Driving us nuts

Mental illness, mental health, the realm of psychiatry and psychology -- whatever you want to call it -- presents some of the problems in the sociology and philosophy of health and illness in particularly high relief. I'm going to touch on some of the highlights now, which is all I can do in a single blog post. I've written about some of these specific issues in more depth before, for example here where I discuss the apparent "epidemic" of mental illness and explain it as a growing availability of diagnostic labels; here, where I discuss the problem of evil in the context of biological theories of the mind; and here where I discussed the very different kinds of criteria that can lead to a diagnosis of mental illness -- personal distress, disability, or the disapproval of others.

But now I'm just going to take a quick look around from the treetops. Psychiatry has always been in an uncomfortable relationship with the rest of medicine. Whenever the specific, biological basis of a formerly psychiatric disorder is fully understood, the disorder tends to leave the realm of psychiatry and become the province of neurologists, or possibly some other kind of doctor such as an infectious disease specialist. I mentioned recently that tertiary syphillis used to be conflated with schizophrenia. Now that we know it is an infectious disease, it is no longer considered a psychiatric disorder. Similarly, the dementias associated with aging used to be considered "insanity," but today people with Alzheimer's Disease and vascular dementia see neurologists, not psychiatrists. (The neurologists can't do anything for them either, but we still pay for visits.)

Psychiatric diagnoses depend, not on X-rays or blood tests, or feeling lumps or hearing odd sounds from the viscera, but on checklists of behaviors. If you have two from column A and three from column B, you have the disease. There are several problems here, of which the most basic are:

1. Somebody has to decide that the behaviors in question are undesirable or pathological;
   
2. Somebody has to decide that a certain amount of them, in a certain combination, constitutes a "disease";
   
3. Somebody has to decide that Hermione Hassenfeffer does, in fact, manifest the necessary combination of behaviors in sufficent degree to merit the diagnosis.

I try to be pragmatic, rather than profoundly philosophical about this. Sometimes the reality of psychiatric disease is not worth disputing -- it can be like Justice Potter Stewart's definition of pornography: "I know it when I see it." People who are walking down the street having loud, incomprehensible conversations with entities who are not there are either schizophrenic, or they are cell phone users.

However, even in this case I must acknowledge recent commenter Spiritual Recovery, who experienced a psychotic break and then recovered without the usual drug treatment. This can certainly happen -- it happened to Kurt Vonnegut Jr.'s son Mark, who wrote a book about it. One question is whether jumping in immediately with antipsychotic drugs can actually exacerbate the situation. Would more people recover spontaneously if we didn't start messing with their brains? Maybe, who knows? There is also the question of whether there are cultural contexts in which people who we would consider mentally ill may have a useful social role to play as shamans or visionaries, which enables them to channel and manage their hallucinations. I have heard of this idea before, I don't have any personal knowledge as to its validity. Certainly it doesn't apply to everybody who we would label as schizophrenic -- people who are severely disabled by schizophrenia-like symptoms who up just about everywhere, as far as I know.

But the general point is a strong one. The existence of schizophrenia certainly does depend on the social context, at least at the margins. Ted Kaczynski was diagnosed with paranoid schizophrenia (thereby sparing him execution) although he does not have hallucinations or hear voices. His conviction that industrial civilization is bad for humanity was ruled delusional by the court appointed psychiatrist. Hmm. Exactly what constitutes a delusional belief system is, inevitably, in the eye of the beholder.

But other diagnoses are far less certain and stable than the diagnosis of schizophrenia. I've said a lot about depression. Everybody knows that the difference between the normal human experiences of sadness and grief, and the disease of depression, is a matter of judgment. There are extreme cases where almost everyone would agree that there is something intractably and disturbingly wrong with a person; and there are probably many more cases that people would argue about.

But at least depressed people generally speaking don't like being depressed and want relief. There is another category of diagnoses in which the allegedly sick person feels just fine, thank you. Homosexuality used to be one of them. To the extent homosexuals felt they were diseased, it is because that is how other people treated them. They felt guilty, rejected, humiliated -- but they liked having sex with people of the same sex. Now the APA has been persuaded not to call homosexuality a disease, and even if it's no picnic being gay in Kansas, you can move to the South End or Greenwich Village and everything will be just fine.

The personality disorders which remain on the list also tend to be questionable, although in different ways and perhaps to a lesser extent. Sociopaths have something wrong with them because the rest of us say so. Generally speaking, they do not agree. What kind of a "disease" is it that the victim doesn't mind having? People with so-called borderline personality disorder drive the rest of us nuts, but they think it's our fault. They are usually quite unhappy, but they attribute to the people around them, not to themselves. Well, we aren't about to change to make them happy, even if it were possible. But these "diseases" are matters of degree, they manifest in enough different ways that it isn't clear that they are always the same "thing," if they are a thing at all, and it isn't clear that they ought even to be called diseases.

It is common to justify the concept of mental illness in terms of functional impairment and disability. If people can't hold a job, can't have stable and satisfying relationships with others, can't maintain their personal hygeine, and so on, something is clearly wrong. But again, that may be a consensus, but it's a matter of context, and opinion. Not everyone holds a job, after all, and we don't consider non-working spouses to have anything wrong with them. Quite possibly many of them would not be able to hold a job, were they put to the test. What about the people we used to call hobos, migrants who may take odd jobs but are content to be homeless and camp out in out of the way places? There are many people with odd behaviors, who might merit a diagnostic label, who live on the margins of society but seem reasonably content.

Psychiatrists want to be credible within the medical profession. In the past, there was little or no demand that psychiatric treatments be proven efficacious by the methods used for medical treatments. For that matter, medical treatments didn't have to be shown to be effective either, but psychiatry came to the evidence-based game comparatively late. The theories used by psychiatrists were firmly held and passionately defended, but they were largely speculative and often quite fungible and vague. Psychiatrists used to be convinced that schizophrenia was caused by suppressed conflicts and desires, and that autism was caused by emotionally distant mothers. Now they give drugs for schizophrenia and autism has been handed to the neurologists.

Oh yes, drugs. Although psychiatric disorders, almost by definition, are of unknown etiology, in order to be considered "scientific" psychiatry needs randomized controlled trials. It's a lot easier to do one for a drug than it is for talk therapy. For one thing, drugs are perfectly standardized -- a specific dose of a specific chemical. Counseling is very difficult to package as a standard product in a standard dose. For another, although psychiatrists nowadays like to talk about "rewiring neural circuits" by talking to people, they don't really have any way of proving that they have done so. Even if nobody knows how the drugs work, at least everybody believes that they are doing something concrete and biological.

Having said all of this, let me be absolutely clear. However problematic the concept of mental illness, there really are people with mental illnesses, who really do suffer, and who are best served if we agree that they are sick. There should be no more stigma associated with mental illness than there is with influenza, heart disease or diverticulosis. There should be equal access to appropriate, comprehensive treatment. There should be an equal commitment to making sure that treatments really work. But we need to understand mental illness correctly, and that requires a very critical, skeptical examination of the current set of concepts, the system of care, and treatments.

That's something I will try to do more of here. I'm very interested in hearing people's ideas about all this.

'Nuff Said Department

From my old friend* Marc Rodwin, in the latest Health Affairs:



As Marc concludes:

To paraphrase Mark Twain’s comment on reading his obituary in a newspaper, the reported recent demise of medical practice as a result of rising malpractice premiums has been greatly exaggerated. The perception that increased malpractice premiums cause a crisis is at odds with evidence from the AMA surveys. These surveys indicate that premiums have consistently been a small percentage of total practice expenses . . .Claims that the level of malpractice premiums justify a tax credit to prevent physicians from leaving the practice of medicine are hyperbole, especially when physicians’ income is viewed compared with that of others. Average physician income in 2003 was between the ninety-fifth and ninety-ninth percentiles for all Americans.

I got nothing to add. The AMA and its paid representatives in Congress need to start worrying about other issues.

*I was his TA for a course in health policy many years ago.

Just thought this was interesting . . .

While I'm too busy to post anything substantive right now (proposal writing) here are the "top stories" from the CNN web site as of 12:25 pm, Eastern Time:

# Powerful quake reported near New Zealand
# Gunmen storm garage in Baghdad
# Horses tread back-high flood to safety
# King warns Saudi media about women's pictures
# Adopted dog helps save girl with cracked skull
# Teen jailed for her own safety, prosecutors say
# Bubonic plague found in mice at campground
# Zoo visitors shocked as bears eat monkey
# Report: U.S. cultural treasures could be history
# 'Da Vinci Code' prompts parody from albinos
# Paris Hilton's Mother's Day gifts stolen
# Bars require fingerprints to get a beer
# SI.com: Bonds says he's haunted by Babe Ruth

So yeah, okay, there is at least one legitimate story in there. The NZ quake was near some uninhabited islands and did no damage, but you now, it's an earthquake! While the gunmen were storming the garage, four (4) U.S. troops were being killed in Iraq (bringing the daily average of dead coalition troops this month to 3.25, the highest since January of 2005 -- but hell, who's counting? -- there's still no Iraqi government, Iraqi children are starving, and a couple of hundred Iraqis are blown up, tortured to death, or shot every day -- maybe they'll get around to reporting on some of that. But Paris Hilton's Mother's Day gifts -- now that's news we need to know.

