not the part everybody talks about, where most people have insurance. That hasn't even happened yet. But the ACA changed the way Medicare pays hospitals and reimburses providers -- you know, those "cuts" the Republicans used to scare elderly voters into putting the current crop of wingnuts in Congress. That doesn't hurt beneficiaries at all -- in fact it helps them. For one thing, hospitals have an incentive to keep people healthy and at home, instead of getting paid for failure when people have to be readmitted.

The slowdown in health care cost growth is more than just an artifact of the 2007-2009 recession: something has changed. The fact that the health cost slowdown has persisted so long even as the economy is recovering , the fact that it is reflected in health care prices – not just utilization or coverage, and the fact that it has also shown up in Medicare – which is more insulated from economic trends, all imply that the current slowdown is the result of more than just the recession and its aftermath. Rather, the slowdown appears to reflect “structural” changes in the United States health care system, a conclusion consistent with a substantial body of recent research.
• The ACA is contributing to the recent slow growth in health care price and spending and is improving quality of care. ACA provisions that reduce Medicare overpayments to private insurers and medical providers are contributing to the recent slow growth in health care prices and spending In addition, ACA reforms that aim to improve the quality of care are reducing hospital readmission rates and increasing provider participation in payment models designed to promote high-quality, integrated care.

This whole story is being completely ignored, not only by the corporate media, but by Democratic politicians who should be explaining this to the people and engaging in a full throated defense of the achievements of health care reform. Why isn't that happening?

Thursday, November 21, 2013

How bad can it get?

I have a confession: I somewhat self-censor myself because I don't want to be Debby Downer. That may seem a bit terrifying because I probably don't come off here as a cockeyed optimist.

So, here's the straight dope. I am not entirely sure that our American polity, our Republic, our civil society, is going to hold together. And I don't just mean a time of turmoil like the '60s or the '30s. I'm not in favor of riots but a good dose of civic unrest wouldn't do us any harm right now. No, I'm talking about the country being governable, about what's left of broad based political participation in a political regime granted consensus legitimacy evaporating. To be replaced by . . .

Dunno. Fascism, secession, or just plain chaos are all possible. Here Peter Turchin sees things falling apart consistent with a historical cycle in which concentration of wealth reaches a destabilizing maximum. The mechanism he focuses on is only a small part of the story, in my view, although there is probably something to it. Basically, there aren't enough high status social resources and formal offices to go around among the elites, so the ruling class fractures and its factions exploit popular unrest in their competition with each other. Or, a governing faction gets wise and makes needed reforms to save capitalism and the state, as in the 1930s. If that doesn't happen, you get Naziism, Communism, civil war, or a failed state.

While we do have to pay attention to the ruling class, the loss of legitimacy among the common people, increasingly left out of the fruits of economic growth and economic advance is just as important in the story. And in this particular instance, we're up against some real physical limits that haven't previously existed for modern civilization, although such limits have destroyed earlier empires. Then as now elites aren't confronting them because they are trapped in their short-term view of their own self-interest.

Anyway, projections of the solvency of the Social Security Trust Fund in 2050 don't mean shit right now. That's my point. If nothing focuses the mind like a hanging, we should probably be focused by now. But we aren't.

Wednesday, November 20, 2013

Update on Previous Post

I have to link to The Guardian because as of this writing, it is completely unmentioned on the web sites of CNN, CBS, and ABC. (11:00 am ET)

Representatives of most of the world's poor countries have walked out of increasingly fractious climate negotiations after the EU, Australia, the US and other developed countries insisted that the question of who should pay compensation for extreme climate events be discussed only after 2015. The orchestrated move by the G77 and China bloc of 132 countries came during talks about "loss and damage" – how countries should respond to climate impacts that are difficult or impossible to adapt to, such as typhoon Haiyan.

We are well and totally screwed.

Update: As of 11:40 am, CNN is reporting that Chi Chi Rodriguez has been hit in the groin by a golf ball.

