He who pays the piper . . .

Thanks to Blake for turning me on to the open-access International Journal of Environmental and Occupational Health, based in the land of the bowler and bumbershoot.

If you scroll down to the commentaries you'll find a link labeled "Inappropriate Ads in Peer-Reviewed Journals." Lee Friedman and Elihu Richter looked at a year's worth of advertising in The New England Journal of Medicine and JAMA (formerly the Journal of the American Medical Association, but they rebranded and now the letters officially don't stand for anything. However, it is still in fact if not in name the journal of the American Medical Association. Go figger.)

Anyhow, these magazines, which cost hundreds of dollars a year to subscribers, took in advertising revenue in 2001 of almost $18 million (NEJM) and over $27 million (JAMA). And that's not counting classified ads -- those are display ads, mostly from (drum roll please). . . . . .

You guessed it, drug manufacturers. Excluding ads from non-profit organizations and self-promotion for the journals and their owners (the Massachusetts Medical Society and the AMA), drug companies bought more than 90% of the display ads in both journals. Advertising in JAMA represents, get this, 23.5% of the gross revenue of the American Medical Association. (AMA publishes several other journals. They get much less advertising than JAMA, but the total revenue for the association from drug company ads is nevertheless even more than this.) The authors could not get information about Mass. Medical Society's overall finances, but $18 million a year must mean a lot to them. In fact, I suspect that as far as MMS is concerned, when you've got your drug company ads, you've got just about everything.

Now, AMA has a substantial lobbying operation in Washington, and I can tell you from plenty of personal experience that MMS is a major presence at the Massachusetts Statehouse. I just wonder whether they would ever think twice about really annoying their principal benefactors.

The Ownership Society

That's the society where they own you.

We've already squandered a substantial share of the universe's finite supply of bits beating the long-dead horse of Consumer Directed Healthcare™ here and at Critical Condition, but since the Bullshitter in Chief plans to ride this zombie steed into the chamber of the House for his State of the Union speech, we might as well keep working it over.

The concept that everybody should have really crappy health insurance, with high deductibles and co-pays, and then get various tax breaks -- straight deductions for expenses, and tax advantaged health savings accounts -- to subsidize their high out-of-pocket expenses -- would seem to have three consituencies who would find it rationally in their interest: financial services firms that would get to administer the health savings accounts, and skim off management fees; rich people for whom the tax breaks are worth a lot and who will benefit from the upward redistribution of income that the whole scheme implies (kind of a long story); and employers -- particularly in low-wage, labor intensive industries, such as retail and restaurant chains -- who will be relieved of pressure to provide decent health care insurance to their employees. (And by the way, they aren't waiting. Friendly's restaurant chain has just announced that it's moving hundreds of its full-time employees into high deductible, high co-pay insurance plans.)

Opposed would be physicians and hospitals, insurance companies (whose business will become less lucrative), and oh yeah -- everybody who eats and breathes. We've already explained why this scheme is not going to hold down health care costs, is not going to "empower consumers," is going to cause millions of people to be impoverished by misfortune, and is going to make health care less rational and effective by reducing use of preventive and early intervention services and causing people to end up sicker and needing more expensive treatments.

But now, just for the heck of it, the Commonwealth Fund has sponsored a survey of consumers to see how they like the high-copay, high deductible plans, compared with real health insurance. (Warning: presentation uses bizarre slide show technology, and the PDF crashes my Acrobat every time.) Big surprise! They don't like them nearly as much. This was an Internet survey, so it can't be presumed to be representative of the population, even though they weighted it by obvious variables such as income.

Still, for what it's worth, people who had the so-called consumer-driven plans (high deductibles and health savings accounts) were far less likely to be satisfied with their plans, spent more on out-of-pocket expenses, and "were significantly more likely to avoid, skip, or delay health care because of costs than were those with more comprehensive health insurance, with problems particularly pronounced among those with health problems or incomes under $50,000. About one-third of individuals in CHDPs (35 percent) and HDHPs (31 percent) reported delaying or avoiding care, compared with 17 percent of those in comprehensive health plans."

The only way to sell this to the public is to bamboozle them. The gang in charge used to be pretty good at that, but I'm betting this one will go the way of Social Security privatization. Anyhow, it had better.

Sound mind in a sound body . . .

Dementia is such a tragedy, and causes such difficulty for spouses, children and others who are close to people with dementia, that we are likely to overestimate its prevalence. Only about 2% of people age 65 to 69 are diagnosed with dementia, and even at age 75 the prevalence is only 5%. However, about a third of people in their 90s have dementia. Let me disclose that this is personal, because my father has dementia. I prefer not to say much about it here, except that it makes me keenly aware of the personal and social costs of dementia, and of the kinds of resources and services that families coping with dementia need. I will write more about this subject in coming days.

We often assume that increasing prevalence of dementia is simply a price we pay for increasing longevity, but that is probably only partly true. Findings reported in the Annals of Internal Medicine, and described here, tell an astonishingly different story. This was what is called a prospective longitudinal cohort study, so it's a strong design. Of 1,740 people 65 and older, with normal cognitive function at the beginning of the study, after 6.2 years 158 of them had developed dementia. But for people who reported exercising for at least 15 minutes three times a week -- and that doesn't mean running wind sprints or playing tennis, it includes walking, swimming, and stretching, etc. -- the incidence was 13/1,000 person years, compared with 19.7/1,000 person years for people who exercised less -- that's about a 40% reduction in risk. And while there could be some doubt as to causation -- possibly people who are prone to dementia are also less likely to exercise for some reason -- it was the frailest people who benefited the most.

As we have discussed ad nauseum here, obesity, diabetes, and related cardiovascular complications are the biggest public health problems confronting the U.S. right now, and physical activity is even more important than diet in preventing them. People who get plenty of vigorous exercise generally don't even have to worry about their calorie intake, because their bodies will automatically regulate their appetites appropriately. Marketing of junk food certainly contributes to the problem, but we live in an environment with a new kind of toxicity -- an environment that poisons our behavior. Television makes us stupid, utterly corrupts our politics, and degrades our culture. It also makes us sick, kills us, and now it appears, may ultimately destroy our minds.

Turn it off and go for a walk.

The Secret Santa

Once again, sadly, it's subscription only (I almost wrote prescription only), but the new Health Affairs theme issue on hospitals does an excellent job of telling the same important story 8 different ways. I'll depend mostly on Stuart Altman's version since I am a Heller School alum, with an assist from Alan Dobson and colleagues. (Links take you to the abstracts.)

First Dobson. Americans, we are told, don't like to pay taxes, even to pay for stuff they actually need and use. Or at least the people who make the largest campaign contributions make sure they keep their own taxes low. So, one way to keep taxes low is for government to underpay for the stuff it buys. Specifically, in 2002, Medicare payments to hospitals paid 95 cents on the dollar for the cost of hospital services, and Medicaid, on average, paid 92 cents. So-called "free care," schemes by which states reimburse hospitals for care of the uninsured and indigent, paid less than 20% of those costs. Hospitals aren't allowed to print money, so where does all that free money come from? It comes from overcharging private payers, mostly insurers. They paid 122% of the cost of the services they paid for in 2002, and that subsidized Medicare, Medicaid and free care. So one thing that will happen as Congress continues to tighten the screws on Medicare and Medicaid is that hospitals will either have to jack up their prices for private payers, or cut back on services.

Enter Stuart. In the name of spreading freedom and democracy to the United States, we are about to hear in the State of the Union address that we're going to have consumer directed health care. Yes, we've already worked that over pretty well here and at Critical Condition (where this is cross-posted). But Dr. Altman et al point up another little problem with it. Part of the idea is that hospitals will have to post their prices for everything, and since "consumers" (that what we'll be, instead of patients) will be paying for a big chunk of hospital services out of their own pockets (from big deductibles, co-payments, and whatever is in their finite Health Savings Accounts), they'll presumably go shopping around for the cheapest hospitals.

The classic version of a hospital in the U.S. is a non-profit charitable institution that provides a broad range of services and has a social mission, such that it tries to take care of everybody in need and provide benefits to the community. That's why all that cost-shifting happens in the first place -- it's the only way for hospitals to fulfill their social mission. Otherwise they'd have to refuse all Medicare and Medicaid beneficiaries, and uninsured patients. But there are already growing number of specialty hospitals, usually for-profit, that don't have emergency departments and that only provide particularly profitable services. They'll easily beat out general hospitals for the cherry picked customers in a brave new world of price transparency and comparison shopping by consumers. Meanwhile, in trying to compete with each other, the charitable general hospitals will have to drive down their own prices.

Stuart predicts that the hospital industry could end up like the airline industry -- highly cost-efficient specialty hospitals will drive the classic hospitals into bankruptcy, just as carriers that service limited, highly profitable routes with scanty amenities have sent the big airlines that used to fly everywhere the way of the dinosaur. Write the Brandeis Jeremiahs:

Downsizing, service reduction and salary cuts are not the only eventualities that could occur. It is also likely that the hospital industry could become tiered -- one system with modern up-to-date facilities, some focused and specialized, that serve the privately insured, and one poorer, underfunded and possibly publicly supported system that serves everyone else (Medicare and Medicaid patients, the poor, the uninsured, and many of the chronically ill); one system that dominates suburban areas with high income, high employment, and extensive insurance coverage, and one that serves the inner city, poor rural areas, and retirement communities.

And I'll just add, if those latter constituencies get served at all. Welcome to The Ownership Society, and the Culture of Life, backing into the future, over a cliff.