And I have more to say about this . . .

Like most psychiatric diseases, bipolar disorder is diagnosed based on a set of behavioral symptoms. Nobody knows what the underlying biological process or abnormality is in BPD, or for that matter whether there is only one -- in other words, whether it is really one disease. (In the past, doctors thought that schizophrenia and tertiary syphillis were one disease. They still don't know whether what we call schizophrenia is one disease, but it probably isn't.)

The basic description of bipolar disorder is cycling from periods of what looks like clinical depression to periods of unusual self-confidence and exuberance which can pass over into an irrational state called mania in which self-confidence turns into grandiosity, racing thoughts become divorced from reality, and assertiveness may turn into aggressiveness. Some people stop short of the extreme manic state. The milder form, called hypomania, may actually be desirable -- a period of creativity and joy.

Well, four and five year old children are like this naturally. One moment they are calm and quiet, then they are exuberant and creative, then they have a tantrum, then they sulk. In their exuberant, creative phases they indulge in fantasies which they seem fully to believe. In their tantrums, it is impossible to reason with them.

In school, children are required to spend long periods quietly focusing on tasks which are often not very interesting. They are required to speak only when they have permission. They may play energetically only during brief, specified periods. Most children do not like to do these things, and some simply will not. In the old days, when children didn't conform, their teachers would smack them on the back of the hand with a ruler, beat them on the buttocks with a rod or a paddle, or make them sit in the corner wearing a bizarre, humiliating hat. Parents usually demanded comparable conformity at home, and used similar measures to enforce it.

I presume these methods were at least somewhat effective, or they would not have been so widely used for so long, but clearly they had pernicious secondary effects, as we say. Nowadays they are out of favor. When children fail to conform their behavior to the demands of adults, we label them as diseased and drug them. Reasonable people may disagree as to whether and under what circumstances this is appropriate, but there is very widespread concern that far too many children are being drugged and that it ought to be a last, desperate resort.

Like physical violence against unruly children, the drugs have side effects. The most widely prescribed are amphetamines, which are among the most dangerous of addictive drugs and can even produce psychotic states. For children diagnosed with bipolar disorder, as I wrote below, lithium and Depakote are the common prescriptions. These drugs also have side effects.

But anti-psychotics are another matter entirely. These drugs are so toxic that even desperately ill adults often cannot take them. They are associated with severe weight gain, hyperglycemia and diabetes, and hypercholesterolemia and heart disease. They can cause severe neurological complications, damage the liver and kidneys, and cuase a life-threatening metabolic disorder. The "clinical trial" for quetiapine in 4 and 5 year olds is a "phase IV" trial which is supposed to test the safety of the drug in a new population. There is no need for such a trial. We already know the answer. The drug is not safe. It is not safe in adults, albeit it is sometimes the lesser evil. To give it to children, whose brains are still developing and whose liver enzyme systems are underdeveloped; children who are not physically ill but whose behavior is troublesome, who may or may not have some completely unknown neurological abnormality, is grotesque. The purpose of this is for a drug company to try to sell more pills and make more money.

That's my opinion.

Now this is really seriously over the line . . .

Some "doctors" at Harvard Medical School -- led by one Joseph Biederman, MD -- are running a clinical trial to test the atypical anti-psychotic Quetiapine in pre-schoolers -- kids 4 to 6 years old -- who have been "diagnosed" with bipolar disorder. Read all about it here in case you are incredulous.

Applying the diagnostic label of bipolar disorder to a 4-year-old strikes me as an outrage to begin with. Quetiapine is prescribed for people with schizophrenia, which is a serious, disabling, and incurable disease, but most people can't tolerate it and stop taking it. It is also sometimes prescribed to adults for the manic stage of bipolar disorder but that ought to be a last resort, in my view. Here are some of the side effects, from Medline Plus:

* drowsiness
* dizziness
* agitation
* pain
* weakness
* dry mouth
* vomiting
* indigestion
* constipation
* stomach pain
* headache
* excessive weight gain
* thinning of hair or nails

* fainting
* seizures
* shaking of hands that you can not control
* changes in vision
* rash
* uncontrollable movements of your arms, legs, tongue, face, or lips
* painful erection of the penis that lasts for hours
* fever
* very stiff muscles
* excess sweating
* fast or irregular heartbeat
* unusual bleeding or bruising
* loss of appetite
* liver damage
* flu-like symptoms
* lack of energy

Not to mention hyperglycemia and diabetes. And oh yeah, cataracts. They tried it for elderly people with behavioral problems from dementia, but it, uhh, killed them.

Then there are side effects called Neuroleptic Malignant Syndrome -- which is potentially fatal -- Tardive Dyskenesia, which is an irreversible movement disorder,

As the prescribing information says, "Chronic antipsychotic treatment should generally be reserved for patients who appear to suffer from a chronic illness that is 1) known to respond to antipsychotic drugs and 2) for whom equally effective, but potentially less harmful treatments are unavailable or inappropriate."

While it is questionable whether a diagnosis of bipolar disorder can even be made with any confidence in a 4 year old -- and it is certainly rare -- there are standard treatments which are much safer than Quetiapine, starting with the first-line treatment lithium. Some children are prescribed valproic acid (Depakote) and other anticonvulsants which have mood stabilizing effects. But medications are most effective if combined with psychosocial and behavioral therapy.

How this trial ever got approval is beyond me. No, I'm not a psychiatrist or an M.D. But I'm a citizen who also has a right to his views about whether the potential benefits justify the risks. (Thanks to ABC News for the tip-off.)

State Secrets

You really need to pay attention when you read the paper. The NYT article about Dusty Foggo (whose identical but totally opposite twin Fusty Doggo has graced us with a visit) has this buried smack in the middle:

Among those identified as a co-conspirator in [Duke Cunningham's] plea agreement was Brent Wilkes of San Diego . . . . Mr. Wilkes's nephew Joel Combs led a company with a multi-million dollar contract to provide bottled water to the CIA in Iraq, a contract reissued through a local company to disguise the CIA's role.

Once again, the New York Times has sold out the country to The Terrorists. Now they know that the CIA agents in Iraq consume millions of dollars worth of bottled water. We don't know how many millions of dollars were in the contract, but multi- means at least two. We also don't know the time frame of the contract but federal contracts are usually done by fiscal year, so let's say it's 12 months. So let's be conservative, and call it $2 million a year. Down at the Stop & Shop a half gallon of Zazz seltzer costs $1.29, but buying wholesale, and in bulk, I figure they ought to be able to get a gallon of water for less than a buck. Two million gallons of water a year is about 5,480 gallons a day. It gets mighty hot in Iraq so I suppose the average CIA agent might drink a half gallon a day or even a little more. So I figure, there are at least 10,000 CIA agents in Iraq.

Now let's see if they try to classify this blog.

As I said a long time ago . . .

It was a big mistake for Chimpy and the gang to mess with the CIA. I'm actually surprised that it's taken this long for the piano to fall on them.

Political Malpractice

As I believe I mentioned a couple of days ago, one of the bogus gestures of the supremely, world historically, reality shatteringly b-o-o-o-o-o-o-o-o-o-o-gus Health Week was an attempt to impose a cap on medical malpractice awards, which the Senate Democrats, activating their newly installed gonads, blocked.

Now, the medical malpractice system is for sure not as good as it could be. Actually, the biggest problem is not with malpractice law per se but with the socio-political context in which it sits. Because we do not have comprehensive, universal health care in this country, or an adequate social safety net, people who suffer severe injuries from medical intervention, or for whom medical intervention fails to provide a solution, may find that they have no way to pay for their long-term, possibly life-long needs. Their only recourse may be a malpractice suit. But whether people win compensation does not depend on the extent of their injuries or need, but on whether their physician is found to be negligent, which is almost beside the point.

In any case, complaints about the system from doctors and insurers -- at least the ones that Republicans like to channel -- focus on "frivolous" lawsuits and "greedy trial lawyers" winning "excessive" awards. In the new NEJM (abstract here for you commonfolk) David Studdert and half of Harvard Medical School give us the straight dope on malpractice. Based on a sample of actual claims -- yes, it's that obsolete "reality based" thinking -- they find that while 37% of claims did not involve medical error, in their judgment, most of them did not result in any compensation to the plaintiff. For the 27% of claims they thought were without merit, that did result in some sort of compensation, the compensation was much less than it was for meritorious claims ($313,205 on average, vs. $521,560.) In almost all of these cases, the plaintiffs did suffer injury. Had they not received some compensation through the malpractice system, they would have had no other recourse.