Tuesday, November 19, 2013

If you get your info from the corporate media . . .

you probably know that George Zimmerman has undergone his monthly arrest. Maria Bartiromo is moving to Fox (why even have to pretend to be a journalist?). Virginia State Senator Creigh Deed was stabbed, Rob Ford clotheslined a 5 foot tall Toronto City Councilor. Obamacare is a Trainwreck! It's a disaster! We're all going to die! (If you read some liberal blogs you will also learn that in fact, more and more people are signing up for it and, just like Cervantes told you, they're getting the web site fixed and come January 1, it will be a fait acompli. Nonetheless, it is true that we are all going to die.)

What you probably don't know is that right now, as I write this, and has been true for the past week, the Annual Conference of Parties to the United Nations Framework Convention on Climate Change has been happening in Warsaw. You might think it's kind of important, I suppose, but as far as CNN, ABC, and CBS are concerned, it's a secret. That's why I've had to refer you to Climate Progress, which is kind of like Wikileaks, I guess, in that they tell you stuff Americans aren't supposed to know.

There are important issues under discussion in Warsaw. No, it's not going to result in an international agreement to save civilization and, in addition, Miami Beach. It is, however, intended to set up for an agreement to be signed in 2015. Many important issues are under discussion including raising $100 billion, which used to be a lot of money; issues of justice and reparation for damage caused by climate change (and that's very deep stuff); and how the responsibilities for reducing carbon emissions and mitigating harm are to be distributed among the nations that were industrialized early, and those that are less developed.

These are difficult questions. The U.S., as the largest source of carbon emissions to date, is obviously very much affected by them. As perplexing and divisive as it may be for us to work through these problems, it is essential for Americans to be engaged in them. The U.S. must be a constructive participant in these talks, and actively engage in the plans and goals that result, if all this talk about what Social Security and Medicare will be like in 2050 even to matter. But we aren't. It isn't even on the front page of the CNN web site. Although Jonathan Edwards' new law practice is. Along with the question of whether a Kmart ad is too "racy" and the story of a 400 pound high school football player. At least we know what's important.

Sunday, November 17, 2013

Should the Redskins change their name?

Enough of this sanctimonious political correctness. The Washington Redskins proudly bear their name as a symbol of something very important in our national heritage -- i.e., racism.. I think the NFL owners should continue to show solidarity and support the 'Skins and their owner Daniel Snyder by changing the names of some of the other teams.

The New York Giants should be named the Hymies. And the jets can be the Dagos. The San Francisco '49ers, obviously, will be the Poofters. And the Arizona Cardinals, the Wetbacks. And of course, the Detroit Tigers will be the Jigaboos. The Miami Spics. Problem solved. Why can't anybody else see the obvious?

Friday, November 15, 2013

Catholic Bishops: all the moral authority of a tapeworm

I'm a sociologist, and one focus of my study is how people understand their lifeworlds and their well being. So I ought to be good at understanding major social institutions and the basis of their attraction, like for example the Catholic Church. But I just don't get why this atavistic, intellectually ludicrous and morally depraved enterprise doesn't wither and blow away.

Here's the Bishop of Springfield, Illinois organizing an exorcism to drive Satan from the body politic, "in reparation for the sin of same-sex marriage." For all of the new Pope's conciliatory words, when he was still Jorge Bergoglio he said that gay marriage in Argentina was "a 'move' of the father of lies who wishes to confuse and deceive the children of God." So Bishop Paprocki will perform an exorcism as the governor signs the same sex marriage bill.

Here's the idea, as I understand it. God is beneficent, all knowing, and all powerful. God created the universe and people (the latter "in his own image"). He put the people in a garden in which he also placed two trees, from which he instructed them not to eat. Despite his being all powerful and all knowing, another being, in the form of a talking snake, succeeded in getting the people to eat an apple, which he didn't know about at the time because he was apparently distracted elsewhere. So God cursed the people for their sin of doing what he presumably knew they were going to do and which they did because they were of the nature which he made them.