The Lessons of History

My aunt is about 80 years old, the widow of a preacher who was active in the church, doing the unsung and unpaid job of pastor's wife. She has been moderately liberal her entire life; she once got quite upset with me for saying that the United States has practiced imperialism.

The other night over dinner she asked, "Do you think we're like Germany in the 1930s?" Indeed, I think the comparison is apt. Although the specific demagogic ideology and outrageous actions of the current administration are obviously different from Nazi rhetoric and practices, the basic dramatic arc is the same. Here we have a gang of ruthless thugs conspiring to terminate republican institutions, seize unchallenged power, and set the nation on a course of mass violence in order to extend their power into the world and consolidate it eternally in what the Nazis called the Fatherland, and we are now instructed to call the Homeland. They purvey a mystical vision -- in the early case, sanctification of a racialized conception of German nationhood, today sanctification of radical individualism and corporate rapacity, allied with an atavistic, hallucinatory version of Old Testament theocracy -- to intoxicate the people and render truth and reason impotent.

And most important, we see only the most feeble resistance from elites, even those who would seem to stand to lose a great deal, even everything. A paradoxical combination of fear and incredulity that this is really happening seems to be at the heart of the liberal apathy. It is absolutely clear that the cabal that runs the country today is nothing more than a gang of murderous thieves and liars, yet we are having civil debates about whether or not the president of the United States does, as he claims, have absolute power, unaccountable to any law of the United States or international treaty, to imprison and torture anyone in the world, including U.S. citizens, on U.S. soil, without any possibility of review by any court or restriction by the Congress; to spy on citizens without any warrant or judicial review; to invade foreign lands; and in fact to ignore any law he chooses not to obey. The Democrats in the Senate have made it clear that they have no intention of meanginfully opposing the lifetime appointment to the Supreme Court of a man who unabashedly believes that the president does indeed have all the powers of Caesar Augustus.

We read on page 19 of the nation's leading newspaper, in a two paragraph article, that an investigatory arm of Congress has concluded that the president broke the law, on the same day that a huge front page story tells us that a special counsel investigation, after a decade, has concluded that a former Commerce Secretary might have underreported his income but there isn't actually any evidence for it. The nation is systematically abandoning its public health, social welfare, scientific research and physical infrastructure; and mortgaging its future to foreigners, so that wealthy people won't have to pay taxes, and to pay for young americans to slaughter and be slaughtered in a remote land for reasons that no-one can explain. But the corporate media largely ignore these developments. To the extent they pay attention to the war in Iraq, they simply internalize lies about the objectives and intentions of the cabal.

Oh, and by the way -- like Hitler, George W. Bush has never been elected president. He holds the office by fraud. This minor detail, like his dissolute and criminal past, is not to be mentioned in respectable circles. The profession of journalism has adopted a new standard. The job of a reporter is to write down what powerful people say. It makes no difference whether the reporter happens to know it isn't true. It is inappropriate for reporters to independently verify facts, then tell us whether a powerful individual is lying; that would not be balanced. In fact, they don't even have to identify the liars. They can just take dictation from a cabinet secretary, presidential staffer or public relations flak, then report it as information from an anoynymous senior official. Its veracity is not the reporter's problem. So we have a de facto state controlled media. "Opposition" politicians may also be quoted at times, though far less extensively than potentates of the ruling party. But they are far too cowardly to say anything that might seem to impugn the motives, truthfulness, or sincere patriotism of their rulers. And, just as before, grossly exaggerated or fabricated threats to the nation and its way of life -- then communists and jews, today radical Islamists and secular humanists -- against whom only an all-powerful heroic leader can protect us.

I haven't even mentioned half of the disasters which loom on the present course. Surely many Germans must have foreseen the catastrophe that awaited their nation, but they resisted only feebly. Again, that paradoxical combination of fear and disbelief. If it isn't really happening, what are you so scared of? And if you are scared, then shouldn't you act?

Addendum: Shortly after I wrote this, new polling data came out showing the Resident's job approval rating at 36% (58% unfavorable). So now I'm more puzzled than ever. Exactly what in the delta quadrant of the galaxy are Joe Biden and Harry Reid afraid of? That the soon-to-be-indicted traitor Karl Rove will call them names?

Just so you know . . .

I'm heading to the woods for a couple of days, won't be able to post until Sunday afternoon at the earliest. It's just as well though, because in my present state of mind I need some time to compose a rant sufficient unto the day.

In the Soviet Union, people generally knew enough not to believe television or newspapers. We all need to get into the same habit.

In Other News . . .

Yeah, yeah, I know there's a lot going on in the world right now. (And by the way, Osama bin Laden is the best friend George W. Bush ever had.*) But we might expect the corporate media to pay at least a little bit of attention to subjects such as major legislation before Congress that will affect the health care and economic welfare of tens of millions of Americans -- and as a matter of fact, in the end, most of us.

I'm talking about the Medicaid bill. The reconciliation will be before the House as soon as they get back to work, and while you can't read about it in the New York Times, or hear anything about it on NPR or the boob tube, you can read about it here, in a summary by Jocelyn Guyer of the Georgeown University Health Policy Insitute.

Frankly, when I first read this, I thought I must be losing my marbles, but evidently it was the conference committee members and staff who were smoking the wacky tobacky. In what Guyer presumes is a drafting error, the bill allows states to charge preganant women below the federal poverty level the full cost of all "non-pregnancy related" services; ditto for all services provided to parents, seniors and people with disabilities. Okay, maybe they didn't really mean that and they'll fix it, but the stuff they did mean is pretty sick. Sickest of all, states can charge elderly and disabled people premiums to enroll in Medicaid, without limit. (Again, they may have intended to cap these at 5% of income but right now, the bill does not do that). And they can charge 10% of the cost of services for children in families between 100% and 150% of poverty, and $3 co-pays for drugs. Same for low-income seniors and people with disabilities. Etcetera.

Well in case you didn't know, the Federal Poverty level for a family of three right now is $1,341 a month. Also in case you didn't know, the average rent for a one-bedroom apartment in a low rent district of Boston is about $1,000 a month.

What this will mean is simple. If states take advantage of these options, a lot of poor elderly and disabled people will be unable to afford coverage entirely, because they will now have to pay premiums; and many people and families that do have coverage won't be able to afford the co-payments for all the services that they need. And that's the whole point -- to save money by getting people off the roles, and stopping people from using services and buying drugs by putting up financial barriers. The point of doing this to poor children, poor people with disabilities, and poor elderly people, is to pay for tax cuts for rich people and the war in Iraq. And the point of doing that? Why it's to foster a culture of life, of course. It's the Christian thing to do.

*And come to think of it, have you ever seen them together?

Your chance to make a nomination

Our friends at Community Catalyst sponsor the annual Bitter Pill Awards for "the most absurd, outrageous or deceptive drug ad or promotion" in the past year. (That slick looking little guy is their spokespill Pharmie, who may pay us a visit here from time to time.)

I can think of two or three strong candidates, and I'll bet you can too. Get over there and make sure your favorite drug company scam gets proper recognition.

Re-reading Plagues and Peoples

Historian William McNeill published Plagues and Peoples in 1976. The book was important as a seminal effort at synthesis across disciplines. McNeill did his best to master ideas and knowledge in microbial ecology and disease vectors, the co-evolution of parasites and hosts, and infectious disease pathology, and then to plug this knowledge into our understanding of human history. He made a few mistakes, and at a few points he trumpeted speculation as confident conclusion, but he inspired a new way of thinking about humanity's place in the world, on the side of the humanities; and about infectious disease, on the side of epidemiologists and biologists.

Until the late 19th Century, nobody knew what caused infectious diseases and epidemics. Most of the measures that people took in response to them were useless or harmful. Cities were deathtraps whose populations could only be sustained by a continual influx from the countryside. Periodic episodes of mass dying occurred inexplicably amidst an ongoing random harvest of seemingly healthy people. Yet we now understand that these episodes were not random at all (nor were they divine retribution), but in fact they had a great deal to do with human patterns of habitation, migration, and agriculture. Conversely, they powerfully influenced these patterns, as well as the history of social domination and conquest.

We didn't begin to develop truly effective countermeasures until the mid-20th Century, and yet the brief time since World War II has been sufficient for those of us in the developed countries to completely forget what life was like before the present revolutionary era. With the conquest of smallpox, polio, tuberculosis, rheumatic fever, and most of the other great scourges of humanity, we came to believe that infectious disease would soon be essentially banished as a cause of death in the wealthy countries. The issue became one of global inequality, but even that seemed only a temporary situation.

The emergence of HIV changed our thinking, and powerfully vindicated the importance of McNeill's mode of cross-disciplinary analysis. It demonstrated, first of all, that microbial evolution could still outrun human ingenuity, with catastrophic consequences; while social science became the essential discipline for controlling the epidemic, in the absence of any biological technology for cure or immunization. (Yes, the very low-tech latex condom does the job, but it's a behavioral science problem to get people to use them.)

The threat of a flu pandemic also engages sociology and economics, of course, because we now understand that ordinary seasonal flu as well as flu pandemics are intimately linked to food production and distribution practices in which people live intimately with poultry and pigs, and bring live birds to large central marketplaces. Should a killer pandemic occur, we will gain a great deal more social science knowledge the hard way, by observing how people react -- knowledge which will be essential in preparing for the next infectious disease emergency. Then there are the issues of microbial drug resistance, biological warfare and terrorism, other emerging infections -- all of which centrally engage social science.