However, there were far worse problems. Only 73% of claims that were meritorious resulted in compensation. One out of every six claims involved errors, and received no compensation. Furthermore, the majority of negligent injuries, it has been found previously, do not result in any claims at all. What is more, administrative and legal costs amount to 54% of the total amount paid to plaintiffs, nearly 80% of which costs were incurred in litigating meritorious claims. Finally, it is important to note that many claims which ultimately were found not to involve medical error could only be so classified as a result of the investigation and discovery resulting from litigation. These claims were not "frivolous" when they were first filed, but required the legal process to be properly evaluated.

The bottom line is, greedy trial lawyers are not abusively extracting money from the system. On the contrary, most people injured by medical error receive no compensation at all. Average compensation is in the hundreds of thousands, not millions of dollars. Eliminating non-meritorious claims would reduce the cost of malpractice by only 13%, but it would obviously be impossible. The purpose of the system is to judge claims. Some that are not ultimately found meritorious will have to enter the system in order for that to happen. The vast majority of the money spent in the system is spent on adjudicating and paying meritorious claims.

If physicians want to reduce the cost of malpractice insurance, the best thing to do would be to reduce the rate of malpractice.

Department of Repetition and Redundancy

Ranking Democrat on the House Intelligence Committee Jane Harman, today:

Last week I said the CIA was in free fall. Now, I think the White House is in free fall, and paying the price for refusing to obey the National Security Act and brief the full Intelligence Committees in detail on the NSA program. Americans are alarmed – and rightly so – because this Administration continues to operate parts of the NSA program in violation of FISA and the 4th Amendment. Today, 14 members of the House Intelligence and Judiciary Committees introduced legislation to require all aspects of the NSA program comply fully with FISA.

Does anybody see the problem here?

Okay, Dont' Ignore it After All

It turns out that the Enzi Bill to override state health insurance regulation, that I wrote about yesterday, isn't such a dead issue after all. Not only that, it's even worse than I realized, because in addition to invalidating state regulations on required services, it also overrides state regulation on risk rating.

Remember that I talked a while back about the death spiral, where without regulations, insurers will charge more to businesses with older and/or otherwise less healthy workforces, until they can no longer afford any coverage for their employees. States prevent this by restricting the price differential insurers can impose. Insurers don't really mind, in fact it helps them, because they just put everybody into one large pool, so that the customers with the healthiest workforces pay a little more, and those with the least healthy less, than they would under strict "risk rating." This benefits society by spreading the cost (after all, we're all going to get old eventually), and reducing administrative and marketing costs. The Enzi bill will end community rating.

What a horrible piece of crap this is. According to Families USA (linked above):

CBO concludes that this terrible bill would raise premiums for one-fourth of businesses in the small group market, and some individuals will find it harder to get coverage for conditions or services that are now mandated under state laws. This wholesale elimination of consumer protections will, at best, trim only 2-3 percent from the premiums of some businesses with young, healthy workers.

Oh, and by the way -- the bill would also destroy the recently passed universal coverage legislation in Massachusetts (which I have agreed to be optimistic about for the time being). What is hardest to figure out is why they are doing this. Who is the constituency? Who is bribing them to hurt America in this way? It most certainly isn't going to get them any votes.

No more Mr. Nice Guy

The blogosphere has it's own weather, and while proper classification of the various phenomena and, more remotely, the power to predict await the development of a true blogosphereological science, I can make a descriptive report that we are currently experiencing an Infundibulum Storm* over the issue of Civility. A lot of it has to do some guy named Cohen whose idiocy is apparently more offensive than the idiocy of the average idiot because he has a column in the same newspaper that thinks that selectively leaking classified information that was known to be false, while intentionally blowing the cover a CIA operative working on counterprofliferation, was a major triumph of statecraft. Since, like 99.9999% of the American people, I do not read the Washington Post, it doesn't seem all that important to me.

Still, to put my own oar into the maelstrom, I got over the civility thing a long time ago. Let's see, when was it? I started to feel kind of uncivil when the corporate media turned into a pack of rabid dogs over a decade-old land deal in which the Clinton's got scammed out of a few thousand dollars, on the premise that they couldn't have been victimized if they hadn't done something wrong although nobody ever seemed to have the slightest idea of exactly what that was. But that was not enough to cause me to start using the wrong fork or slurp my soup.

Nope, I think I really started to get significantly uncivil when they spent the 2000 electoral campaign telling us that Al Gore was unfit to be president because of the color of his suits and because he had claimed to have invented the Internet, uncovered Love Canal, and to have been Oliver in Love Story, none of which he had ever actually claimed but it was fun to keep saying so. Meanwhile George W. Bush was a really nice guy, and a straightshooter who we should vote for because we wanted to have a beer with him. Were there, you know, public policy questions confronting the country? Evidently not.

So by that time I was wiping my chin on my sleeve and using mild epithets such as crap and damn in front of the ladies. But I would have to say that I really became downright rude when the corporate media joined the government of the United States in a campaign of lies, to lead the country into a war of agression for the purpose of gaining control by military force over the petroleum of the Middle East, killing hundreds of thousands of innocent people, destroying the reputation of the United States throughout the world, and by the way failing to achieve its objective. I didn't particularly like it either when the President of the United States asserted that he has the absolute, unaccountable power to make people disappear forever into secret prisons, there to torture them, even torture them to death, and that neither the Congress, the courts, nor international treaties can restrain this power in any way. I actually got ticked off enough to bang my fist on the table and say stuff like "fuck those assholes" when they gave massive tax cuts to rich people while trying to take housing, health care, retirement income, and even food away from poor people, while stealing hundreds of billions of dollars they borrowed from foreigners to enrich their cronies at Halliburton and Raytheon and make our grandchildren pay it back, which they won't be able to do because they will be impoverished by the collapse of our oil-fueled economy.

I'm definitely uncivil about stuff like that and I get even more uncivil when people who pretend to be liberals and to agree with me that oh yes, tut tut, all that just isn't right, tell me that the real problem is that I'm angry about it. If I would just calm down and pay the proper respect due to the office to the man who is, after all president, all that bad stuff would go away. To that I say, uncivil as it may be, you are a coward, and a fool.


*Infundibulum is the Latin word for funnel. In a meterological funnel cloud, all kinds of random shit such as houses, cows, and '57 Chevies gets scooped up and spun around together. In a blogospheric infundibulum, in contrast, it's all about people furiously quoting, insulting, and responding to each other in a whirling boil of indissoluble interconnected referentialness.

Ignore this post

You probably don't know that Board-Certified Homevideoneurodiagnostician Bill Frist has declared this to be "Health Week" in the Congress, because the corporate media, to their credit, have largely ignored it. The basic idea seems to be for the Republicans to move outrageous proposals that they know won't pass, in order to score points with some of their base constituencies. I was committed to joining in the mass movement to completely ignore this, but then I decided it might be instructive with respect to some recent topics to take a quick look.

The first thing they tried was to cap jury awards in malpractice suits. That didn't get the 60 votes it needed to break a Democratic filibuster. (And let's acknowledge the resurrection of the minority from the dead.) The malpractice system definitely has flaws, but excessive compensation to horribly injured people is not one of them. (Okay then, malpractice is now on the to-do list here.)

Now they have an even more nefarious proposal. Under cover of a bill to allow small businesses to form purchasing cooperatives across state lines, they want to override state regulations requiring that health insurance be comprehensive. The plans could be lower in cost because they wouldn't have to cover things like mammograms, well-child care, or even chronic disease care.

If you've been reading Stayin' Alive, you already know that one of the most pernicious consequences of our fragmented health insurance system is that insurers don't have an incentive to keep you healthy, because by the time you get sick, you probably won't be their problem any more. Therefore, while it saves society money to provide services like cancer screenings and immunizations, preventive care represents a cost to insurers that they might not recoup. That is why state regulations require that plans offer certain basic services. But now "Dr." Bill Frist wants to kill you, so that businesses can save money, and give some of it to Republican candidates.

You can read all about Sickness Week in Forbes. Or you can ignore it, which is what I recommend.

The Grim Accountant

I have said before that I object to the well-meaning work of Iraq Body Count, which purports to keep track of civilian deaths in Iraq from military intervention, by compiling information from news reports. The figures provided by IBC are taken as reality by the corporate media, and even by the person principally responsible for those deaths, who once said there had been about 30,000 of them, apparently based on the IBC data.

While purporting to create a record to challenge the conscience of the world, IBC is in fact reifying a gross undercount of the true toll of the Iraq war, and sanitizing a situation which is far worse than they make it appear. It is not only that a large proportion of deaths in Iraq from bombings, shootings, and other violent trauma do not become the subject of news reports, although that is most certainly true. It is also that the vast majority of deaths caused by military intervention are not directly caused by explosives and projectiles at all.