Some time later (it used to be about 4,000 years later, but since the Bishops now say they accept scientific accounts of human antiquity it's impossible to say when all this shit supposedly happened nor is it in any way coherent) God impregnated a woman with his son, who was also himself, who he then deliberately had tortured to death to pay for the sin of eating the apple, but he wasn't really dead he just rose up into the sky. That means God will no longer have to torture everybody in hell forever, just the people who don't believe this crap.

Nowadays some of the people who God made in his own image are marrying people of the same sex, which God does not want them to do, but it's happening because some other dude -- maybe the same entity as the snake, it's not clear -- is making it possible. God can't do anything about that himself, but if a bunch of old men in fancy silk dresses chant and wave incense around and ring bells and snuff out candles, maybe the snake thing will slither away after all.

The old men will do this during their breaks from raping children, of course.

The 12th Century is so over. Get used to it.

Wednesday, November 13, 2013

Hey Indeedy . . .

Donald Berwick was Obama's nominee to be head of the Center for Medicare and Medicaid Services but served only during a recess appointment because the Republicans in the Senate called him a socialist. (He had praised the British National Health Service, among other evidences of Commie sympathies.) He has an essay in today's JAMA, which I think you probably can't read because you don't have the magic cookie. He says stuff I've said here before, but better, beginning with:

It could be exciting. The ambitious nation that rallied to create the Marshall Plan, get to the moon first, and birth Medicare and Medicaid decides to move toward the health care it needs: universal, responsive, and affordable. But that task does not unite the nation; it rends it into political tatters.

But why? What's his diagnosis? As he points out, we're spending twice what other affluent countries are spending, and getting less. They give quality care to everybody, with better patient safety, better outcomes and more investment in prevention. Here are his explanations:

Vested interests: We pay more than any other country, which means that people and institutions are on the receiving end of all that money. They happily invest some of it in lobbying and political contributions to keep the gravy train flowing.

Diffuse interests: The majority of ordinary people who would benefit from sensible reforms aren't organized or powerful. I will add that they are also misled.

Abdication of professional responsibility: The American Medical Association opposed Medicare and every other proposal to provide government-sponsored insurance throughout most of its history. The AMA has changed on that point but doctors still don't advocate for universal, comprehensive health care, single payer or otherwise. They're more interested in keeping their incomes high.

Public distrust of science: Don't get me started. It's easy to convince people that evidence-based guidelines discouraging overtreatment and overdiagnosis are a conspiracy to "ration" health care and murder grandma, because they think science is an elitist conspiracy against the people. Thank the Koch brothers.

Contempt for the poor: If people can't afford health care, it's obviously their own fault.

There's a bit more but those are the high points. Look, the Affordable Care Act isn't the greatest policymaking ever, by a lot. It was cobbled together so as to keep the insurance companies and hospitals and AMA from torpedoing it. But it will make things a bit better, and creates a base for substantial progress in the long term.

Bill Clinton needs to shut up and butt out. The Democratic panic and instinct to retreat in this situation is just pathetic. Stand up, stand your ground, wait out the tempest. In six months, it will be a fait acompli, and there will be no going back. 

Monday, November 11, 2013

Don't Panic

By the end of this week the federroble gummint has  promised to announce progress in enrollment in health insurance through the Affordable Care Act. Via my inbox, a preview from Avalere Health -- it's going to be a very small number, maybe just 50,000.

You already know how the corporate media will play this -- there seems to be a law that you have to say "trainwreck." Republicans will yell and scream that we have to repeal this disastrous mistake, and Democrats will start panicking and filing legislation to delay the individual mandate.

Pish tosh. Avalere also points out that enrollment in Medicare Part D - the Bush administration prescription drug benefit that is now taken for granted - was almost as slow. In fact, 2/3 of the people who ultimately voluntarily enrolled did so after coverage began, and fewer than 10% had enrolled one month before open enrollment ended. In other words, if we have the same experience, the Affordable Care Act will look like a big success by March, but it will look like a miserable failure in December.

Yeah, the bad web site has slowed things down a bit, but basically, people are procrastinators. The problems with the web site will be long forgotten by November of 2014.

Friday, November 08, 2013

It's complicated . . .