The evolving interdisciplinary approach to infectious disease gets a good, accessible discussion by Johannes Sommerfeld here in the journal of the European Molecular Biology Organization. So it's good news that people are putting their heads together about these problems. The bad news is, we haven't triumphed over infectious disease after all, and it is very likely that in the near future, a microscopic package of genetic information will once again change human history. At least this time, we'll know what it is.

(By the way, if you want to bone up on the biology of flu, and you don't mind concentrating really, really hard, head on over and see what Revere is doing at Effect Measure. I'll try to hold down my end here.)

Right to Life

Here's what White House squawk box Scott McLellan had to say about the Supreme Court Decision upholding Oregon's law allowing physician assisted suicide: "The President remains fully committed to building a culture of life, a culture of life that is built on valuing life at all stages. And that's the President's commitment."

Although you wouldn't know it from TV or newspapers in the United States, the World Health Organization recently released the World Health Report 2005. You can download the overview here, and if you're really into this stuff you can get the full report at the site. Here are a few highlights that might be of interest to people who value life at all stages.

1. Each year more than 4 million babies die within a month of birth, and 6.6 million more children die before they turn five.
   
   
2. Each year about 529,000 women die in pregnancy or childbirth -- 68,000 as a result of unsafe abortion.
   
   
3. While many countries have seen improving maternal and child health, the worst-off countries have not, increasing global disparities.
   
   
4. Solving this problem does not require any expensive technology, but it does require basic public health and care systems, including trained midwifes and backup medical services when they are needed.
   
   
5. The total cost to achieve this within the 75 countries that account for most maternal and child mortality is estimated to be $52.4 billion in addition to current expenditures.

The cost to the United States Treasury of the Iraq war, as of this writing, is estimated to be $234,365,799,016. Actually it will be more by the time you click on the link.

I have a nomination for the Nobel Prize in Hypocrisy.

Can these clowns do anything right?

No, but it's mostly because they don't want to. I'm not sure why the Medicare Part D debacle has gotten scant attention in the blogosphere, but I expect it's because of the underlying wonkish complexities of it all. We bloggers are supposed to be snappy and snarky, and this particular mess just doesn't have an attractive surface.

Medicare beneficiaries are showing up at the pharmacy and not getting their prescriptions because of a couple of different categories of screwup, but they all come down to the same basic cause. Instead of just letting the Medicare program pay for people's prescription drugs directly, as it does for their doctor visits, Congress set up the program as a massive subsidy for drug and insurance companies. Benefits have to come through an insurance company, that sets up whatever schedule of deductibles, co-pays and approved drugs it wants to. (That's in addition to the built-in deductibles in the Medicare financing.) Presumably, with the help of a supercomputer and an accurate prognostication of exactly what drugs you are likely to be prescribed in the future, you can choose the plan that provides the coverage you happen to need at the lowest price to you.

From the point of view of the members of Congress, this has two benefits: since hundreds of different insurance companies are actually purchasing the drugs, they have little or no bargaining power with the drug companies and they can't negotiate lower prices. At the same time, they get to make a profit by administering the program. That's all taxpayers' money that's being wasted to line the pockets of two industries that just happen to be major campaign contributors. Oh yeah, the bill was largely written by then-Representative Billy Tauzin, who is today the head of the drug industry lobby.

Not surprisingly, a lot of people have yet to figure it out -- the vast majority of beneficiaries have yet to enroll in Part D at all, while some of those who did evidently chose wrong and found out they couldn't actually get their prescriptions paid for after all.

"Dual eligibles" -- people who receive both Medicare and Medicaid -- are a particularly troubling category of problem. They already had prescription drug coverage under their state Medicaid programs, but the new Medicare benefit is supposed to take over paying for that portion of their drugs that it covers. As far as I know most states attempted to make this switch automatically for their dual eligible populations on January 1 but there were massive screwups. Either people wound up in plans that didn't cover their prescriptions, or they didn't get into the databases at all and pharmacists were unable to verify their coverage, or they wound up in plans with high co-pays that they couldn't afford. This problem is so bad that half the states have pledged to continue paying for drugs under their Medicaid programs until it gets straightened out. If you don't happen to live in one of those state's, you are urged to "contact your regional office of the Centers for Medicare and Medicaid Services." Right. And BTW, if dual eligibles don't enroll in Part D, they can lose their Medicaid benefits entirely.

Which brings us to another dirty little secret: many retiree health plans receive subsidies from Medicare to continue covering people, but if people enroll in Part D, they lose those subsidies and, in turn, the people lose their coverage. Some people, in nursing homes, were enrolled in Part D without their knowledge and will have to disenroll in order to keep their retiree benefits -- or more likely some people will have to do it for them.

Then, once people have used up the first $2,250 in coverage, people will hit the dread doughnut hole, where they will have no coverage at all but will still be paying premiums. Oh, and by the way -- Part D completely excludes any coverage for Barbiturates, Benzodiazepines, or prescription vitamin and mineral products. Why? I dunno, I guess these particular chemicals are anti-Christian or something. Maybe if you can't sleep or you're anxious, or you're malnourished, it's because you don't pray enough. But if you have a seizure disorder, you're out of luck.

And, in the middle of all this godawful mess, the relevant information on the Medicare web site is down. Go ahead -- go there and try clicking on the links that say "Prescription Drug Coverage" and "Want to learn more about prescription drug coverage?" Dead as Clarence Ray Allen.

The bottom line for me? As long as corporations run Congress, they'll never do anything right for us. But they'll do just fine for themselves.

Then and Now

Back in the '60s, the great menace that justified an illegal war against a country that never threatened us, the erosion of civil liberties including warrantless surveillance of U.S. citizens and the infiltration of peaceful political groups, and the labelling of dissenters as traitors, was the International Communist Conspiracy™. FBI Director J. Edgar Hoover was particularly obssessed with Martin Luther King, Jr. I was going to write about this today but President Gore beat me to it, so I get the day off.

On this particular Martin Luther King Day, it is especially important to recall that for the last several years of his life, Dr. King was illegally wiretapped-one of hundreds of thousands of Americans whose private communications were intercepted by the U.S. government during this period.

The FBI privately called King the "most dangerous and effective negro leader in the country" and vowed to "take him off his pedestal." The government even attempted to destroy his marriage and blackmail him into committing suicide.

This campaign continued until Dr. King's murder. The discovery that the FBI conducted a long-running and extensive campaign of secret electronic surveillance designed to infiltrate the inner workings of the Southern Christian Leadership Conference, and to learn the most intimate details of Dr. King's life, helped to convince Congress to enact restrictions on wiretapping.

President Gore didn't spell it out, but the specific method the FBI used to try to blackmail King into committing suicide was to threaten to make public tape recordings made in hotel rooms where he had adulterous assignations. Dr. King was a great champion of humanity, but he was also human. The impostor who pretends to be president today claims he is listening to our telephone conversations because he wants to keep us safe. What sane person would believe him?

Blood and Sand

I have written on occasion about public health in occupied Iraq, but today I'm going to do my best to give an overview of what we know, and in particular what we don't know. Specific, credible numbers are unavailable because Iraq does not have a functioning public health system. We lack meaningful disease surveillance, vital statistics, or health care utilization data. The World Health Organization does not offer any recent information on population health in Iraq, and the Iraqi Ministry of Health, as far as I have been able to determine, does not produce any systematic public information. The UN Development Program conducted a survey of Iraq's infrastructure in 2004, which included an assessment of health care facilities, but for unstated reasons the report has been taken down.

Iraq's people were suffering prior to the invasion and occupation, after decades of misrule, war, and international sanctions. Indeed, this was a principal justification that many liberal hawks gave for supporting the war -- that it was the only way to quickly end the sanctions regime, and provide for the welfare of the Iraqi people. Sadly, as the third anniversary of the invasion approaches, all indications are that public health in Iraq has only deteriorated.

Recently the individual who is most culpable for the tragedy conceded that approximately 30,000 Iraqi civilians have died as a result of the war. He was apparently referring to the figures compiled by Iraq Body Count, an organization which counts deaths documented in news reports and other publicly available sources. Obviously, this method captures only traumatic, mostly violent deaths directly attributable to the wartime situation, and is far from a complete count even so. Even in the extraordinarily violent environment of Iraq today, however, most deaths are from other causes. The first question is how the overall death rate may have changed since the beginning of the war. (Of course, deaths are not the only indicator of population health.)

In the absence of a functioning vital records system, researchers from U.S. universities and Al-Mustansiriya University in Baghdad conducted a survey in September, 2004, based on area probability sampling methods, to estimate how the death rate in Iraq changed from the 14.6 month period before the war started in May 2003, to the 17.8 month period following. They estimated that the mortality rate had nearly tripled, and that 100,000 excess deaths of civilians had occurred up until that date. Although the corporate media insist that we should not believe this result, it is in fact based on sound methods and is about the best we can do under the circumstances. (Actually, this is undoubtedly an underestimate. The investigators deliberately excluded the city of Fallujah so as not to "skew" the results.)

At about the same time, the British organization Medact issued a report drawing attention to devastated sanitary infrastructure, rising malnutrition and damage to hospitals and public health laboratories, and declaring a public health crisis in Iraq. Earlier, in May 2003 shortly after the invasion, UNICEF conducted a rapid assessment of children's nutritional status in Iraq and found that acute child malnutrition had nearly doubled since before the war, from 4% to 7.7%. Acute malnutrition is a very serious condition that leads to permanent developmental deficits. Prior to the war, UNICEF was able to refer malnourished children to a network of Nutritional Rehabilitation Centers, but this system collapsed with the invasion. I have not found any information that it has been re-established.