UNICEF finds that one third of Iraqi children are now malnourished and underweight. Excerpt from the UN News Service report:

One in three Iraqi children is malnourished and underweight, according to a report released by the United Nations Children's Fund (UNICEF) in Amman on 2 May.

"Under-nutrition should not be accepted in a country like Iraq, with its wealth of resources," said UNICEF Special Representative for Iraq Roger Wright from the Jordanian capital, Amman. Wright added that ongoing insecurity served to deter parents from visiting health centres for essential services, while many health workers had been kidnapped or killed in different parts of the country.

According to the report, a full 25 percent of Iraqi children between six months and five years old suffer from either acute or chronic malnutrition. A 2004 Living Conditions Survey indicated a decrease in mortality rates among children under five years old since 1999. However, the results of a September 2005 Food Security and Vulnerability Analysis – commissioned by Iraq's Central Organisation for Statistics and Information Technology, the World Food Programme and UNICEF – showed worsening conditions since the April 2003 US-led invasion of the country.

The problem is particularly dire in the south, especially in the provinces of Basra, Diala, Najaf, Qadissiyah, Salahuddin and Wasit, due primarily to a lack of health funding. Health ministry officials acknowledge that the public health situation remains below international standards, but expressed hope that the recently formed government in Baghdad would provide more funding.

It is impossible to say how many children have died already as a result of this situation, but it is almost certainly more than 30,000. The situation is much worse than that, however, because people who survive chronic malnutrition as children will grow up to be unhealthy, and can expect reduced intellectual ability, weaker immune systems, and short lives. Other reports have shown how deteriorating health care, contaminated water, and other poor conditions are causing an increase in mortality at all ages. War is stealing the future of Iraq. I would like for Iraq Body Count to please go out of business, or else fundamentally change its methodology and the message it conveys.

The last person elected . . .

President of the United States, WJ Clinton, has acted presidential by brokering an agreement with the sugar water industry to stop selling most of their poisonous products in schools. This is an issue I have railed about here frequently, and you're probably wondering why it took me a few days to get around to commenting.

Well, there are only 37 hours in a day, and I had to find the time to make sure this was on the up-and-up. I don't want the perfect to be the enemy of the good, on the other hand the companies obviously must have seen this outcome as preferable to waiting around for 80% of the states to pass bans. So, there are a couple of flaws which are worth pointing out.

The most egregious is that the agreement allows so-called "sports drinks" to be sold in high schools. These are concoctions like Gatorade© (invented by a University of Florida athletic trainer, and the University gets royalities on every bottle) which are just sugar water without the bubbles, plus a bit of pottasium. If you are engaged in high intensity exercise for a long time, then you can safely consume sugar because it is burned off without a glycemic spike. Unless you are running a marathon, however, it is unlikely you will need to worry about electrolyte replacement.

Most people who consume these drinks aren't doing anything of the sort. Even if you are doing hard work, be it riding your mountain bike on a Sunday afternoon, clearing brush on your Texas "ranch," catching a comparatively big fish* or watching war on TV, you are probably better off just drinking water. I am quite sure that 99% of the high school kids who buy these drinks out of vending machines at school aren't taking them to track practice, where liquids are provided anyway. They are just a backdoor way of getting sugar water past the ban, and they are marketed so as to make you believe they are good for you. Sadly, no.

Another problem is that the agreement allows anything that can be legitimately labeled as "100% juice." Unfortunately, that isn't necessarily okay. The beverage industry has developed some strains of grapes with incredibly high sugar content, so that "grape juice" becomes a way of getting a whole lot of sugar into an all-juice product. Some juice blend drinks are just empty calories, really no different nutritionally from soda. You need to read the label. Nutritionally worthwhile juices contain vitamins, minerals and even dietary fiber, and have considerably less sugar than soda. Not everything called juice qualifies. Specific nutritional standards, rather than just the "100% juice" concept, are needed.

So, while this agreement is a win, not least because it establishes the legitimacy of the issue, it shouldn't stop state laws from going forward. And we still need to do something about solid food, including not only vending machines but the french fries and pizza provided in the cafeteria. Maybe then we'll have a chance to start beating back the obesity epidemic.

*Whoops!

Today in the United States

As I believe I have mentioned before, I do the Today in Iraq post on Sundays. It's sort of a penance, I guess, on behalf of our nation that has so disastrously failed to live up to the ideals we glibly announce to the world and condemn others for dishonoring. I call it a penance because it is always painful to wade through the grotesque violence of a typical day in Iraq, and the rushing sewer of lies that continues to issue from our government and military.

Like many of us, I feel profoundly betrayed by the putative opposition party and the purportedly independent news media, in the entire sordid history of this war. Even today, while the ineluctable force of reality has at least turned them from mindless cheerleaders to what they want us to perceive as constructive critics, hardly anyone of prominence will tell us the truth.

This is a war for control of natural resources. All other rationales that its perpetrators have given are pure fabrications, and were quite clearly nothing but fully conscious and deliberate lies -- and the Democrats in Congress knew perfectly well that they wre lies, as I am quite sure did most reasonably savvy reporters. But they all went along with the game. To tell the truth about the war would force the political leadership, and the corporate elite who control the mass media, to enter into a public discourse about the fundamental issues facing the nation, and the world. This they will not do.

They have begun to tiptoe around the edges of the burning ground. The Republicans claim we need to drill for oil in the arctic wilderness and eliminate environmental regulations in order to increase the supply of petroleum. The Democrats want to raise automobile fuel economy standards by 15% or so by 2015, promote "research" into alternative fuels, and -- disgracefully -- suspend the federal excise tax on gasoline.

All of this is equivalent to bailing Lake Superior with a sponge. These proposals are essentially worthless, and their proponents know it full well. They merely serve to deceive the people into thinking that we have only a small problem which can be solved with the expenditure of a few dollars and the acceptance of some inconveniences. To link the price of gasoline to the carnage going on halfway around the world would demolish the national fantasy.

Let me say this slowly and clearly. This is what any responsible political leader must stand up and say to the people. There is a very good chance that there will never be as much petroleum extracted from the earth's crust in any future year as will be extracted this year, in 2006. If that turns out to be true, it won't be off by enough to matter. From now on, or very nearly now, global oil production will decline, year after year after year. It will never go up again. The world won't "run out" of oil, in the sense that there will be none left, but the oil that is left will cost more and more to extract, and there will be less and less of it.

Meanwhile, as we continue to burn what is there at the maximum possible rate, and to burn more and more coal and natural gas to make up for the shortfall, we will only accelerate the change in global climate.

This twin crisis is as threatening as anything our civilization has confronted before, including the rise of Nazism and Japanese militarism, and the threat of nuclear anhilation. But they are either ignored, or actively denied by the political elite and the corporate media. The reasons are not hard to see. Doing what is necessary to meaningfully address these problems would overturn the national power structure, and would demand that Americans accept major changes in their way of life. The captain of the Titanic didn't see the iceberg, but our captain and all of his officers do. They just won't tell us, and they're steering straight into it.

A Couple of Interesting Pieces . . .

from the new JAMA. I'm not even going to bother continuing to express my annoyance about it being subscription only. (Whoops! I guess I just did.) Anyway, you common rabble will just have to take my word for it about the following.

Joseph Ross, Elizabeth Bradley, and Susan Busch use data from the Behavioral Risk Factor Surveillance System (which is misnamed, it's not a surveillance system but a telephone survey) to examine use of preventive health services by people without insurance, including the relatively affluent. It turns out that while more affluent people in general are more likely to use preventive services, the gap between the insured and uninsured is just as large among the well-to-do as it is among the impecunious.

Specifically, 83% of uninsured women with incomes under $15,000/year got cervical cancer screening (Pap tests) as recommended; so did 84% of uninsured women with incomes above $75,000. (Yup, some well-to-do people choose not to buy health insurance.) While 67% of high income women got mammograms compared with 56% of low income women, the gap between the insured and uninsured was just as great at both levels. The pattern for colon cancer screening was similar -- 48% of uninsured high income people got them as recommended, compared with 65% of insured high income people.

In present policy debates, this is important because it proves, beyond a reasonable doubt, the utter folly of the Republican push to get people to buy high-deductible insurance plans that don't pay for routine care; and pay for routine care out of tax-deductible accounts. That is supposed to "contain" health care costs by making consumers think twice about spending. The problem is, as should be obvious, that consumers forego spending on services that will prevent far more expensive disease -- even when they can afford them. Q.E.D.

Moving on, before lining your bird cage you may have read about the study by Banks, Marmot, Oldfield and Smith comparing health status in the U.S. and the U.K. Before I say anything else, I must protest that they made the bizarre decision, which the editors bizarrely endorsed, to include only white, non-Hispanic people in their data from both countries, supposedly to avoid the confusion that would be caused by the differential health status of ethnic minorities. Uhh, those are also actually people who live in and are in most cases citizens of those countries. It would have been very easy to include them and simply account for the differences in the analysis; and the health status of minorities in both countries is obviously a matter of compelling public concern. I will not hesitate to use the R word.

