Map of life expectancy at birth from Global Education Project.

Thursday, January 28, 2016

A couple of thoughts about Zika virus

Epidemics are scary, and often the fear is exaggerated and leads to all sorts of irrational behavior. All we need is to recall the lunacy over Ebola virus in 2014, which was never a significant threat to the United States. (Of course it was awful where it was epidemic, and the lack of sympathy here in the U.S. for people in the affected regions was at least as appalling as the misguided panic.) The flu pandemic hoax of 2010 was another excellent example.

However, the WHO's alarm over Zika virus does seem proportionate. But this is a complicated story. The virus, which is related to Dengue, has never particularly concerned anyone until now. It is indigenous to tropical Africa and southeast Asia, and was known only to produce mild symptoms. So why is it suddenly thought to be causing catastrophic birth defects in the Americas?

I don't know the answer, but I can offer a pretty good hypothesis. In areas where it has long been endemic, chances are excellent that a woman will have been infected at some time before she ever becomes pregnant, and therefore likely has long-term, perhaps lifetime, immunity. Assuming it is really true that infection during pregnancy causes microcephaly and other serious damage to the fetus, it didn't happen often enough that anybody noticed. Now, a note of caution: we are seeing a coincidence in time of the arrival of Zika in the Americas and an apparent spike in these birth defects. It's only a strong suspicion that they are related, it might be something else we don't yet know about.

In any event, if this is what is really happening, it's a variation on a classic theme. The indigenous people of the Americas were decimated by contact with Europeans because Europeans had all sorts of endemic diseases to which they had evolved relative immunity. But a population naive to an infectious disease is the formula for disaster.

In this case, it shouldn't be a long-term disaster because even as the epidemic of birth defects is raging, girls below reproductive age are getting infected, and presumably their babies will not be at risk. Of course that sanguine analysis depends on the probability of their getting infected before they ever get pregnant, and of a previously uninfected woman becoming infected while she is pregnant. Based on the African experience, we have to presume that the math works out pretty well.

But even an occasional instance of microcephaly is a terrible event. These babies will have very limited existence. So I do hope the vaccine comes soon. Meanwhile, this is a reminder that the prospect of disaster from emerging infectious disease always looms in the modern, densely populated, densely connected world. We need a World Health Organization that is well funded, highly competent, and gets full cooperation from the governments of the planet. We're short of that now.

Monday, January 25, 2016


A blog I occasionally visit, which you might enjoy, is Conscious Entities. The proprietor, who appears to be largely self-educated on the subject, but has done it well, it preoccupied with the so-called "hard problem" -- explaining our conscious experience, our self-awareness, within the modern naturalistic world view.

Of course, I may be the only entity in the universe which has the experience I call consciousness -- maybe the rest of you are zombies. That's one of the hard things about it. The only consciousness we can observe is our own. It seems a fair assumption that since humans are similar to each other in other fundamental ways, we all share the phenomenon of consciousness; and those of us who are not psychopaths are wired to believe it instinctively, through the capacity of empathy. It's less certain with other animals, but that very imponderability leads to all sorts of conflicts about ethics.

For those of who think that metaphysics is dead, the problem of consciousness is an irritant. It feels as though there is some realm outside of the material in which our selves exist. If that is not the case, then we are saying that consciousness is indeed a material phenomenon. Yet we can't detect it, and it seems unnecessary for the evolved functioning of the organism. You could presumably write a lot of instructions that process sensory inputs and generate behavioral outputs that look exactly like a conscious human, but without the consciousness part.

It's a puzzle, and since we can't detect consciousness in others directly, all we can do is talk about it.

Wednesday, January 20, 2016

People are all mixed up

Here is a thoughtful and eloquent essay about the humane practice of medicine from a physician. Dr. Newman, like me, thinks that the biological reductionism of medical practice is not good for patients. He espouses humility in medicine, and understanding the profession as both art and science.

It appears that he also occasionally drugs his patients and sexually assaults them, or so it is alleged, which would seem harmful to the cause. I find this quite mysterious -- certainly I can't see how it is gratifying or why anybody would do that. If you think about Bill Cosby's public persona and his (rather prissy) hectoring about rectitude and respectability, it seems these are kindred spirits.

The Jekyll and Hyde story is archetypal, I suppose. All people are a mixture of good and bad, but some people conceal more than others, and have more extreme polarity. I guess you never really know.