Again in October 2004 -- which seems to have represented a window period for information -- the Iraq Ministry of Health issued a report which, according to the summary in Nature, stated that:

Disruption to water supplies during the conflict means that roughly 20% of urban households now have no access to safe drinking water. This has led to 5,460 cases of typhoid in the first quarter of 2004, the report estimates. In rural areas, more than half of households are without fresh water or adequate sanitation.

More Iraqis may have died as a result of ... neglect of the health sector over the past 15 years than from wars and violence. Measles and mumps are infecting thousands of children, partly because a third of them are chronically malnourished, it is reported. There were 8,253 cases of measles reported in the first half of 2004, with Basra particularly badly hit. In 2003, there were just 454 cases. Likewise, the first four months of 2004 saw 11,821 cases of mumps, nearly 5,000 more cases than there were in the whole of the previous year.

It is now more than a year later, and the only up-to-date information available is anecdotal. The intrepid Dahr Jamail reports that in the region of most active combat, particularly al-Anbar province, U.S. forces continue to raid, disrupt and damage hospitals in pursuit of insurgents. Even without the attacks, hospitals are barely functioning due to lack of electricity, non-functioning equipment, shortages of drugs and supplies, and curfews which force personnel to go home and services to stop after 5:00 pm.

Jamail also reports that unemployment is approximately 70%, most Iraqis cannot afford to feed themselves adequately, and hospitals in general are barely functional.

Nearly three years after the invasion, the U.S. can no longer legitimately blame Saddam Hussein for conditions in the country. Yet the administration has announced that it does not intend to spend any additional funds on the reconstruction of the country. Trends since September 2004 have undoubtedly been negative, so it is reasonable to suppose that excess deaths since the invasion are now at least somewhere close to 200,000 and probably mroe. But the future burden of a malnourished, chronically infected, psychologically traumatized population without access to medical care will continue to devastate the country for decades, regardless of how soon stability can be established and economic and social conditions improve.

I Digress

I'm sure that by now you have heard all about the CIA attack, using Predator drones, that destroyed 3 houses in Pakistan and killed numerous civilians. (The Pakistani government is saying 18, some local reports give much higher numbers.) If you weren't up late Friday night, however, you may not know that the U.S. administration leaked word of this attack, and the hairhatted elocutionists were stumbling all over each other with anticipation that Ayman al-Zawahiri had been killed. It turns out, of course, that he was apparently nowhere in the area.

The disastrous consequences for international relations, and for the pursuit of the al Quaeda conspirators, are obvious. Also obvious is that the Commander in Chief authorized this action. The CIA and hence the top national security leadership knew that the intelligence could be wrong, and even if it was correct it clearly wasn't very specific since they destroyed three different houses. Therefore they knew it was nearly certain that innocent people would be killed and maimed, and entirely possible that only innocent people would be harmed. From the standpoint of the War on Terror™, the action was clearly insane. At best, if Zawahiri were killed, it would still have damaging repercussions for the stability of the Musharraf government, and do little or nothing to reduce the probability of future attacks. But the worst has happened, and the U.S. national interest has been severely harmed.

But that doesn't matter to the administration, because the calculation in this case was purely political. Killing Zawahiri would go a long way toward rescuing their standing with the public, while the U.S. electorate will care little about the murder of Pakistani civilians. It really pains me to say that, but that's how it is.

And now, an administrative statement. I'm going to do the Today in Iraq post tomorrow. In preparation I'm going to do a review for this blog of what we know about the public health situation in Iraq, which will probably go up tomorrow morning. I'm honored to have the opportunity to contribute to the important volunteer effort at Today in Iraq, and I hope that you'll pay us a visit.

And Grandma wins again!

A new study finds that over the counter cough remedies are no better than placebo.

Actually, as a matter of fact, they're worse. In this study, they also kept track of whether kids with colds who took cough syrups with dextromethorphan or diphenhydramine let their parents sleep better than kids who took a placebo. The verdict? The parents slept worse when they gave the kids the stuff with the active ingredients. Although the news article I linked to doesn't spell it out, a likely reason is that those active ingredients, although they don't suppress coughs, can cause insomnia. Give your kids Robitussin, and they're more likely to keep you up at night than if you don't. Oddly enough, these ingredients can also cause drowsiness. Not to mention occasional severe side effects such as hallucinations and cardiac arhythmias. Plus which, they cost a fair amount of money. What they don't do is suppress coughs.

On the other hand, the placebo wasn't exactly nothing, it was a sweet syrup. That obviously could make kids feel better, and it might even make them salivate, which could help relieve some of the symptoms, at least briefly. Grandma's solution was hot ginger tea with lemon and honey. That really works! And no side effects. And cheap.

Is there any chance in a million years that the FDA will stop allowing the drug companies to make false claims for this stuff? Just askin'.

Addendum: I forgot to mention that persons of youthfulness shoplift cough syrup and chug whole bottles of it in order to experience the side effects. Not that there's anything wrong with that. They cough anyway.

Addendum addendum: I also forgot to tell you how to make the tea, in case you weren't listening to grandma. Slice up some fresh ginger and boil the living crap out of it, a good 10 minutes. Then strain it and add the lemon juice and honey. If it's for a kid, you need to cool it off so it can't scald, obviously. You can make up a big batch ahead of time, then heat up a cup on the stove top or microwave as needed or requested.

In local news . . .

We don't usually have a state and metro section here, but I do want to draw attention to a bill in the Massachusetts House to get foodlike toxins out of the public schools. In Connecticut, the Coca Cola company managed to convince the (Republican) Governor to veto a similar bill. This is what we're up against folks -- rapacious corporations that want to poison your kids in order to line the pockets of their executives and investors, who are perfectly willing to bribe politicians (through "campaign contributions") and lie to the public in the service of their greed. There's only one thing to do: fight back.

If you vote in Massachusetts, call your representative. If you don't, find out what's happening in your own state and get involved.

The Evil Machine

On a couple of occasions I have referred to all the badness associated with the automobile, and made banal observations about how a great country that doesn't want to be shipping trillions of dollars abroad to pay for petroleum, invading foreign lands to secure access to same, spewing toxins and particulates into the air and thence to its citizens lungs, filling the atmosphere with C02 thereby melting the polar caps and wiping out the world's amphibians and coral reefs, and getting everybody stressed out driving over congested streets and highways for two hours every day to get to work and back, etc., probably ought to have excellent public transportation, and encourage patterns of development whereby people live and work close to transit stations and can walk to the grocery store. But you don't have to take it from me, of course, you can take it from the hypertensive ranter Jim Kunstler who says it all so much better.

But our friend Keeping Eyes Open, formerly known as MAR, tipped me off to this essay by the dynamic community organizer Meizhu Lui, who emphasizes the relationship of car dependency to inequality and social injustice. Meizhu takes off from the New Orleans evacuation plan, which as quickly became grotesquely obvious, didn't take into account all those folks who didn't happen to own cars -- who, as it turns out, were just about all poor, and African-American. She points to the unaffordability of car ownership for low-income people, and how this cuts people off from jobs, various forms of self-employment, and even medical care. (In rural areas, lack of transportation is a major barrier to health care access.) So car dependency just entrenches and exacerbates poverty and inequality.

In the public health community, we took on the tobacco companies, we were tenacious, and we are finally gaining the upper hand. Now we are taking on the "food" companies. (At least the stuff Phillip Morris sells really is tobacco.) But we have dealt with the car problem in a half-assed manner. (That's a technical term from poli-sci.) We've pressured the companies to make cars safer and more fuel efficient, but you know what? We never accepted the idea of a safer cigarette, we insisted that tobacco marketing should be stopped, and people should stop smoking.

It's little remembered nowadays, but General Motors actually purchased all the urban street car companies in the U.S. and shut them down, to get rid of the competition. Turnabout is fair play. We won't eliminate the automobile, obviously, but we can make it unnecessary for most people most of the time. I can't think of a single area of public policy that promises more benefits -- to public health, to our quality of life, to our economic security, to the planetary ecosystem, and oh yes, to world peace. Of course, it also requires a major public investment, but the U.S. only invests in warships and fighter planes. That's called the Free Market System.

Just as I thought

A few days back I concluded that the Abramoff investigation must be a case of career civil servants in the DoJ rising up against the totalitarian regime. The NYWT tells us all about it. There is hope for America (I think).

Darwin was Wrong

Or rather, his knowledge was incomplete. Bacterial evolution doesn't only work in the standard Darwinian mode -- mutation and natural selection. By various mechanisms, bacteria can exchange genes across species. They can do this by a kind of interspecies sex -- live cells contacting each other and swapping genes on small pieces of DNA called plasmids; by actually leaving DNA around when they die and their cell walls disintegrate, DNA which can be absorbed by other bacteria; and through the action of viruses.

This creates a major problem for us humans. Bacteria sometimes cause problems for us, and we want to kill them. I've written about bacterial drug resistance before, of course, but I want to get into a bit more deeply right now. The best introduction to the issue that I have found is this Scientific American article by Stuart Levy (PDF, rather badly scanned, I'm afraid), who also heads up the Alliance for the Prudent Use of Antibiotics at Tufts.