That said, the differences are dramatic. In both countries, there are gradients in health status according to social class (income and schooling), but among comparable age groups, English people (by which in this case we mean English people of European ancestry) are much healthier than Americans (by which we mean Murrkins of European ancestry). The data includes information from actual physical examinations as well as self-reports, so it is pretty bullet proof. 12.5% of Murrkins age 55-64 have diabetes, compared with 7.2% of Anglo-Saxon and Celtic Subjects of Her Majesty (ASCSHM). 42.4% of Murrkins have hypertension, compared with 35% of ASCSHM. 5.4% of Murrkins have had a heart attack, compared with 4.2% of ASCSHM. And on and on. In fact, the rate of diabetes among high income Murrkins is much higher than the rate among low income ASCSHM.

Why is this? While it is true that 100% of ASCSHM have life-long health insurance, whereas many Murrkins do not, that does little to account for the disparities, which don't have a whole lot to do with health care anyway. Murrkins started to get fatter sooner, which may make some difference; and social inequality is greater in the U.S., which has an as yet not fully explained relationshp to population health status (but doesn't explain why wealthy Murrkins are about as unhealth as poor ASCHSM).

Don't forget, the Brits spend half as much on health care as we do. We're obviously wasting our money.

Totally off topic but it might interest somebody

I swear on the graves of all my ancestors that this blog will never degenerate into any sort of a personal diary, but this may be of some general interest so here you go. Jeopardy! (exclamation point obligatory) is, as far as I know, the only non-inane game show on TV. It's actually intellectually stimulating and possibly even educational in a vague, unfocused way. (Artificial intelligence researchers have discovered that human-like intelligence depends very much on a vast archive of factoids, so watching Jeopardy! quite possibly does make you smarter.)

So I figured it would be an excellent adventure to try to get on the show. I took an on-line test, and wound up with an invite to a contestant audition, which I took yesterday. They processed us in a group of about 20, starting with taking polaroids and collecting five of those little personal bon mots -- most embarassing moment, weird things you collect, horrible job you once had -- that Alex uses for the personality interviews during the first round. The people who run these auditions evidently harbored youthful dreams of being in show biz so they did a little stand up, with lots of artificial perky enthusiasm and lame jokes to warm us up.

Then we took a 50 question written test, writing down the answers to Jeopardy! clues that were presented on a screen. Next, we all took turns playing a fake game of Jeopardy! -- not a whole game or a real game, just about 5 minutes without keeping score -- in groups of 3, of course. Since Alex obviously wasn't there, the clues were recorded by Johnny Gilbert (who has the world's easiest job). Then they did the personality interview with each contestant in turn.

The outcome is that we're in the contestant pool for a year. They start taping in August and I could get a call any time from June through April, or never. They didn't give us any indication of the outcome or what any individual's chances might be. It is clear, however, that they aren't necessarily looking for the best players. They need people who can play a decent game, but they are casting the show. They want people who will play quickly and decisively, have a lot of positive energy, and be appealing on TV. Is that me? Who knows.

As for the game itself, knowing a lot of useless information is certainly helpful, but the real challenge is ringing in. You need to read the clue while Alex is reading it aloud (a distraction you have to ignore) so you have time to decide whether to ring in or not before he is through. When he is done, a human operator activates a light that signals that you can ring in. If you try to ring in too soon, you are locked out for 1/4 second, but if you do wait for the light, obviously you have to beat the other contestants. It's very difficult not to jump the gun, and it's easy to make a decision to ring in thinking the answer is about to come and then have it just not show up in the frontal cortex. I would imagine that keeping up concentration and focus for a whole game is quite tiring.

Answers to minor questions:

They now pay $1,000 for third place and $2,000 for second. So at least that helps pay for the trip to LA.

If there's a tie, both winners get the full amount, they don't split it. The reason people almost always play to win, and not to tie, in Final Jeopardy is that experience counts for a lot and you don't want to bring back a competitor who has already played the game. That's cold, but it's a jungle out there.

Alex is only the second game show host in history to have had a mustache. (He has since lost it.) Who knows who the first one was? (Please make sure your response is phrased in the form of a question.)

An oldie but goodie

The execrable Christopher Hitchens decided to attack the estimable Juan Cole and got stomped on as a fly by an elephant. Do read. It's not really about Hitchens, it's about war. Here's the story on Hitchens, from yours truly, which I first wrote last year.

Christopher Hitchens, like Lyndon Larouche, used to present himself as a leftist. For many years he had a column in The Nation in which he vied with Alexander Cockburn for the “Most Acerbic” award (a magnificent scarlet inkwell filled with sulphuric acid). Things started to get a little weird in the 1990s when he developed an obsessive hatred of the Clintons. His reasons were partly respectable (triangulating, Dick-Morris-employing betrayers of the revolutionary vanguard) and partly insane (Bill’s serial sex crimes made Ted Bundy look like a boy scout; Whitewater [in which they were guilty, Guilty, GUILTY!) was the financial scandal of the century; Hillary not only murdered Vincent Foster, but conspired with her lesbian lover to seduce, rob and kill dozens of wealthy young fops whose mutilated bodies turned up in seedy alleys all over the DC metro area . .. well, maybe I made up that last one but it’s in the spirit of the thing.) Once he could no longer demonstrate his superiority to the bleating herd of liberal sheep by cheering on Ken Starr, the Iraq war became his next opportunity. His bellicose rantings were enough to drive Dick Cheney to the Quaker meetinghouse. He finally resigned from The Nation, claiming that the refusal of the magazine’s other writers and editors to fall to their knees in grateful acknowledgment of his intellectual and moral superiority on the question of war was proof of their bigotry and hatefulness. He wrote a final hissy fit essay in which he burned every bridge from London to Lompoc.

As some people have noticed, the Iraq war has not turned out the way it was supposed to. Some of the war’s portside chickenhawk supporters have since issued mealy mouthed retractions; others have concentrated on giving Chimpoleon and his pals unsolicited advice about how to do it better. Hitchens, however, has devoted himself to escalatingly vicious and absurd attacks on the war’s opponents. It’s not unusual for polemicists to turn against their own comrades but Hitchens’s case is particularly disgusting and bizarre. I think that chronic alcoholism destroyed brain cells in his cerebral cortex that normally inhibit irrational emotional responses in the limbic system. Something ticked him off around 1994, and the anger just fed into a positive feedback loop that slowly and steadily grows more intense. Eventually, he’ll lose one too many neurons and lapse into a vegetative state.

Unfortunately for the rest of us, he's still a few dead neurons away from the PVS. But at the rate he's going, it shouldn't be long.

Back to the file cabinets . . .

Okay, I have to finish up with this insurance stuff, however profoundly it may bore people, because it's important, damnit! I've discussed casualty insurance, then I've discussed how health insurance (which is only partly insurance, hence much confusion is caused by the name) is different with respect to the issue of moral hazard. Now we come to the issues of adverse selection and risk rating.

As you will recall, adverse selection is the obvious problem that people who think they are likely to suffer a casualty in the near future are more likely to buy insurance. In other words, if you are diagnosed with terminal cancer, you might just rush out and buy a life insurance policy. That would make selling insurance a losing proposition, unless insurers do one or both of two things: a) Refuse to sell to people who are at relatively high risk, or b) Charge higher premiums to people at higher risk. In practice, they tend to do a little bit of both.

Now, as we have also seen, although they have to do this, it makes their product less desirable. If they could do it perfectly, insurance would in fact be worthless. In the case of health insurance, if insurance companies could predict that your medical expenses in the coming year will be $7,862.56, that's what they would charge you for a premium, plus their administrative expenses and profit. So you wouldn't buy the insurance, you'd just pay the bills yourself, which would be cheaper for you.

In practice, the vast majority of people get insurance as part of a group, typically employees of a particular company. Let's assume there is no government regulation (which is counterfactual, of course). Then insurance companies would negotiate with employers over what product to offer and the cost. Companies would generally want the insurance to be available to all of their employees, or at least all of their employees at or above the pay grade that they want to cover, and they would want to get the same deal for all their covered employees. That's simpler for them, it avoids creating disgruntled employees, and it assures that all the company's valued employees will get health care. In that circumstance, the insurance company will charge the employer a premium based on the average risk for all its employees. In an unregulated market, they may adjust this based on the nature of the industry, and the employer's historic experience.

For example -- and this is absolutely true -- during the early years of the AIDS epidemic, florists were charged more for insurance on the grounds that their employees were more likely to be gay, and hence at risk for AIDS. Once an insurer has a relationship with a company, the premium may be adjusted each year based on experience. These procedures are called risk rating and experience rating. Also, in the real world, insurers typically won't provide coverage for new employees for "pre-existing conditions" -- diseases they already have when they join the company -- for some period of years. They don't want people choosing jobs that provide insurance that meets their needs (adverse selection, in other words).