That would not be any particular romantic or other personal relationship, but rather the Affordable Care Act and the bizarre non-system it is jury-rigged to somewhat improve. It is a true fact, which the prez failed to make clear (or probably didn't really grok himself) that some of those people who are getting cancellation notices are actually relatively affluent individuals who intentionally chose cheap catastrophic coverage because they figure they can afford to pay out of pocket for routine medical expenses. That single class of people will now have to pay more for more comprehensive policies, and won't get enough subsidy for it to end up cheaper, or perhaps no subsidy at all.

I wish I could have explained even that little piece of the whole story more simply. Now, whether any particular one of those people ends up better or worse off depends on whether they are hit by a bus or something next year. If they are, before their catastrophic coverage kicks in the deductible from the old policy would have been more than the premium for the new one. (Still complicated, sorry.) But, they probably won't be and in any case, they feel as though their choices has been restricted.

True enough. It's also true when you pay into Social Security and Medicare and pay your regular income taxes of course. And Randroids don't like that. But it's nothing new and it isn't tyranny. Let's be up front here: there is a redistributive element to the Affordable Care Act. It's intended to make the working poor, childless unemployed people, and moderate income people better off, and somebody has to pay for that. There's a modest tax on medical devices, a tax on very high end insurance policies, reductions in Medicare spending that come out of hospital incomes (basically), limits on insurance company expenses and profits (which are somebodies' income), and oh yeah, some relatively well-to-do people will buy insurance with benefits they don't need or want and that will help subsidize needier people.

In other words, like every public policy ever promulgated, there are winners and losers. In this case, the losers are people who can afford it, for the most part. (Not clear whether some lower level jobs in the insurance industry will be lost since they aren't allowed to do medical underwriting any more. But more customers should mean it's a wash, at worst.) But to be clear, the howling over Obamacare isn't really because it's a trainwreck, or communism, or tyranny -- it's because a small number of relatively well off small business owners and trust fund babies will have to spend a few bucks they were planning on spending elsewhere. You can object to that if you like, but that's really what the issue is.

Thursday, November 07, 2013

yes, we are idiots

I checked out one of your major broadcast network evening news shows last night. Item 1: Obamacareyaddayaddayadda. Item 2: Miami Dolphins 300 pound lineman is allegedly bullied. Item 2: IPCC issues new report. Commercial.

What sayeth said IPCC report? Oh, just stuff like this:

  • Warming of the climate system is unequivocal, and since the 1950s, many of the observed changes are unprecedented over decades to millennia. The atmosphere and ocean have warmed, the amounts of snow and ice have diminished, sea level has risen, and the concentrations of greenhouse gases have increased.
  • Each of the last three decades has been successively warmer at the Earth’s surface than any preceding decade since 1850. In the Northern Hemisphere, 1983–2012 was likely the warmest 30-year period of the last 1400 years (medium confidence).
  • Ocean warming dominates the increase in energy stored in the climate system, accounting for more than 90% of the energy accumulated between 1971 and 2010 (high confidence). It is virtually certain that the upper ocean (0−700 m) warmed from 1971 to 2010, and it likely warmed between the 1870s and 1971.
  • Over the last two decades, the Greenland and Antarctic ice sheets have been losing mass, glaciers have continued to shrink almost worldwide, and Arctic sea ice and Northern Hemisphere spring snow cover have continued to decrease in extent (high confidence).
  • The rate of sea level rise since the mid-19th century has been larger than the mean rate during the previous two millennia (high confidence). Over the period 1901–2010, global mean sea level rose by 0.19 [0.17 to 0.21] m.
  • The atmospheric concentrations of carbon dioxide (CO2), methane, and nitrous oxide have increased to levels unprecedented in at least the last 800,000 years. CO2 concentrations have increased by 40% since pre-industrial times, primarily from fossil fuel emissions and secondarily from net land use change emissions. The ocean has absorbed about 30% of the emitted anthropogenic carbon dioxide, causing ocean acidification.

