Map of life expectancy at birth from Global Education Project.

Thursday, January 31, 2019

A real national emergency

Actually there are a few of them but Rajan Menon offers a good, succinct discussion of the opioid epidemic. When a few fanatics hijacked airliners and flew them into buildings, killing about 3,000 people, the U.S. went on a nearly two decade freakout. Since then, 400,000 Americans have died from prescription or illicit opioid overdoses, some 70,000 of them in 2017.

Individual 1 did indeed declare a public health emergency in that year, but never actually did anything about it. Congress did appropriate $6 billion a year to combat the crisis, but that has had no discernible effect. And let's be clear here: illicit drugs do not come into the United States by means of illicit border crossings and would not be stopped or even minimally affected by a wall. They come concealed in cargo that passes through ports of entry, in boats, and even by means of the U.S. Postal Service (mostly through China). And of course a lot of the drugs that are killing people aren't smuggled into the country at all, they are manufactured here, legally, and either prescribed or diverted.

The reason we have this national emergency is largely because of the amoral actions of pharmaceutical manufacturers, notably but not exclusively the Sackler family, owners of Purdue Pharma, who have already paid $634.5 million in fines for deceiving the public about its product Oxycontin. Three of its employees were also fined $35 million, which the company paid for them. The company also settled lawsuits with states for some $44 million, and six more states are suing them now. Doesn't matter to them, they took in $35 billion selling the product and the family is worth $14 billion. Now that's a crime.

A lot of the deaths now are due to other synthetic opioids, such as fentanyl, much of it illicitly manufactured. But the people dying from these poisons became addicted from prescribed drugs, or from illegally diverted drugs, or from the culture of opioid abuse created by the drug companies. They took doctors out to fancy parties and paid them honoraria and told them lies to encourage them to freely prescribe drugs they knew to be addictive and dangerous. And of course there were dishonest physicians who handed them out to anyone in exchange for money. The drug companies could see that there were ridiculous levels of consumption of their products in some communities but they did nothing about it. So this is just mass murder for profit. But billionaires are allowed to do that.

Tuesday, January 29, 2019


Specifically, the freedumb to let your kids get seriously ill. I believe I may have mentioned previously that all but three states allow parents to opt out of mandatory vaccination for their children to attend school. Most of these allow only "religious" exemptions but of course anybody can claim to have one. Other just allow for "personal beliefs," which means there isn't actually any mandate at all.

It is a basic principle of medical ethics that people have to give informed consent for medical interventions. However, the situation with children is different. We don't let people starve or poison their children out of personal conviction or religious belief, and we don't let them refuse life saving treatment for cancer or other diseases either. People's rights to raise their children don't extend to abuse and neglect. That's a societal consensus. I see no reason why refusing vaccination should be an exception.

Update: Some people have no sense of irony.

Sunday, January 27, 2019

Sunday Sermonette: Best grift ever

Here's the rest of Genesis 41. It's just a little bit, but it starts to tell the real story of what's going on here.