(Wow, I am bored already myself.) People who don't get health insurance through employment have a problem in this system. Even if they could afford to pay the premiums an employer pays -- let's say the person is a self-employed consultant making big bucks -- insurers will want to charge them more, a lot more. The reason is that since they aren't part of a group, the insurer can't predict what they are likely to cost in terms of claims, and the insurer has to worry about adverse selection. Even a physical exam and medical history can't rule out that the person secretly knows they are at risk for some reason. And as we all know, they will do that exam and take that history and people who are indeed at high risk will be unable to afford insurance or won't be able to buy it at all -- and those are exactly the people who need it most.

(Whew, we're getting toward the end of today's post.) So, let's say there is no regulation, and insurance company A sells cheap policies to companies that employ mostly young, healthy people. Those companies will flock to company A for the cheap policies. Company B tries to charge all employers the same, but the customers who are least costly have all gone to Company A. So Company B has to raise its premiums. That causes employers who have middling costs to switch to Company A, which will offer them a middling rate. Company B has to raise rates to the remaining employers even further, and so it goes, till Company B is out of business and every company is paying based on its actual cost of providing health care to its employees. This is called the Death Spiral. The problem gets worse because companies with older and less healthy employees are at a competitive disadvantage. This tempts them to discriminate in hiring and termination; or else they have to drop insurance for their employees, or charge more to older people, or some combination of the above. The same thing is happening in non-group markets. Pretty soon, the only people who can get insurance are the ones who don't need it -- and/or people with health problems or who are over 50 can't get work.

Next: The half-assed solutions we have now, and the real answer.

Inverse Spam

For some inexplicable reason, there are dozens of people all over the world -- many whom apparently live somewhere in Southeast Asia or the Pacific Islands and barely speak English -- who believe that I have a certain anatomical deficiency. At least that's what I gather from my e-mail. (For the record, no problem there guys, don't know where you got that impression.)

Anyhow, there's another spammer who sends me all kinds of weird junk all the time who on this particular occasion piqued my curiosity with a link to an article from a newspaper in London, Ontario, about Louis Guillette of the University of Florida:

Sat, April 29, 2006
By JOHN MINER, FREE PRESS HEALTH REPORTER

A renowned U.S. scientist who has documented fertility and sex changes -- including decreasing penis size -- due to environmental contamination says he wouldn't apply pesticides on his own lawn. Delivering a special series of lectures this week at the University of Western Ontario, Louis Guillette has been drawn into London's lawn-care debate during question periods and talk-show interviews.

"The use of these compounds just for cosmetic reasons, just because you don't want to make dandelion wine from your yard or whatever, I think is inappropriate," Guillette, who is associate dean for research at the University of Florida, said in a lecture
yesterday at UWO's Schulich School of Medicine and Dentistry.

snip

A zoologist, Guillette has spent the last decade studying the influence of environmental contaminants on fetal development and reproductive systems of wildlife and humans, including the differences between alligators living in contaminated Florida lakes and those in cleaner ones. He found abnormalities in sex organs, dramatic differences in egg-hatching rates and hormone levels.

Penis size of the animals from the polluted lake was smaller than animals from the less-polluted lake. "This is important because it is not just an alligator story. It
is not just a lake story. We know there has been a dramatic increase in penile and genital abnormalities in baby boys," Guillette said.

A followup study by another scientist involving healthy couples with 5,000 healthy babies also found reduced penis size with higher contamination levels.

"Are (their penises) so small they are actually having problems? We don't know. These are baby boys," he said.

Actually, Frontline did a story on Guillette's alligator research, with considerably more detail, available here, and you can read the scientific report in General and Comparative Endocrinology, 1996, 101(1). I actually haven't been able to find the research involving human beings, and I don't know what kind of "contamination levels" they are talking about with the baby boys. Maybe it hasn't been published yet. But there is a ton of research on this involving reptiles and amphibians exposed to certain estrogenic herbicides and insecticides.

I wrote earlier about the "white male" effect in environmental policy, whereby white males -- who tend to be highly individualistic and hierarchical in their cultural orientations -- are much more likely to oppose environmental regulation and to be unconcerned about environmental risks than others -- including non-white males and women of all ethnicities. Maybe this is an issue that will make them think again.

Dusting the bannisters while the shit hits the fan

Now that the high price of gasoline has become a political issue, what has the ever courageous, forward-looking Democratic leadership decided to do? Run against the oil companies and promise lower prices.

Michael Ruppert is an unclassifiable hybrid between a genius and a nut. For many years, he has been screaming about the imminence of the global oil peak and its consequences for human civilization. His writings on this subject are well-researched, lucid, and entirely credible. His web site, From the Wilderness, has a wealth of resources and useful links on the subject of fossil fuel supplies and the geopolitical implications. Alas, he has marginalized himself by also being among the farthest out 9-11 theorists, and that's saying something. I'm essentially a 9-11 agnostic, although I do lean toward the LIHOP (Let It Happen On Purpose) class of theories in the general sense. Last I checked, Ruppert was convinced that the CIA carried out the entire plot, including controlled demolition of WTC 1, 2 and 7, and that no plane of any kind hit the Pentagon. Whatever.

Anyhow, you don't have to take Ruppert's word for it about Peak Oil. How about the Army Corps of Engineers? (PDF) Here is a bit of what the U.S. Army has to say:

Petroleum experts Colin Campbell, Jean Laherrere, Brian Fleay, Roger Blanchard, Richard Duncan, Walter Youngquist, and Albert Bartlett (using various methodologies) have all estimated that a peak in conventional oil production will occur around 2005. The corporate executive officers (CEOs) of Agip, ENI SpA (Italian oil companies), and Arco have also published estimates of a peak in 2005. These reliable estimates all project that conventional oil peak production will occur within the next few years (Campbell and Laherrere 1998; Youngquist 1997; Campbell 2004). Reduced demands caused by high prices may delay the peak slightly, but the peak is certainly within sight. Note that the peaking of conventional oil should not be confused with total oil production. Total oil production includes such commodities as natural gas liquids, deep water oil, and polar oil. Inclusion of these will delay the peak to 2008 (Aleklett 2004). Estimates of peak production are not without controversy. . . .

A 2000 U.S. Geological Survey report estimates a much higher availability for the future of petroleum based on three things—reserves growth, higher recoverable fractions, and greater amounts new discoveries (Ahlbrandt, Pierce et al. 2000). The USGS report presents an optimistic picture for the next 20 years or so. Even if there predictions are true, the overwhelming majority of this oil is projected to be in the former Soviet Union, the Middle East, and in North Africa. North American potentials are predominately in the arctic, including National Petroleum Research Alaska (NPRA) and Arctic National Wildlife Refuge (ANWR). Jean Laherrere made an assessment of the USGS report and concludes that:

"The USGS estimate implies a five-fold increase in discovery rate and reserve addition, for which no evidence is presented. Such an improvement in performance is in fact utterly implausible, given the great technological achievements of the industry over the past twenty years, the worldwide search, and the deliberate effort to find the largest remaining prospects."

Laherrere also concludes that reserve growth numbers are not realistic as this only occurs in the United States where the SEC requires a different reporting scheme for petroleum finds than the rest of the world uses (Laherrere 2000). Reserves will not grow as predicted. In fact, some oil companies such as Shell have significantly downgraded their reserve estimates in the recent past (Shell Oil Co. 2005).

It's pretty clear who the Army believes. And 2005 was, uhh, last year. So the Republicans want to drill in ANWR and give us all $100 -- or rather, borrow a hundred dollars for us from the Chinese and let our kids pay it back. The Democrats want to tax the oil companies, eliminate the federal excise tax on gasoline, and uhh, err, uhh, well, hmmm. The Army, while conceding that global oil production has peaked and will now inexorably decline, still proclaims that world-wide consumption of energy will increase 60 percent by 2030 and may triple by 2050. They seem to have a bit of an arithmetic problem there. Yeah, yeah, natural gas production is supposed to increase to make up part of the shortfall but natural gas will peak by 2020 and has already peaked in the U.S. The rest can only come from coal and that means more CO2 pumped into the atmosphere along with all the other harms from coal mining and burning. And you can't put coal in your Escalade, that is for sure.

So what does genius/nutcase Ruppert have to say? Quite a lot, but here a few choice bits:

The US government continues an unwinnable war in Iraq while building massive permanent bases and the largest embassy compound ever built. Not only does the US have no intention of leaving Iraq , it has committed—whether under Republican or Democratic leadership—to staying forever—whatever that means. The Empire’s position is clear, not as a result of what it says, but as a result of what it has done. America ’s primary plan to deal with Peak Oil is to fight or intimidate for energy supplies wherever it deems necessary. That, of course, has forced the rest of the world—with a few notable exceptions like Norway and Brazil —to dance to the same sheet music. As a result, I would estimate that of every ten units of energy (or money) expended preparing for Peak Oil today, nine are spent preparing for war while only one is spent building lifeboats and teaching people how to survive. This is sheer insanity.