And? Oh, just Stuff like this:

Thousands of people in vulnerable areas of the Philippines are being relocated as one of the strongest tropical cyclones ever observed spins toward the country. With sustained winds of 315 kph (195 mph) and gusts as strong as 380 kph (235 mph), Super Typhoon Haiyan was churning across the Western Pacific toward the central Philippines. . . . As it moves across heavily populated areas of the central Philippines, Haiyan's high winds and torrential rain are expected to affect millions of people. The storm system had a diameter of about 800 kilometers (500 miles) as of early Thursday afternoon.

But you know, we can't interfere with the right of the Koch brothers to increase their inherited fortune without limit, because Freedom.

Wednesday, November 06, 2013

The real meaning of Republicanism

This essay in NEJM is, unfortunately, off-limits to the common rabble as far as I know, but doctors Michael Stillman and Monalisa Tailor explain what these people who are fighting to their last breath to prevent people from having health insurance are really doing. Fair use excerpt:

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer. The year before, he'd had similar symptoms and visited a primary care physician, who had taken a cursory history, told Mr. Davis he'd need insurance to be adequately evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and ineligible for Kentucky Medicaid, however, he'd simply used enemas until he was unable to defecate. By the time of his emergency department evaluation, he had a fully obstructed colon and widespread disease and chose to forgo treatment. Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation. As his wife sobbed next to him in our examination room, he recounted his months of weight loss, the unbearable pain of his bowel movements, and his gnawing suspicion that he had cancer. “If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

They go on to tell of a woman with a lung nodule who couldn't afford a PET scan -- so the surgeon refused to operate; and other horror stories. Research has found that 45,000 Americans die every year because they can't afford health insurance -- and note that these are nearly all people under 65. But the disinformation campaign has been effective: " During our appointment with Mr. Davis, he worried aloud that under the ACA, “the government would tax him for not having insurance.” He was unaware (as many of our poor and uninsured patients may be) that under that law's final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to comprehensive and affordable care."

These conservative billionaires who fund the astroturf "Tea Party" and Sens. Cruz and Rubio and all their co-conspirators are evil, repulsive, psychopathic bastards. That anybody will vote for these disgusting creeps proves that our political culture is profoundly diseased. 

Monday, November 04, 2013

Guest lecture

Here's some of what I will be saying today. The students have read two histories of the controversy over leaded gasoline and its ultimate banning. (One is Kevin Drum's famous Mother Jones article, the other an academic essay by Herbert Needleman, a scientist who was a pioneer in recognizing the harm caused by low levels of exposure to lead.) A major part of this story is of course that a powerful industry for decades dishonestly attacked science and scientists, including Needleman, in the completely amoral pursuit of economic self-interest, at incalculable human cost. This plot has been reproduced endlessly -- tobacco, acid rain, pesticides, global warming, you name it.

But you need to understand not only that this happens, but why it works. The fact is, risk assessment is hard, and inevitably freighted with uncertainty. And even after you manage to narrow down those uncertainties, there are still value conflicts about the implications of our knowledge.

In order to understand an environmental risk, you need to go through four steps:

Hazard identification

Dose-response assessment

Exposure assessment

Risk Characterization

Hazard identification means that relevant people -- those who can cause the next steps to be taken  -- recognize that some chemical or other phenomenon present in the human environment might be dangerous and we ought to study it. The fact is that most of the chemicals commonly used in consumer products or emitted into the air, water and soil have not been studied much, if at all, for their potential harm to humans and other living things. Until Needleman and others came along, this was basically true of lead. We knew it was toxic at high doses, but assumed to be harmless at the levels of exposure people experienced from gasoline and paint.

Dose-response assessment means figuring out what the consequences are of exposure to the chemical at the continuum of plausible levels and patterns. This is very difficult because, obviously, you can't experiment on people. We do experiment on animals, notably mice, but let me give you the news: mice aren't people and there are plenty of well known cases in which exposure harmless to mice are dangerous to people, and vice versa. Epidemiological data is very difficult to interpret, for reasons I have discussed here before. Basically, it's difficult to separate out the exposure of interest from everything else that goes along with it, e.g. exposure to lead from gasoline depended on where you lived and spent your time so maybe the observed effects aren't because of lead at all. A corollary is that you can't easily measure people's exposure. In the case of lead, because it persists in the body, you can measure the concentration in blood, which helps. But there will still be arguments over acute vs. chronic exposure, and yes, there are confounders that go along with blood lead levels as well as imputed exposures. And you have to know what effects to look for. If you aren't measuring the relevant endpoints, you won't see them, obviously.