46 Joseph was thirty years old when he entered the service of Pharaoh king of Egypt. And Joseph went out from Pharaoh’s presence and traveled throughout Egypt. 47 During the seven years of abundance the land produced plentifully. 48 Joseph collected all the food produced in those seven years of abundance in Egypt and stored it in the cities. In each city he put the food grown in the fields surrounding it. 49 Joseph stored up huge quantities of grain, like the sand of the sea; it was so much that he stopped keeping records because it was beyond measure.
Okay, so Joseph is putting a stiff tax on all the farmers. The author doesn't tell us exactly how much, but it's "all the food produced." That can't be taken  literally obviously but it's apparently all of the surplus.  And he isn't borrowing it, he's confiscating it. He doesn't even bother to keep records of who he took it from. And evidently the farmers aren't allowed to store up any surplus for themselves. They have to give everything to Joseph.
50 Before the years of famine came, two sons were born to Joseph by Asenath daughter of Potiphera, priest of On. 51 Joseph named his firstborn Manasseh[e] and said, “It is because God has made me forget all my trouble and all my father’s household.” 52 The second son he named Ephraim[f] and said, “It is because God has made me fruitful in the land of my suffering.”
53 The seven years of abundance in Egypt came to an end, 54 and the seven years of famine began, just as Joseph had said. There was famine in all the other lands, but in the whole land of Egypt there was food. 55 When all Egypt began to feel the famine, the people cried to Pharaoh for food. Then Pharaoh told all the Egyptians, “Go to Joseph and do what he tells you.”
56 When the famine had spread over the whole country, Joseph opened all the storehouses and sold grain to the Egyptians, for the famine was severe throughout Egypt. 57 And all the world came to Egypt to buy grain from Joseph, because the famine was severe everywhere.
 Okay, you see what's happening, right? Joseph confiscated the grain from all of the farmers, and now he is selling it to the hungry people. God is starving the whole world, so that Joseph can sell the grain he took from the farmers and put the money in his own pocket. If you aren't yet entirely sure that this is what's happening, wait for chapter 47. There will be some rigamarole in between, but it will be missing the real point.
  1. Genesis 41:51 Manasseh sounds like and may be derived from the Hebrew for forget.
  2. Genesis 41:52 Ephraim sounds like the Hebrew for twice fruitful.

Friday, January 25, 2019

The Merchants of Death

This study by authors including my colleague Brandon Marshall nails them. For those of you who don't know, pharmaceutical companies promote their products by giving physicians free meals, paying for their travel to conferences, giving them speaking fees and honoraria, consulting fees, and otherwise crossing the palm with silver. They do this because it works -- it is associated with increased prescribing of their products.

It turns out the more payments they made in a U.S. county to promote opioid prescribing, the more prescriptions were written, and in turn, the more overdose deaths there were. The strongest association was with the number of physicians receiving payments, rather than the total value of the payments. In other words, it doesn't take a lot of vigorish to get results.

Purdue pharmaceutical is being sued for misrepresenting the risk of its product oxycodone, but all of this marketing is inappropriate and should be banned. Physicians should base their prescribing decisions on the scientific literature and consensus guidelines, not on who buys them a fancy dinner. The drug companies are killing people to satiate their greed.

Wednesday, January 23, 2019

The Wetware

This is an idea I have discussed briefly before, but here's a real scientist discussing the relationship between the complexity of the human brain and it's likelihood of failure. We tend to take ourselves for granted but we've found that what seem to us to be our simplest capabilities are so far impossible to model or emulate with computers. Just making a plan to get through the next hour, let alone life, is a unique capability of Homo sapiens.

But the danger is that when this astonishingly capable machine goes awry, it can go spectacularly wrong. Dr. Paz refers to mental illness, specifically ADHD, anxiety, depression, PTSD and autism, but of course schizophrenia can get a lot weirder. People can know for certain that they are being controlled by radio waves from Mars or have ideas that don't translate into any sense the rest of us can make of them.

But I'm more interested here in malfunctions that aren't necessarily associated with diagnosable mental illness. In some cases, psychiatrists will attach a diagnostic label to these but they are not diseases in the same sense as measles or atherosclerosis. The person with the "disease" may not suffer at all or think that she or he needs to be cured or fixed in any way. The "disease" is only a problem for the rest of us. This is true of some of people who are diagnosed with a personality disorder, but many of these disorders are not really coherent sets of characteristics. They are diagnosed by deciding that a person has 5 out of 8 indicators (all of which are subjective anyway), so that two people with the same diagnosis may have almost nothing in common.

Most people with those diagnoses are just annoying, some are lonely, and some are quite miserable. But then there is psychopathy. This is a medical term for what used to be called just plain evil. For example, the guy in Wisconsin who kidnapped a 13 year old girl after murdering her parents just because he wanted to possess her. He can probably be diagnosed as a psychopath, although he's something of an unusual case since apparently he showed no signs of it until he suddenly did this grotesque crime.

Then there are people who clearly can't get diagnosed as insane but nevertheless manage to go down a road of preposterous delusion, like the guy who shot up the pizza restaurant in D.C. because he believed the absurd story that it was the headquarters of a child sex ring run by Hillary Clinton. People who believe that, believe it or not, are generally not schizophrenic.