The US has stepped up deliveries of weapons systems and military advisors to oil-producing regions around the world. This has been matched by similar deliveries to the same regions by Russia , China , Pakistan , Saudi Arabia , Venezuela , France, Britain, India and many other countries. A best-selling novel in China, The Battle in Protecting Key Oil Routes, has the Chinese navy destroying a US carrier battle group. The popular book documents a bloody contest over control of the Straits of Malacca, that narrow channel through which most of China ’s, Japan ’s, and Korea ’s energy passes.

China’s Hu Jintao, clearly one of the world’s only major leaders with both plans and choices, is making direct calls on Saudi Arabia and Nigeria as George W. Bush haplessly points to hydrogen fuel cell cars as a solution. Don’t worry about how many American people will buy into such Bush nonsense. Worry about how many world leaders are watching these same clips and asking, “Is that the best he can do? America is in deep shit.”

All of Africa, especially West Africa—exactly as I predicted in 2003, in Crossing the Rubicon and in last year’s lecture series which became our newest DVD Denial Stops Here—is exploding with armed insurrections from the Western Sahara region to Angola. It is West Africa where I believe we will see proxy wars likely intensifying this year, which could trigger a global nuclear exchange in very short order.

But murder, far more callous, is about to be perpetrated by the Democratic Party as it enters the 2006 midterm campaigns with what is surely—barring a miracle—going to be one of its major planks in 2008: “Don’t worry,” they will promise, “the Democrats will restore cheap gasoline for all and find a no-pain answer to all of our energy woes. High prices are the fault of greedy oil companies and price gougers, not a lack of supply.”

Climate Change and hurricanes not only continue apace but have accelerated. Now that we are just weeks away from a new hurricane season, fully 23% of Gulf of Mexico production remains shut-in after last year’s hurricanes. Recently the Department of Energy acknowledged that most of that would never be rebuilt due to high investment costs at mature and post-mature reservoirs. Aside from the fact that it’s not cost effective, this is also because of rig shortages. This is what FTW warned you about almost a year ago. When and if we ever have a chance to look back we will historically mark Katrina and Rita as the singular moment in time when a true US economic and military resurgence became impossible; the moment when the Empire began it’s collapse. In other words, that was the moment when the Empire passed from decline to terminal status.

On April 4th, Dow Jones’ MarketWatch reported that $6 to $7 gasoline might be coming this summer. Is there anyone in this room tonight who does not believe that $6-$7 gasoline would be an unmistakable sign of collapse?

And by the way, even as the price of oil climbs, producing countries are moving away from pricing petroleum in dollars. As the dollar has now begun its long, inexorable decline, the pain for American consumers will just grow worse.

I want to keep writing about health insurance, and medical advances (and retreats), and eating right and being well and all of that useful and interesting stuff. But it just doesn't seem very important if we are really this screwed.

Am I missing something here?

Not that it's news, exactly, but people are taking note of the latest report by charlie Savage of the Boston Globe that George W. Bush has proclaimed himself to be absolute dictator, above the law, and unaccountable to Congress, the courts, or the people -- from whom he has the absolute right to conceal any and all information about official actions he takes as Commander in Chief, by which he means Commander in Chief of the United States, not just of the armed forces.

Of course, the administration proclaimed all this publicly a long time ago. This includes the power to do absolutely anything. It includes the power to spy on American citizens, listen to their telephone calls, read their mail and their Internet correspondence, find out what books they have been reading, watch their movements, keep track of their associations, without a court order and without having to tell anyone. It includes the power to make people (including U.S. citizens) disappear into a secret network of prisons, with no possibility of judicial review or even the knowledge of anyone except high administration officials and secret intelligence agents, there to be tortured, even tortured to death, for as long as the Commander in Chief cares to confine, conceal and torture them. These are powers which Mr. Bush proudly proclaims, and boasts of exercising, and the Attorney General has so testified before Congress. The corporate media have treated these claims as an interesting constitutional question, about which scholars have various opinions and may politely disagree. The Democrats in Congress have largely ignored it, or muttered some tepid reservations.

So, uhh, shouldn't people be kind of upset? You know, people like the Majority Leaders in the House and Senate (what are their names again, anyway?), Democratic candidates for President, editors of newspapers, maybe retired presidents (wouldn't you think Jimmy Carter might have something to say? WJ Clinton?), prominent television commentators. I mean, I vaguely remember as a school child being taught that the United States is a democracy, a government of laws not of men (nowadays we'd say people), that we had a constitutional order of checks and balances, a bill of rights, stuff like that. Since none of that is true after all, wouldn't you expect people to at least feel a bit confused? I guess outrage is too much to ask, but a sense of impropriety, at least, could be expected.

I guess not.

Knowing too much

We've talked a few times about the counterintuitive conclusion that screening the general population for common diseases usually does more harm than good. As an extreme example, there are companies that sell whole body CT scans to rich people, who feel that they are doing everything they can to detect cancers, vascular disease, and other potential problems early, so they can live forever, but what they are really buying is likely to be a sack 'o woe.

It isn't just the unnecessary dose of radiation. In the first place, as we've discussed before, even a test with what appears to be a high degree of "specificity" -- that is, 90% specificity means that only 10% of people who don't have the problem will test positive -- will yield more false positives than true positives if the problem exists in a fairly small percentage of the population. This results from Bayes' Theorem, which everyone should understand. If you have a positive test, you end up with additional diagnostic tests, which may be expensive, painful, or dangerous; unnecessary treatment, which may be same as the above; anxiety, lost time at work or whatever else you do, anxiety among friends and family, and wasted resources of the medical system which could have been better applied elsewhere.

Furthermore, many diseases, no matter how dread, may not end up harming you even if you have them, because something else will get you first. Prostate cancer is a good example. Autopsies find that the majority of men over 70 actually have prostate cancer, but few of them die from it or even have symptoms. But, if they had been unlucky enough to have detected it, they would have had surgery, erectile dysfunction, incontinence, all that nasty stuff.

Finally, treatments for many diseases don't work particularly well anyway. An excellent example of that is clinical depression -- which isn't exactly a disease anyway, but a set of slippery, uncertain diagnostic criteria. There is a movement underway in the United States, spearheaded by drug companies, to screen the general population, starting with school kids, for mental disorders. In the UK, the NHS wants to screen everybody for depression. Writing in the British Medical Journal, Simon Gilbody, Trevor Sheldon, and Simon Wessely blow this idea to dust. (Why are half the men in England named Simon?)

a) Most of the people who test positive on depression screening instruments don't have depression, they just happen to be unhappy at that particular moment. They will end up getting unnecessary treatment, stigma, and whatever other badness may ensue.
b) Most people who really do have important clinical depression are going to be diagnosed eventually anyway.
c) Most of the people who really do have depresion aren't treated very succesfully.

Furthermore, Trevor and the Simons say this believing that the common treatment for depression, antidepressant drugs, is actually beneficial. There is some question about that.

So if your doctor suddenly starts asking you a lot of weird questions about how you felt in the past week, such as "I had trouble keeping my mind on what I was doing," or "I felt lonely," or "I could not get 'going'," you might just say, "And how about you doc? Did you feel happy? Did you feel sad? Are you human too?" (All of these questions, except the one about being human, are from the Center for Epidemiological Studies Depression Scale, a common screening instrument.)

Bizarro world . . .

These days you have to pick and choose your outrages. So first, this is from my friends at the North American Indian Center of Boston:

President Bush has proposed zeroing out Urban Indian Health Programs from the FY 07 budget of the Indian Health Service. The National Council of Urban Indian Health (NCUIH), a Washington DC based urban Indian controlled organization, has issued a statement on behalf of the 34 urban Indian health programs asking Congress to restore funding in the amount of $34,054,000. . .Please contact your Senators and Congresspersons asking them to support restoration of urban funding. At this writing, the FY 07 Appropriations Bill is scheduled to go to the House floor on May 18, 2006 for a vote. In the Senate, the Indian Affairs Committee has recommended restoration of funding for urban Indian Health programs. There is no date set for a Senate vote but one is expected before Congress goes into August recess. . . .

Urban Indian Health Programs offer culturally-competent services including access to Traditional Healing Practices. Behavioral Health/Alcohol Substance Abuse programs provide service treatment/intervention models mirroring Native beliefs and values. Urban Indian patients seek treatment and follow through with service plans at a rate far exceeding those Indian patients who access treatment from non-Indian providers.