There's a lot of concern right now about pandemic flu -- and if you enjoy being scared, I recommend you visit Effect Measure where the apocalyptic flu thing is getting the full run down. That is indeed worth worrying about, but if we do experience The Big One soon it will be a transient event. It will sweep through the global population, kill some number of tens of millions of people and cause substantial economic disruption, and then it will be gone. The population will have immunity to that particular strain of influenza and we'll get back to what passes for normal these days. Antibiotic resistant bacteria, however, are a continual, and growing problem. In the worst case, if pathogenic bacteria that we have no way of controlling become pervasive in the environment, it will become impossible to do surgery safely; minor injuries could be fatal; people will lose limbs, eyes, internal organs, to infections that are readily treatable today.

This is not, however, a matter of fate. It is entirely a function of human greed and folly. The problem does not arise simply because we treat bacterial infections. That alone, if done properly, creates little risk of creating widespread antibiotic resistant bacteria. Because maintaining the genes that confer resistance imposes some metabolic cost on bacteria, if antibiotics are not present in the environment, there will be selection pressure against the genes and they will become scarce in bacterial populations. The danger arises when antibiotics are continually present.

For that reason it is difficult to prevent antibiotic resistance in hospitals, where continual, heavy use of antibiotics is unavoidable. Resistant nosocomial infections will probably continue to cause trouble for the foreseeable future, although people are working hard to reduce the problem. But of greater concern is the presence of resistant strains in what epidemiologists call the community, which means every place that isn't a health care facility. These arise because antibiotics are routinely fed to livestock in feedlots; sprayed on fruits and vegetables; and because people take antibiotics that they don't actually need, and don't finish courses of antibiotics even when they are prescribed appropriately. Remember that resistant genes are dangerous even when they occur in non-pathogenic organisms, because these "good germs" can pass them on to pathogens.

And that brings us to another, growing problem, the proliferation of anti-bacterial everything and anything for the home. Consumer products companies market antibacterial bathroom soap, kitchen cleaners, toys, high chairs, car seats, doggie toys, even clothing. Bacteria can evolve resistance to the agents used in these products, which confers cross resistance to some antibiotics. These products are essentially useless -- you can't possibly make your home sterile, nor would you want to. There is no evidence that they protect people against infections, either.

The advice is the same as you got from your grandmother. Wash your hands frequently with ordinary soap and warm water. Clean your clothing and bedding in hot water. Dry it in the dryer, or hang it in the sun. Keep your house clean, with water and detergent. Wash your fruits and vegetables, cook your meat thoroughly. Don't buy any of that junk. Don't ask your doctor for antibiotics, let her figure out if you really need them. And, politically, we need to work to limit use of antibiotics in agriculture.

Listen up folks! This is really, really important. If you're worried about dying and stuff, it's far more important than the War on Terrorism™. Really.

The Double, Triple, or Fourfle Whammy, Revisited

While we're on the subject of how we treat people with mental illnesses here in the Greatest Country on Earth, it's important to remember that people with severe mental illness are also disproportionately likely to suffer from other chronic and acute diseases. In the chronic category these include co-morbid substance abuse disorders, obesity and diabetes (which are side effects of anti-psychotic and sedative medications), ill-effects of tobacco use, and HIV infection. On the acute side they include injuries from trauma and exposure.

I happen to know a lot about HIV so I'll just throw out a few factoids. A study of middle aged and older persons living with HIV in New York City and Wisconsin found that 27% had thought about suicide in the prior week. A study of HIV seropositive women found that 38% reported needing mental health services in the prior six months. A study comparing HIV+ and HIV- homosexual men found that HIV+ men had significantly higher levels of psychiatric symptomatology and depression. Psychiatric morbidity is associated with significantly poorer health related quality of life for people living with HIV. In addition, psychiatric morbidity is known generally to be associated with poor medication adherence, particularly in affective disorders. A study conducted by somebody well known to this writer, for the City of Boston in 1997, found that, among Latino men and Latina women living with HIV in Boston, a history of mental illness and reported psychiatric symptomatology was associated with an extraordinarily high rate of a history of homelessness.

So, along comes the Compassionately Conservative President’s New Freedom Commission on Mental Health, which in 2003 noted the high prevalence of co-morbidity among people with mental illnesses and found that “While mental health and physical health are clearly connected, a chasm exists between the mental health care and general health care systems in financing and practice.” The report goes on to promise a new era of integrated, coordinated care, in which people's behavioral health and medical providers work together.

Well, here it is 2006 and we don't actually have any proposal whatsoever to do anything about this. People's docs still aren't talking to their shrinks and social workers (if they're lucky enough to have the latter two), and the people have to go to three or four different places, where they often have three or four different case managers, and keep track of nine different medications while they are sleeping in a shelter. Oh, wait. There is a new initiative at the Substance Abuse and Mental Health Services Administration (SAMHSA): they're trying to steer more funding to so-called faith based organizations. Maybe the folks can go down to the local church now and have their demons exorcised.

References: Kalichman SC, Heckman T, Kochman A, Sikkema K, Bergholte J. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 2000;51(7):903-7.
Schuman P, Ohmit SE, Moore J, Schoenbaum E, Boland R, Rompalo A, Solomon L. Perceived need for and use of mental health services by women living with or at risk of human immunodeficiency virus infection. J Am Med Womens Assoc 2001;56(1):4-8.
Dickey WC, Dew MA, Becker JT, Kingsley L. Combined effects of HIV-infection status and psychosocial vulnerability on mental health in homosexual men. Soc Psychiatry Psychiatr Epidemiol 1999;34(1):4-11.
Otto-Salaj LL, Heckman TG, Stevenson LY, Kelly JA. Patterns, predictors and gender differences in HIV risk among severely mentally ill men and women. Community Ment Helth J 1998;34(2):175-90.
Sullivan G, Koegel P, Kanouse DE, Cournos F, McKinnon K, Young AS, Bean D. HIV and people with serious mental illness: the public sector's role in reducing HIV risk and improving care. Psychiatr Serv 1999;50(5):648-52.
Sherbourne CD, hays RD, Fleishman JA, Vitiello B, Magruder KM, Bing EG, McCaffrey D, Burnam A, Longshore D, Eggan F, Bozzette SA, Shapiro MF. Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. Am J Psychiatry 2000;157(2):248-54.
Mehta S, Moore RD, Graham NMH. Potential factors affecting adherence with HIV therapy. AIDS 1997;11:1665-1670.

Most vulnerable

So-called right-to-life activists -- opponents of abortion and advocates for keeping terminally ill people without cerebral cortexes metabolizing by means of artificial life support -- are fond of saying that "Society is judged by how it treats its most vulnerable citizens." Okay, if that's what y'all believe, consider this.

The Center for Studying Health Systems Change, with funding from the Robert Wood Johnson Foundation, has been conducting the Community Tracking Study since 1996. This is a largely qualitative, longitudinal study of 12 local health care markets around the U.S. Results of their latest round of interviews, site visits and data aggregation are reported in Health Affairs by Robert Hurley, Hoangmai PHam, and Gary Claxton, and this one is free. (

There is a lot in here that ought to trouble us, but I'll just focus on mental health. As our readers know, I'm a skeptic about a lot of the diagnostic labelling in psychiatry, its reductionist approaches to treatment, and the confusion between individual pathology and social injustice. Nevertheless, there really are people with really real mental illnesses that render them largely helpless and cause great suffering. According to Hurley, et al:

Public mental health services have been severely affected by state budget distress, since so much of this care is funded by state funds and federal block grants that have not increased to meet growing costs. In virtually every site, observers portray public mental health systems’ ability to care for people with chronic mental illnesses as being in serious decline and disarray. Homeless shelters and local jails are characterized as the twenty-first-century versions of the state mental hospital of fifty years ago. Many general hospitals have phased out inpatient psychiatric units because, they contend, they lose too much money serving publicly or unsponsored patients.

There is also a severe shortage of emergency mental health services, and community mental health providers are unable to meet the need and must turn away all but the most severely mentally ill. Let's not forget that Mr. Bush took office promising to "reform" the mental health system. He was actually talking about screening 100% of the population for mental disorders and he appointed the so-called "New Freedom Commission" to recommend ways of providing integrated, comprehensive mental health services to everyone who needs them. As we now know, this was really just part of an effort to sell more psych-meds, but it didn't even accomplish that because they never had any intention of actually spending money to do something about the problem.

Of course, we are wasting public money, not saving it, by warehousing mentally ill people in prisons and cycling severely ill people in and out of acute care hospitals. But it's not about money anyway. It's about whether we want to live in a decent, ethical society.