Exposure assessment means figuring out who is exposed to how much of the stuff and by what routes. This is also very difficult because chemicals travel through the environment along complicated paths that are affected by all sorts of influences -- wind, rain, temperature, the food chain, human behaviors, on and on. And chronicity of exposure matters as much as amount.

Finally, risk characterization means putting it all together: somehow multiplying the dose response by people's actual exposure to say "Ultrafine particle pollution from highways is causing 180,000 heart attacks each year in North America," or something like that. (I just made up the number but it does apparently cause cardiovascular disease and also triggers myocardial infarctions.) However, that's not the only consequence of UFP pollution and you need to somehow translate all of the harms of an exposure into a common currency that can be compared with the benefits. In other words, we aren't going to give up cars, trucks and buses even though we know they cause harms. We need some method of weighing harms against benefits. And of dealing with uncertainties while we do this.

Hence, people argue. That's never going to stop but at least we can develop a common understanding of the available information. Or at least it would be nice if we could.

Friday, November 01, 2013

A righteous rant

This one from British doc Iona Heath. (I'm not 100% sure you can read this, I can't test the site without my magic cookie.) Anyway, she reminds me of Ivan Illich's famous book Medical Nemesis. Illich, writing back in 1982, argued that medicine, on balance, did more harm than good. Heath doesn't go that far, and neither do I, although in 1982 Illich had a defensible case. Medical intervention has become more effective since then, as the longer survival of people with heart disease, which I discussed a couple of days ago, demonstrates. However . . .

In addition to the downside that those longer lives are often spent in a condition of sickness and disability, medicine inflicts harms directly. First of all, money wasted on ineffective, futile or harmful medical intervention is money taken from some better use. And that includes improving the social and physical conditions of people's lives in ways that will keep us all healthier in the first place. It also includes putting disease labels on people who have no symptoms and whose only "disease" is some lab test that is outside of an arbitrarily defined range of normality.

Those people then have to live with anxiety and the sense that they aren't really healthy after all. They may take pills that cost them money and have adverse effects. They may undergo biopsies, or surgery, go back for repeated physician visits just to be told the results of yet more and more lab tests. As Heath writes:

[W]e have, for the first time in history, separated our notions of disease from the human experience of suffering and have created an epidemic of disease without symptoms, defined only by aberrant biometrics. An ever greater proportion of healthcare resources are directed towards reducing these numbers to some fictitious state of normality. In the process, those who are perfectly well are not only assigned labels that in themselves can be shown to compromise health but are also exposed to treatments with significant adverse effects. . . . . If nothing else, this serves to distract attention from the government’s failure to meet its own responsibilities for health protection through fiscal and legislative measures, such as promoting greater socioeconomic equity, nurturing vulnerable families, and such policies as minimum pricing for alcohol, and plain packaging for cigarettes.

Extending the range of what is considered abnormal clearly expands markets for pharmaceutical and other interventions, and thereby the possibilities of maximising commercial profit. . . . As more and more people previously considered normal are included within the definition of, for example, hypertension, diabetes, or breast cancer, outcomes improve: rates of hypertensive stroke or diabetic foot amputation or breast cancer mortality seem to fall. In this way, extending the definitions of disease and lowering the thresholds for preventive interventions create the illusion of improved population outcomes, while there is no difference at all in the outcomes for affected individuals. Clinicians, health policy makers, and politicians have found it difficult to resist these seductive illusions of progress.
 We are chasing a mirage. Health is not a biological state read off of an elaborate construct of structured biological measurements. It is a condition to which medicine can contribute sometimes, in some circumstances, but too much medicine is bad medicine. Somehow our culture cannot encompass that.