Monday, January 18, 2016

One thing that doesn't get said enough on MLK day

It is not just outrageous, but grotesque, that the FBI headquarters is still named for J. Edgar Hoover. The gay-hating homosexual racist far right blackmailer who, among other crimes against the people of the United States, tried to extort Martin Luther King into committing suicide. Read this and barf.

Members of Congress have tried to get legislation passed to take Hoover's name off the building, but it never goes anywhere. It seems he is still very popular with one of the two major political parties.

Thursday, January 14, 2016

Long Term Problem

John Iglehart, in the new NEJM, does the Cassandra thing with Long Term Services and Supports, also called Long Term Care. (I'm not sure what the public access is to this piece.) The kicker is that right now, this problem is getting essentially no attention from politicians.

Most people who have chronic disabling conditions get most of their care from unpaid family members or friends -- some 40 million people currently in that role. Many of them end up leaving the workforce because they can't handle both jobs simultaneously. What many people don't seem to know is that their health insurance -- whether it's private insurance or Medicare -- won't pay for long term health care, in a nursing home or in the community, and won't pay for essential non-medical services such as housekeeping. It costs more than $90,000 a year to be in a nursing home, and $43,000 to be in an assisted living facility or to get full-time home health aide services. Very few people have that kind of money.

Right now about half the people who need LTSS are over 65 but that percentage, and the absolute number, will obviously increase as the population ages. Not everybody will ever need to pay for LTSS -- some of us are lucky enough to die before we develop severe disabilities -- and others won't ever have to pay for it because we'll be able to rely on family members. But 16% will spend more than $100,000 and few elderly people have that kind of money. I think you know what happens in that case -- you have to spend everything you have, then Medicaid takes over.

It is possible to buy long-term care insurance but it is very expensive and hardly anybody has it. While the Republicans are all promising to repeal the Affordable Care Act, neither they nor Hillary nor Bernie are saying anything about this problem. It's solvable the same way many of our other severe problems are -- tax the rich.

Tuesday, January 12, 2016

Diversionary Tactic

Rita Rubin, in the new JAMA, discusses the relationship between mental health treatment and gun violence. Since we can't seem to get any policies implemented that will actually reduce gun violence, it's fashionable for politicians to use the problem as an argument for improving accessibility of behavioral health services.

I am reluctant to be contrarian about this because I'm all for getting people the help they need. However, this is an excellent example of the way cognitive biases distort our politics. While it is true that mass shooters -- like the perpetrators of the attack on Gabby Giffords and the Aurora, Colorado movie theater massacre -- are disproportionately likely to be seriously mentally ill, such mass killings are a minuscule proportion of all gun violence.

And of course, the vast majority of people with mental illness are not dangerous -- they are far more likely to be victims of violence than perpetrators. And psychiatrists just have no way of predicting who is going to commit violence. So the argument that mental illness is a modifiable cause of gun violence just stigmatizes people who have enough problems already. The real point is to divert attention from what we can do effectively to limit gun violence -- much of which, by the way, is either suicide or what you might call accidental or might not.

After a mass murder in Australia in 1996, that country imposed much more restrictive gun laws. They banned some semi-automatic weapons altogether, and required people to get a firearms license and to show a good reason -- not just "self-defense" -- why they needed to own a gun. They bought back 700,000 weapons which were no longer legal. Since then, the incidence of gun violence in that country has fallen substantially, and there hasn't been a single mass killing. And the Australians do not live under tyranny.

So let's not surrender to this diversionary tactic. Yes, let's fix our mental health delivery and payment system. But don't pretend that will do anything to solve the gun violence problem.

Tuesday, January 05, 2016

But, the ACA does fall short

A New York Times survey finds that about 20% of people under 65 who have health insurance nevertheless have trouble paying out-of-pocket medical costs. The problem is that health care in the U.S. is still the most expensive in the world and many insurance plans have high deductibles and co-pays. People who sign up for health care on the ACA exchanges in particular tend to pick plans with high out-of-pocket costs because they are attracted by the lower premiums; but this doesn't necessarily turn out to be a good bet.

We still need universal, comprehensive, single payer national health care. Many of us supported the ACA because we thought it would be the camel's nose under the tent; but if anything it leaves the insurance companies more entrenched. Ultimately, we need a Democratic congress and president who are willing to take them on. I don't know if that's possible any time soon, but it's still the answer.