Signs and Symptoms

Here are some items from psychologist Robert Hare's diagnostic checklist for psychopathy:

*1. GLIB and SUPERFICIAL CHARM -- the tendency to be smooth, engaging, charming, slick, and verbally facile. Psychopathic charm is not in the least shy, self-conscious, or afraid to say anything. A psychopath never gets tongue-tied. They have freed themselves from the social conventions about taking turns in talking, for example. *

*2. GRANDIOSE SELF-WORTH -- a grossly inflated view of one's abilities and self-worth, self-assured, opinionated, cocky, a braggart. Psychopaths are arrogant people who believe they are superior human beings.*

*3. NEED FOR STIMULATION or PRONENESS TO BOREDOM -- an excessive need
for novel, thrilling, and exciting stimulation; taking chances and doing things that are risky. Psychopaths often have a low self-discipline in carrying tasks through to completion because they get bored easily. They fail to work at the same job for any length of time, for example, or to finish tasks that they consider dull or routine. *

*4. PATHOLOGICAL LYING -- can be moderate or high; in moderate form, they will be shrewd, crafty, cunning, sly, and clever; in extreme form, they will be deceptive, deceitful, underhanded, unscrupulous, manipulative, and dishonest.*

*5. CONNING AND MANIPULATIVENESS- the use of deceit and deception to cheat, con, or defraud others for personal gain; distinguished from Item #4 in the degree to which exploitation and callous ruthlessness is present, as reflected in a lack of concern for the feelings and suffering of one's victims.*

*6. LACK OF REMORSE OR GUILT -- a lack of feelings or concern for the losses, pain, and suffering of victims; a tendency to be unconcerned, dispassionate, coldhearted, and unempathic. This item is usually demonstrated by a disdain for one's victims.*

*7. SHALLOW AFFECT -- emotional poverty or a limited range or depth of feelings; interpersonal coldness in spite of signs of open gregariousness. *

*8. CALLOUSNESS and LACK OF EMPATHY -- a lack of feelings toward people in general; cold, contemptuous, inconsiderate, and tactless.*

*9. PARASITIC LIFESTYLE -- an intentional, manipulative, selfish, and exploitative financial dependence on others as reflected in a lack of motivation, low self-discipline, and inability to begin or complete responsibilities.*

*10. POOR BEHAVIORAL CONTROLS -- expressions of irritability, annoyance,
impatience, threats, aggression, and verbal abuse; inadequate control of
anger and temper; acting hastily.*

*12. EARLY BEHAVIOR PROBLEMS -- a variety of behaviors prior to age 13, including lying, theft, cheating, vandalism, bullying, sexual activity, fire-setting, glue-sniffing, alcohol use, and running away from home.*

*14. IMPULSIVITY -- the occurrence of behaviors that are unpremeditated and lack reflection or planning; inability to resist temptation, frustrations, and urges; a lack of deliberation without considering the consequences; foolhardy, rash, unpredictable, erratic, and reckless.*

*15. IRRESPONSIBILITY -- repeated failure to fulfill or honor obligations and commitments; such as not paying bills, defaulting on loans, performing sloppy work, being absent or late to work, failing to honor contractual agreements.*

*16. FAILURE TO ACCEPT RESPONSIBILITY FOR OWN ACTIONS -- a failure to accept responsibility for one's actions reflected in low conscientiousness, an absence of dutifulness, antagonistic manipulation, denial of responsibility, and an effort to manipulate others through this denial.*

*18. JUVENILE DELINQUENCY -- behavior problems between the ages of 13-18; mostly behaviors that are crimes or clearly involve aspects of antagonism, exploitation, aggression, manipulation, or a callous, ruthless tough-mindedness.*

I have omitted three or four items from this list, which don't seem to apply to Mr. Bush. Sexual promiscuity and unstable marital/romantic relationships constitute two of the items. Although these pertained to his youth, he has remained married to Pickles, although who can say what the emotional content of this relationship may be? The other omitted items pertain to interactions with the criminal justice system, which he has managed largely to avoid, due to his family wealth and privilege. Regarding childhood behavior, a school chum reported that he used to shove firecrackers into frog's and throw them into the air to watch them explode.

Is Reality the New Reality?

Last week I trashed the Boston Globe for burying the story of the Iraqi family of 12 killed by a U.S. bomb, and along with it the news that the U.S. has ramped up a major air war in Iraq. (You might think that minor detail would be of interest to at least as many readers as there are loyal followers of Mallard Filmore.) Today Bryan Bender had a well-done, front page, headline story on exactly that, which featured forthright coverage and a photo of the Baiji incident, and analysis by experts of the inevitable consequences of bombing, including death and maiming of the innocent. Once again, the awesome power of Stayin' Alive? More likely, a lot of readers pointed out the minor omission, or maybe Bryan Bender and/or his editors actually decided to notice it all on their own.

But this suggests some questions about reality and the shadow play that appears to the public. It's one thing for the Boston Globe, and other corporate media, to finally start to own up to the realities of the Iraq atrocity, but is it really possible that Alberto Gonzales's Department of Justice is now reality-based when it comes to the vast criminal conspiracy known as the Republican Party?

We are encouraged to believe that it is, when it comes to Duke Cunningham, Jack Abramoff, and their as-yet-unnamed-but-we-all-know-who-they-are co-conspirators. Then there's Patrick Fitzgerald, who is ostensibly an independent counsel, but he's only quasi-independent. He's also a U.S. Attorney and he reports to Dark Prince Alberto in his day job. Given that the DoJ, like the rest of the federal government, is staffed at the top levels by 100% fierce Republican loyalists and professional GW Bush ass kissers, why would any sane person expect any of these investigations to get more than two squares past Go?

The optimistic interpretation is that career civil servants in the DoJ are doing their jobs, without fear or favor, and Prince Alberto just doesn't have a way of stopping them without compounding the embarassment and causing uncontainable public outrage. (Viz. Nixon's Saturday Night Massacre, which backfired.) There is some support for that interpretation in recent history. Civil servants in the CIA, the military, the State Department, and the NSA have leaked information to the press over the past several years which, in a real democracy, would already have ended the Bush administration and one-party rule in the U.S. But DoJ staffers have a power that the leakers don't, the substantive power to prosecute.

Still, I have to say that if these investigations are ultimately allowed to penetrate to the heart of darkness, I'll have to readjust the dials on my cynicism module.

Home not so sweet

We usually think of environmental health as having to do with the great outdoors -- air pollution and industrial waste in the water supply. But in fact, for most of us, children in particular, the most important exposures to environmental toxins are often in the home. The acute conditions of 19th century tenements and factory neighborhoods, which catalyzed public health and housing reform measures, have been ameliorated in U.S. cities. However, in recent decades economic and social forces have siphoned off resources and opportunities from older city centers: the exodus of white middle and working class people to suburbs; corporate relocation away from center cities; "redlining" of urban neighborhoods; and federal cutbacks in aid to cities. Consequently, during the latter half of this century, the urban poor have been concentrated and ghettoized in substandard housing in inner cities.

Back in 1998, the Doc-4-Kids project at Boston Medical Center documented the links between unsafe and unhealthy homes, homelessness (homeless kids do live somewhere, specifically in shelters or welfare motels), and poor children’s health crises -- asthma and respiratory diseases, lead poisoning, injuries, and malnutrition . Extrapolating from smaller studies where large data sets were lacking, the authors estimate the cumulative impact of inadequate housing on children's health in the United States -- which includes nearly 18,000 hospitalizations for asthma per year.

The overall findings of the report support public health studies which have systematically demonstrated that poorly maintained housing is strongly linked with childhood injuries and lead poisoning, and that damp, moldy indoor environments are associated with increased respiratory disease and asthma. A 1974 study of injuries to children associated with consumer products, for example, estimated that 2 out of 3 childhood injuries take place in the home. Ninety-one percent of injuries to children under 5 years of age occurred at home. Residential building conditions and design, including structural elements and defects such as faulty fire detection systems, windows without screens and window guards, steam radiators without covers, high-temperature hot water, missing balusters, and insufficient lighting were strong determinants of injuries.(Gallagher S, Hunter P, Guyer B. A home injury prevention program for children. Pediatric Clinics of North America. 1985;32(1):95-112.)

Well, that's how conditions are where most poor kids live. And there is plenty that we could do about this, for a lot less than what it's costing us to kill children with bombs in Iraq. If the president really believes the he was "elected" to keep us safe, he might consider that.

Too obvious for anybody to think of until now

The dread Joint Commission on Accreditation of Healthcare Organizations (JCAHO, universally pronounced Jayco [hey, Brett Favre is Brett Farv]) has announced a new standard:

New Requirement for Language, Communication Needs

Effective January 1, 2006 revisions made to Information Management standard IM.6.20 require hospitals to collect information about the language and communications needs of patients. Specifically, the standard requires that each medical record contain, as applicable, the patient's language and communications needs, in addition to the patient's name, gender, address, date of birth and authorized representative, if any. This new requirement underwent field review and input was provided by the Hospital Professional and Technical Advisory Committee. Research shows that differences in language and culture can have major impacts on the quality and safety of care and those disparities in health services outcomes are associated with race, ethnicity and language. For more information, contact Amy Wilson at the Joint Commission, awilson@jcaho.org.

Okay, that would seem to be a sensible idea. It never occured to anyone until 2006 that providers should indicate somewhere in the medical record that a person doesn't speak English, and needs an interpreter or a provider who speaks his or her language? 100 years late or not, this is still a win.

Another innovation at JCAHO is the Hospitals, Language and Culture Project, which will end in June of this year. The project is studying a sample of hospitals to assess their ablity to deliver culturally competent services. And oh yeah -- JCAHO even has standards of cultural competency. Who woulda thunk it?

The New Frankenstein?

In a recent post, I argued that the types of biological weapons Saddam Hussein was falsely alleged to possess, which constituted the essential justification for the invasion and occupation of Iraq, would not have been the menace they were almost universally represented to be. (That is, of course, had they existed.)