Then we have people who believe, for example, that building a 30 foot wall along the U.S. Mexico border will reduce the crime rate and keep illicit drugs out of the country. Or that depriving people of health insurance will make them free. Or that reducing tax rates on billionaires will make workers more prosperous. It takes a very complex and capable brain to believe stuff that is completely nuts.

UPDATE:  Here's a dispassionate analysis of the effect of the TCJA. Many are even less optimistic.

The Republican claim that depriving people of health insurance makes them free goes  all the way back to Ronald Reagan.

Here's a list of personal income tax rates in Europe. You will note that the richest countries are at the top, and the poorest countries are at the bottom. Hmmm.

Thomas Piketty and Emanuel Saenz on top marginal tax rates

Sunday, January 20, 2019

Sunday Sermonette: It's a small world

Genesis 41 is quite long, so we'll take it in pieces. Here's part 1.

When two full years had passed, Pharaoh had a dream: He was standing by the Nile, when out of the river there came up seven cows, sleek and fat, and they grazed among the reeds. After them, seven other cows, ugly and gaunt, came up out of the Nile and stood beside those on the riverbank. And the cows that were ugly and gaunt ate up the seven sleek, fat cows. Then Pharaoh woke up.
He fell asleep again and had a second dream: Seven heads of grain, healthy and good, were growing on a single stalk. After them, seven other heads of grain sprouted—thin and scorched by the east wind. The thin heads of grain swallowed up the seven healthy, full heads. Then Pharaoh woke up; it had been a dream.
In the morning his mind was troubled, so he sent for all the magicians and wise men of Egypt. Pharaoh told them his dreams, but no one could interpret them for him.
Then the chief cupbearer said to Pharaoh, “Today I am reminded of my shortcomings. 10 Pharaoh was once angry with his servants, and he imprisoned me and the chief baker in the house of the captain of the guard. 11 Each of us had a dream the same night, and each dream had a meaning of its own. 12 Now a young Hebrew was there with us, a servant of the captain of the guard. We told him our dreams, and he interpreted them for us, giving each man the interpretation of his dream. 13 And things turned out exactly as he interpreted them to us: I was restored to my position, and the other man was impaled.”
14 So Pharaoh sent for Joseph, and he was quickly brought from the dungeon. When he had shaved and changed his clothes, he came before Pharaoh.
15 Pharaoh said to Joseph, “I had a dream, and no one can interpret it. But I have heard it said of you that when you hear a dream you can interpret it.”
16 “I cannot do it,” Joseph replied to Pharaoh, “but God will give Pharaoh the answer he desires.”
17 Then Pharaoh said to Joseph, “In my dream I was standing on the bank of the Nile, 18 when out of the river there came up seven cows, fat and sleek, and they grazed among the reeds. 19 After them, seven other cows came up—scrawny and very ugly and lean. I had never seen such ugly cows in all the land of Egypt. 20 The lean, ugly cows ate up the seven fat cows that came up first. 21 But even after they ate them, no one could tell that they had done so; they looked just as ugly as before. Then I woke up.
22 “In my dream I saw seven heads of grain, full and good, growing on a single stalk. 23 After them, seven other heads sprouted—withered and thin and scorched by the east wind. 24 The thin heads of grain swallowed up the seven good heads. I told this to the magicians, but none of them could explain it to me.”'
I've thought a bit about this literary habit of repetition. Instead of just writing, "Pharaoh told Joseph of his dreams," which we already know about, the whole story has to be told again. It makes for tedious reading, to say the least. I think this is probably because hardly anyone was literate. People would hear this story read aloud. The repetition slows it down and gives hearers a better chance to absorb it all.
25 Then Joseph said to Pharaoh, “The dreams of Pharaoh are one and the same. God has revealed to Pharaoh what he is about to do. 26 The seven good cows are seven years, and the seven good heads of grain are seven years; it is one and the same dream. 27 The seven lean, ugly cows that came up afterward are seven years, and so are the seven worthless heads of grain scorched by the east wind: They are seven years of famine.
28 “It is just as I said to Pharaoh: God has shown Pharaoh what he is about to do. 29 Seven years of great abundance are coming throughout the land of Egypt, 30 but seven years of famine will follow them. Then all the abundance in Egypt will be forgotten, and the famine will ravage the land. 31 The abundance in the land will not be remembered, because the famine that follows it will be so severe. 32 The reason the dream was given to Pharaoh in two forms is that the matter has been firmly decided by God, and God will do it soon.
As we shall see, it's not just Egypt that will suffer famine, it is the entire world. We'll get to that. Regardless, God is a repulsive psychopath. His apparent reason for starving the world is to make Joseph rich. No, he isn't being a humanitarian by storing up grain -- he ends up selling it and gaining tyrannical control. People who don't have the money to buy from him, or land to give him in exchange for food, will starve to death.
33 “And now let Pharaoh look for a discerning and wise man and put him in charge of the land of Egypt. 34 Let Pharaoh appoint commissioners over the land to take a fifth of the harvest of Egypt during the seven years of abundance. 35 They should collect all the food of these good years that are coming and store up the grain under the authority of Pharaoh, to be kept in the cities for food. 36 This food should be held in reserve for the country, to be used during the seven years of famine that will come upon Egypt, so that the country may not be ruined by the famine.”
37 The plan seemed good to Pharaoh and to all his officials. 38 So Pharaoh asked them, “Can we find anyone like this man, one in whom is the spirit of God[a]?”
39 Then Pharaoh said to Joseph, “Since God has made all this known to you, there is no one so discerning and wise as you. 40 You shall be in charge of my palace, and all my people are to submit to your orders. Only with respect to the throne will I be greater than you.”
41 So Pharaoh said to Joseph, “I hereby put you in charge of the whole land of Egypt.” 42 Then Pharaoh took his signet ring from his finger and put it on Joseph’s finger. He dressed him in robes of fine linen and put a gold chain around his neck. 43 He had him ride in a chariot as his second-in-command,[b] and people shouted before him, “Make way[c]!” Thus he put him in charge of the whole land of Egypt.
44 Then Pharaoh said to Joseph, “I am Pharaoh, but without your word no one will lift hand or foot in all Egypt.” 45 Pharaoh gave Joseph the name Zaphenath-Paneah and gave 15 him Asenath daughter of Potiphera, priest of On,[d] to be his wife. And Joseph went throughout the land of Egypt.