That is not to say, however, that it would not be possible to develop biological weapons systems which would in one way or another make the world far more dangerous. This is a complicated subject to which it is very difficult to do justice in this format, so I'll just try to feel a couple of parts of the elephant for you. One place to begin, even though it isn't really a basic introduction, is with the report Biotechnology Research in an Age of Terrorism from the National Academy of Sciences. (You can download the executive summary if you are interested, but not the whole book.) As usual these days, the title demonstrates a distortion in thinking. It is not clear that we are any more in an "age of terrorism" than we ever have been, nor is there any reason to think that violent cults such as al Qaeda, as opposed to governments waging war, constitute the greatest risk for malevolent use of biotechnology.

But the report does not focus on geostrategic issues. Rather, it is concerned with what specific areas of research might have potentially malevolent uses, and what to do about keeping any evil genies in the bottle. It is highly unlikely that the current U.S. administration will look favorably on some of their most important recommendations. The NAS Committee notes that biotechnology research is going on all over the world. Unilaterally restricting and/or classifying research in the U.S. would be feckless, and would only harm U.S. interests.

Nevertheless, the NAS Committee wants 7 classes of experiments to be subject to prior review by the existing Institutional Biosafety Committees at institutions that receive federal funding. (And, through proposed international forums, they hope other countries will take similar actions.) These types of experiments are ones that would:

1. Show how to render a vaccine ineffective
2. Confer resistance to therapeutic agents
3. Make a pathogen more virulent
4. Make a pathogen more transmissible
5. Enable a pathogen to infect new species
6. Make a pathogen less detectable or diagnosable
7. "Weaponize" a pathogen or toxin

With the possible exception of number 5, it is hard to see why anyone would pursue any of these goals except in the context of weapon-related research. (I can imagine someone wanting to modify a pathogen to infect new species as a method of pest control, for example wiping out the rabbits in Australia. One reason this is dangerous, apart from likely unintended ecological consequences, is that it could create a new non-human reservoir for a potential human pathogen.) In fact, the only reason that experiments such as this go on in the U.S. is that the U.S. military conducts them, ostensibly so that they can learn how to defend against novel agents. This research is highly classified, and we can learn little about it. So, even though they don't say so explicitly, the NAS is really talking about providing institutional review of military research.

And that leads us to another of the Committee's recommendations:

By signing and ratifying the Biological and Toxin Weapons Convention (BWC), the United States renounced the use and possession of such offensive weapons and methods to disseminate and deliver them. Given the increased investments in biodefense research in the United States, it is imperative that the United States conduct its legitimate defensive activities in an open and transparent manner. This should clear the way for all biomedical scientists to contribute to development of defensive measures that would mitigate the impact of the use of such weapons . . .

That'll be the day. Or just maybe, it will be January 20, 2008.

If the research the U.S. is doing is indeed purely defensive in its intent, then the less secrecy about it, the better -- for the sake of our international credibility and moral authority, as much as for our immediate personal safety. Sure, certain technical details might be useful to people who want to develop offensive weapons, but the broad outlines of what is going on should be public knowledge, and representative civilians with expertise and security clearances should have access to more sensitive information to provide advice and accountability. And obviously, useful results should be shared with the world.

As it turned out, the anthrax that killed 5 Americans in 2001 and shut down much of the U.S. mail didn't come from Saddam or al Qaeda, it came from a U.S. Army weapons lab. I'll feel a lot safer if they tell me what they are doing, than I do now.

Information Processing

On the front page of my local fishwrapper this morning there's a full-width, banner headline about the 12 coal miners killed in West Virginia, with a big color picture of horrified family members and a story that fills the right-hand column and jumps to most of a page inside. After describing the horrific scene in Sago, the story, written by Globe staff, goes on to put the events in context by discussing the Bush administration's retreat from mine safety regulation, including the history of safety violations at this particular mine and the trivial fines that regulators had imposed.

Deep inside the second section of the paper, amidst department store advertisements, is a reprint of a Washington Post story about a U.S. airstrike in Baiji, Iraq, that killed a family of 12, including six children. Although the headline reads "U.S. strike on house said to kill Iraqi family of 12," it is clear that this is not merely something that somebody said. The article, which is six paragraphs long, includes an eyewitness account by the reporter, who saw six bodies of children removed from the house, and a description of television footage showing the same thing. The article includes the following one-sentence paragraph: "The United States has steadily intensified its use of airstrikes against insurgents in Iraq in the past year, increasing the number of attacks from 25 in January 2005 to 120 in November." As far as I know, that is the first time this fact has been mentioned in the Globe.

Now, I'm not so much of a curmudgeon that I begrudge the newspaper giving major play to the drama of the men trapped in the mine and their frantic families. And they have been journalistically responsible by using these events as a hook to discuss the underlying policy issues.

But when my tax dollars are being used to blow up children in their beds at night, that strikes me as equally important. Those children's parents are also dead, but I would imagine that they have other relatives who are just as heartbroken as the families in Sago. I also know why people mine coal -- it's to make the electricity that operates the computer on which I am now typing. I haven't got a clue why Americans are blowing up children in Baiji, Iraq. I happen to think both stories are approximately equally important, but they won't be equally important in our political discourse, because the corporate media decree otherwise.

Weapons

I seem to be about the only person who remembers this, but the original reason why the U.S. invaded Iraq was not to bring freedom and democracy™ to the Greater Middle East™. Now that we are accomplishing that new mission by dropping bombs on residential neighborhoods on behalf of the Shiite fundamentalist theocracy that God called upon George W. Bush to install in that unhappy land, we might take the occasion of the new year to reflect on the hysteria over Weapons of Mass Destruction™ that infected the corporate media three years ago.

Now there happens to be a super-secret, special fact about Weapons of Mass Destruction™ that as far as I can tell, no politiican or reporter in the U.S. knows: we got 'em, so do lots of countries we’ve decided for now to call our friends, and we're busy developing new and more terrifying ones all the time. But for people we don't like to have them, or appear to want them, or even maybe develop knowledge that might enable them to make some of them someday, is EVIL -- which means we get to bomb or invade them.

But what exactly is a Weapon of Mass Destruction anyway? Take Ricin. Three years ago there seemed to be a new headline every day about somebody somewhere suspected of having ricin, or thinking about ricin, or possibly knowing how to make it. These reports included screaming hysterics about terrorist training camps in Iraq and al Qaeda cells in Europe. For some reason it was always called a "biological weapon." The Boston Globe even called it a "germ weapon," and refused to correct the report because, according to the Globe ombudsman, Congress had declared it to be one, and if the federal government says it's true, so does the Globe. Ricin is actually a plain, old fashioned poison that happens to be derived from a plant (castor beans) -- as are most common poisons. Cyanide, atropine, all the good murder mystery poisons, come from plants. Ricin’s claim to fame is potency by weight, but it's not particularly useful as a military or terrorist weapon. It’s a dry powder, not volatile. You could open a 50 pound bucket of it in the subway and it would just sit there. It's a useful way to knock off your mother-in-law, but there are plenty of other perfectly good ways to poison people, available at your corner hardware store.

Now let's talk about genuine biological weapons – pathogens such as anthrax. Anthrax is not contagious. The idea that a small quantity of anthrax spores could kill thousands or millions of people –which Colin Powell favored us with before the UN Security Council in February 2003 -- is, uh, a bit of a stretch. Powell’s calculations assumed that the exact minimum number of spores needed to cause disease could be distributed precisely into each individual's lungs. By the same sort of calculation, 50 pounds of TNT could kill thousands of people because you could divide it precisely into thousands of firecrackers and insert them into thousands of orifices.

If someone were to spray anthrax spores into the air, most of them would never be inhaled and would never harm anyone. (Did you know? Much of the soil in the Southwest United States is already contaminated with anthrax spores.) Only people unlucky enough to inhale a sufficient number, and to be susceptible (susceptibility varies hugely, for unknown reasons) will be affected. Anthrax can be used to sicken or kill a relatively small number of people, in most plausible scenarios. It's scary because you probably won't know you've been exposed until some time later, and if you don’t get the proper diagnosis in time the disease of inhalation anthrax is fatal, although the terror factor has notched down considerably, or should have, since we have learned that it is fully curable. As we have seen, creating anthrax contamination can cause a substantial economic cost and disruption, as well as kill or harm some people. The anthrax mailer demonstrated a technique of mass disruption that has unique features, no doubt about it. But a truck bomb is a more effective and more certain way to kill large numbers.

Then there are chemical weapons, another category of so-called Weapons of Mass Destruction (where ricin really belongs). The Aum Shinrikyo cult in Japan managed to kill 11 people by releasing sarin gas in the subway, but in 2003, a man killed hundreds in the subway in South Korea by starting a fire with a milk carton full of paint thinner. Chemical weapons aren’t even especially daunting as battlefield weapons because protective clothing and/or chemical antidotes render them ineffective, just as a vaccine defeats anthrax. No such protection is possible from high explosive and projectile weapons.

Don’t get me wrong – you can definitely kill people with anthrax or poison and that is a very bad thing to do. But think about it: sarin, ricin, anthrax – all these are Weapons of Mass Destruction, while cluster bombs, Daisy Cutters, MOABs, Fuel Air Explosives, Tomahawk cruise missiles, aircraft strafing cannons – the weapons that have already killed tens of thousands of Iraqi civilians and military conscripts, and razed entire cities, among other accomplishments – aren’t.

How come? Not because category A is inherently more massively destructive than category B. Rather, it’s because the U.S. military has a lot of those high explosive and projectile weapons, and the means to deliver them, and it uses them. The monopoly of massively destructive so-called "conventional" firepower by the world's military powers means we don't call those things Weapons of Mass Destruction.