Yeah right. Pharaoh has just met this Hebrew slave  15 minutes ago, he's heard a dream interpreted by the agency of a God that Pharaoh does not even believe in, so he decides to spend all of his time with his harem and give the entire kingdom over to this stranger. Makes perfect sense to me. But this is going to a very ugly place.

Friday, January 18, 2019

What really matters

Australia is suffering from its worst heat wave in history. The heat is so extreme that it killed one third of the entire population of flying foxes -- actually a species of bat -- in two days. If this continues, substantial parts of the country will become essentially uninhabitable, as will much of the Middle East and the tropics. And it will continue.

Here's what's been happening with heat waves around the world:

A heatwave was defined as a period of 4 or more days at a given location where the
minimum daily temperature was greater than the 99th percentile of the distribution
of minimum daily temperature at that location over the 1986-2005 reference period,for the summer months.

You aren't going to like it when it happens to you, believe me. Solomon and colleagues in NEJM comment on the global emergency, which is described more fully by Haines and Ebi here. They provide this figure:

I know it's too small to read but you can go to the original. Extreme weather events including massive storms, droughts, and wildfires; heat stress killing people and making it impossible to work; air pollution from burning fossil fuels and wildfires; water shortages; food shortages; vector born diseases; mass migration and socio-cultural stress and destruction. These aren't just off in some distant future. They are happening now, and it will get worse fast.

And here we are squabbling about an idiotic wall on the southern border, all because Vladimir Putin put his stooge in the White House. Listen up folks, this is the gravest emergency humanity has ever faced. World War II happened, and then it was over. This won't be over, ever, unless we stop it, starting now. Nothing else matters if we don't fix this.