So what about nukes? Those are definitely Weapons of Mass Destruction, by anybody’s definition, including mine. Well, it's okay for us to have them, and Israel, China, Russia, France, UK, and now Pakistan and India. (We're supposed to pretend that we don't actually know for sure whether Israel has them or not, by the way. But I don't play stupid make believe games just because AIPAC wants me to.) It's just not okay for anybody else to have them. So let's be clear about the terms of this discussion.

The whole point of the WMD category is not about what kinds of technologies do and do not inherently threaten the most horrible consequences. It’s about who gets to monopolize the use of deadly force. Nerve gas and anthrax do nothing to equalize the battlefield, in reality, but they make for good copy. And even though they seem to really scare people as potential terrorist weapons (we can worry about the exact definition of that another time) it isn’t clear why it’s less scary to contemplate being done in by a fertilizer bomb. Saddam is said to have gassed Kurdish civilians (with the blessing of Ronald Reagan and George Bush the First, so I guess poison gas wasn’t yet a WMD back then) which is indeed a terrible crime. So it would have been alright if he had blown them to pieces instead?

Weapons of Mass Destruction means weapons that relatively weak states or non-state actors might obtain, that we don't want them to have, or that we really don’t care whether they have or not, but which create a useful excuse for belligerence. High explosives can do a lot of damage even without sophisticated delivery systems, as Tim McVeigh and others have proved, but they really become WMDs when married to guided missiles, B1-bombers, and tanks.

So let’s drop this bogus dichotomy. There aren’t two kinds of weapons in the world: Weapons of Mass Destruction, that only we are allowed to have, because we can be trusted not to use them; and every other kind of weapon, that it’s okay for anybody to have even if most people can’t afford the best ones. Possessing sarin or anthrax wouldn’t have made Saddam a threat to his neighbors, and certainly not to the United States. He was militarily impotent with or without them. The lie was not only that he had such weapons, but that it even mattered.

Announcing Critical Condition

Okay, as previously promised, Blake and I are launching a new blog, Critical Condition, which focuses on the state of health care in the U.S. Blake is the kind of M.D. we need more of -- a doctor who thinks critically, and hard, about how to make health care more humane, more patient-centered, more effective, more cost-effective, and more just. So I'm happy to be a part of this project.

We don't want Critical Condition to be a conventional blog where one or a few people talk at the world. When it comes to health and health care, everybody's an expert. We're all experts on our own lives and experiences and the experiences of people we care about, experts on what makes us feel healthy and what we want and need from our health care providers and the system they work in. At the same time, doctors, nurses, other professionals and workers in the health care industry have their own special expertise and points of view. We want to hear from all corners, and facilitate dialogue. That means, anybody can e-mail a post of their own to Blake or to me and if it fits with the mission statement (go to Critical Condition to read it) and makes a contribution, we'll post it for you.

So check it out, and participate!

Medical Education

It strikes me that I have written very little here about an issue that concerns me very much, and that is the training of physicians. I haven't consciously avoided the subject but perhaps I've been reticent because of adverse conditioning -- I find that physicians tend not to like it when non-members criticize their fraternity hazing rituals. Well, I'm over that.

This is a large subject to which more than one major journal is devoted, (Acedemic Medicine is the top one), and general and specialty journals also frequently publish relevant research. My direct pesonal experience consists of a few years teaching a section of a course for first-year students on medical professionalism -- which means everything that isn't biomedical science, including medical ethics, sociology, economics, communication and relationships with patients, and oh yeah, that little tiny subject called public health. I also frequently precept combined M.D./M.P.H. students doing internships in public health, and first year students who are assigned special projects.

Well, the school cancelled the course, because the students complained that it didn't help prepare them to pass the boards and they didn't have time to write papers about ethics while they were trying to pass the anatomy final and learn all the cytokines. Medical professionalism is a large and growing concern at medical schools, they talk about it incessantly, but they don't actually do anything about it. The biomedical science that students are required to study just keeps growing, and now it's almost impossible to keep the undergraduate program to four years. (Medical students are called "undergraduates," even though they have bachelor's degrees, because medical training continues after receipt of the M.D.) Classroom learning does include some training in interviewing, physical examination, and other clinical skills, but it's mostly rote and unreflective. Most of what doctors learn that isn't biomedical science is acquired through apprenticeship.

And there's the problem. Nobody is in charge. How a young physician learns to interpret his or her role; to interact with colleagues, other professionals and patients; to value money, prestige, and service to humanity; to view the place of the physician and medicine within society and in relation to patients; all depend on the role models she or he happens to encounter and the existing culture of the institutiosn where she or he comes to work as a clerk and resident. There is no committee, dean or hospital president who exerts substantial control over the training of physicians. Senior attending physicians who precept students and residents don't have the slightest interest in having anybody tell them what to do, and their students have little or no formal support to help them process and critically evaluate the experiences they have with mentors. It's a self-perpetuating system that is susceptible only to very broad shaping (such as recent moves to limit residents' work hours), with very little individual accountability.

So, that's a very general introduction to the situation. In the future, I'll talk about specific problems that arise from the system we have now.

A Repost

There's no law against this. Regarding my post three days ago on the fraudster Wang, and my apparently hard core positivist take on science, this is a fuller explication of my epistemological point of view which I posted in August:

The Epistemological Foam

Here's a simpler way (I hope) of explaining why most scientific findings are wrong, but science is still right.

The terrain of science is not knowledge, but ignorance. Scientists spend little time with what they already know, except perhaps in the classroom. They are obssessed with what they don't know.

I may call the advancing edge of science -- in every direction -- the epistemological foam. Here is where scientists dredge through mountains of observations for sparks of concordance; where they conjecture, dispute, and squabble; build long and fragile chains of inference; criticize each other's equipment, methods, analysis, and conclusions; clobber each other with contradictory theories and apparently inconsistent observations. Here, instead of knowledge, is the foam of uncertainty, a whirling boil of beliefs that are constantly merging, dividing, dissolving, devouring one another.

Start to move back from the edge, and the foam becomes less active. The bubbles of belief grow fewer, larger, more stable. At last they dissolve into a single fluid, at first turbulent, then rippled, then placid. Here is the Lagoon of Knowledge, whose warm and perfumed waters make us feel langorous and happy. (Some of us anyway. There are those afraid to swim who huddle on the icebergs of faith. Sorry, my metaphors are getting out of hand.)

Swim back out into the foam, and the skin begins to tingle. It's exhilerating, energizing, but also uncomfortable, stinging us with doubt, dissatisfaction, confusion. Out there on the agonizing edge, the foam dissolves truth out of the rock face of the universe, which distills out of the foam and flows back into the ever-growing lagoon.

Wow. Sorry about that. But I hope it makes the point. There is a great deal that we know, far more than we knew even a decade ago, incomprehensibly more than the biblical scribes could ever have imagined. Nevertheless, where science is most active, we know the least, and we are usually wrong.

BTW: One way of putting Ioannidis's argument is that the domain of ignorance is unbounded. Most scientific inferences nowadays are based on statistical reasoning, and chance playing over a boundless terrain inevitably creates spurious appearances of concordance. Of course there are other kinds of discovery, that are more certain but usually less grand. For example, send a robot to Mars, take a picture. Yep, that's really what it looks like. But that barely qualifies as a scientific discovery.

The reference to Ioannidis refers to this article.

The Rose Colored Crystal Ball

I'm not an incurable pessimist. Here is some good news in public health that we can expect, or at least hope for, in 2006.

Eradication of polio: WHO came very close to eradicating polio a couple of years ago, but an outbreak in West and Central Africa in mid-2003, complicated by resistance of some religious leaders to immunization, set the effort back. It's on track again. That outbreak is now controlled. A new oral vaccine has proved very useful in India and Egypt, the two places where control of polio has been technically most difficult. WHO now expects to stop polio transmission everywhere on earth except Nigeria by mid-2006, and to finish the job in Nigeria by the end of the year.

Human Papilloma Virus Vaccines: HPV is a sexually transmitted disease which also happens to be the cause of nearly all cases of cervical cancer. Vaccines are under development against the most common pathogenic strains of HPV. These will begin to become available very soon, and could eliminate most HPV infections and cervical cancer in developed countries, although getting them to women in poor countries is obviously still a problem. (There are religious fanatics who oppose their use on the grounds that if women don't have to worry about HPV, they'll have less incentive to be chaste. All I can say is, some people are really sick and twisted.)

Tobacco: Tobacco use in the U.S. continues to decline, albeit painfully slowly.



The confusing thing about the graphic is that there are more people who report smoking a few cigarettes a day, but there are definitely fewer heavy smokers. One likely explanation is the increasing prevalence of workplace smoking bans, which force smokers to cut down. People who smoke fewer cancer sticks will also find it easier to quit entirely. The more cities and states that pass bans on smoking in public places, particularly restaurants and bars, the more people will quit, and the less children will perceive that smoking is a normal, adult activity. The bad news is that the merchants of death are targeting less developed countries, and global tobacco use is increasing.

Pandemic flu preparedness: We aren't close to being ready, but at least in 2005 government and the corporate media emerged from their delusional state in which the greatest threat to public health was imagined to be bioterrorism, and started paying attention to more probable dangers. People are thinking about pandemic flu (not always very clearly -- I'll have more to say about that later) and in a few years, we may even have a vaccine production capacity based on cell cultures instead of chicken eggs, which will give the world a realistic chance to control a future pandemic. It might be too late for the next Big One, but still . . .