The 2000 U.S. census data shows that 61% of the American Indian/Alaskan Native population reside in urban centers. The 1970 U.S. census showed 38% of American Indians/Alaskan Natives living in cities. Targeted government initiatives at assimilation and acculturation of Tribal citizens have been ongoing since the beginning of Federal/Tribal relations. Tribal citizens have been displaced from their homelands, sent to federal Boarding Schools, endured adoption of Indian children at a rate almost 40% higher than the general population, had Tribal religions, and ceremonies banned by government initiatives and were relocated in massive numbers to cities during the 1950’s and 60’s as part of the Relocation Policy. The government’s policy was a ruthless attempt to force American Indian/Alaskan Native people into the melting pot. Courageously, this did not happen and the 34 urban Indian Health program are housed in cities where the Indian community banded together to created local non-profit agencies serving the interests of Indian people.

Okay then, they can just damn well start being white! And the Republicans have a way to help them get started: $100 to buy gas for the uh, Winnebago. Yup, I thought this was satire, but it's the absolute God's honest truth:

Most American taxpayers would get $100 rebate checks to offset the pain of higher pump prices for gasoline, under an amendment Senate Republicans hope to bring to a vote Thursday. . . Our plan would give taxpayers a hundred dollar gas tax holiday rebate check to help ease the pain that they're feeling at the pump," Senate Majority Leader Bill Frist announced Thursday. . . .

Frist said the rebates would go to single taxpayers making less than $125,000 per year, and couples making less than $150,000. Republican senators said they hoped soaring gas prices would inspire Democrats to support their proposals.

"A lot of these other things we're talking about today, supply, like ANWR, have had Democrats oppose them in the past, when gas was $1.25, $1.50. Gas is now $3," said John Thune, R-South Dakota. "I would expect that there would be a lot more bipartisan support for proposals that would increase supply in this country."

Now, this is so completely fucking nuts that my usual talent for invective fails. Cost of the $100 bribe to shut up and keep driving, and pretend that the party will never end? I dunno how many adult taxpayers there are in the U.S. offhand, but it's gotta be over a ten billion dollars. $34 million for urban Indian health would disappear into a billion dollars like a fact into a Republican's brain. Write your own caption.

The New JAMA: The stuff the corporate media didn't cover

One reason I started this blog is because I was continually frustrated by the lack of correlation between the stuff I read in the medical literature that I thought it was important for people to know about, and the stuff that got reported in the general media. After a year and a half of writing the blog, I'm still not entirely sure what it is that makes reporters think something is worthy of your attention.

Anyhow, until I figure it out, here's the latest. The two items in the new JAMA that appear to have gotten some attention are a study about implantable defibrillators, and a study by people at Public Citizen about conflicts of interest on FDA advisory panels. Both of these got spun like tops in the mass media, and therein lies a hint: there are coporate interests (medical device manufacturers and drug companies) with a direct interest in both of these stories. They probably called up the reporters to spin the stories, and then of course the reporters got on them and talked to the authors and/or various potential counterspinners, and they had the "he said/she said" format they needed. Journalists don't tell you what actually happened, that's not their job. They have to be fair and balanced, which means they have to transcribe what other people say, especially people who have a personal interest in the matter and who can be presumed to be trying to manipulate you.

So here is a story that I think is important. Eric Peterson and sufficient collaborators to sing the Coronation Mass looked at 350 hospitals around the country that provided care for people who had suffered heart attacks. As you probably know, there are process of care guidelines for these and other common conditions that are treated in hospitals. For example, people with heart attacks (I won't go into the technicalities of the different kinds of events that are called heart attacks, but we're talking about the common, basic kind here) should be given aspirin and other anti-clotting agents including a relatively new one called a glycoprotein IIb/IIIA inhibitor, and beta blockers. They should also get some of these drugs prescribed at discharge, and get dietary and smoking cessation counseling if indicated. Seems simple enough but on average, only 74% of indicated treatments were provided. Unfortunately, this is typical: for whatever reason, such standards of care are not consistently followed.

The question has always been, however, whether these process indicators are really valid, in the sense that they predict patient outcomes. Maybe doctors are using appropriate judgment in not always following them. This study finds otherwise -- in the 25% of hospitals with the lowest adherence to the standards, patients with a documented myocardial infarct (death of heart muscle tissue) were nearly twice as likely to die in the hospital as in the 25% of hospitals with the best adherence. Some of the specific predictors had to do with discharge practices, which obviously could not have caused in-hospital mortality, but are probably indicative of an overall culture of diligence and quality.

This study is observational, not experimental, and hence cannot absolutely prove that better adherence to the standards will improve patient outcomes. There could be other explanations, e.g. the less adherent hospitals are seeing sicker and weaker patients. But the authors beat up the numbers every way they could to try to rule this out and the conclusions stand up to the pounding.

One important observation: the hospitals with inferior quality indicators had a higher percentage of non-white patients. This suggests, as have some other studies, that disparities in health care quality according to race and ethnicity may be at least partly explained by where people get their care, rather than differential treatment within a given institution. That requires more study.

This study gives considerable support for the use of these process of care standards as indicators of quality. That has been controversial, and it still will be to some extent, but I think we'll be seeing more and more attention paid to these indicators, and to figuring out why they aren't followed. (How hard is it to give somebody an aspirin, for crying out loud?) We will see more and more pressure to rate hospitals publicly on these indicators. I have been a skeptic, but maybe this is a good idea.

Who will tell the people?

So, the politicians have finally decided they need to do some pandering about the high price of gasoline. Former-failed-Texas-oilman-and-frog-exploder-in-Chief will stop filling the strategic petroleum reserve, "investigate price gouging" (of which I would imagine there is none to speak of) , and suspend environmental regulations on gasoline formulas. That will accomplish nothing except to a) stop the strategic petroleum reserve from growing and b) poison the atmosphere. The Republicans in Congress want to drill in the Arctic National Wildlife Refuge and blame environmental regulations for high gasoline prices in the first place. Bush claims that we wouldn't have these high prices if new oil refineries had been built recently, and blames environmentalists for stopping them.

Actually, the oil companies haven't wanted to build any new refineries. The reason is that they know there won't be any petroleum to refine in them. We could drill for oil in ANWR -- and we'd get enough to last us for a few months.

But the Democrats actually have an even worse idea. Yes they do. They want to suspend the federal excise tax on gasoline (and we all know what happens to taxes that are suspended when it comes time to un-suspend them). Of course, what we really ought to do, and should have done 20 years ago, is to increase the gas tax by four or five times. (We could use part of the money to increase the personal income tax exemption and provide refundable tax credits for low income people, to repair the distributional consequences; and invest the rest in mass transit.)

Evidently there is nobody in political office in this country with the integrity and courage to stand up and tell the people the truth. The price of energy will be volatile -- it will go down a bit, and then up again -- but in the years to come, in the long run, it will just go up. This is a permanent situation, not an abberation or a passing "bottleneck" in supply. We cannot help the situation even one little bit by drilling for more oil, building oil refineries, or making the air even more poisonous than it already is. Our only hope is a national mobilization, on the scale of World War II, to use less fossil fuel -- much less. Starting ten years ago.

I don't hear Nancy Pelosi, Harry Reid, Barack Obama, Hillary Clinton, Howard Dean, not even John Conyers or Henry Waxman, saying anything like that. Like commenter Bo on the previous post says, we are in deep, deep denial. Or, to put it less delicately, we have our heads in a very awkward place.

Am I fiddling while Rome burns?

All of this talk about whether people do or do not take their lisinopril and have their nether regions penetrated by fiber optics is important only if one assumes that we will continue to live in a wealthy country where stuff like that determines whether we will one day make it to the shuffleboard court and the early bird special at Denny's, and we should actually care. Consider this:

This is the trend in crude oil prices through the end of last year. As you are no doubt aware, the price has continued on up and is now at about $75/bbl, more than 20% above where it was when this chart was made. The earlier historic spike represents the OPEC oil embargo followed by the political crisis in Iran, but nothing like that is happening now. The OPEC countries are pumping the stuff as fast as they possibly can. Also, as you can see, we are not experiencing a sudden, sharp spike but rather a steady, long-term upward trend in price.

Sure, much of Iraq's potential production is off-line, the Gulf of Mexico has yet to fully recover from last year's hurricanes, there is some loss of production from Nigeria due to a rag-tag insurgency, but those are pretty minor factors. Although the news readers keep telling us that high oil prices are due to "concerns" about Iran's nuclear program, don't you believe it -- this trend started a few years ago. Any specific geopolitical worries just make a little blip.

You need to read this, which is called the Hirsch Report. It's on the Project Censored website because it was done for the Department of Energy which promptly sent it down the memory hole. It's 67 pages plus appendices, but it's written in a very clear, straightforward style. A former cokeaholic fratboy and AWOL Texas Air National Guard Member through whom God speaks might not be able to understand it, but you can. Read it, because it will put important information in your head that you don't have now, even if you think you understand this. Then come back here for some commentary.

(this is to signify the passage of time)
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Okay. The Hirsch report is now more than a year old. It completely omits the not so minor issue of global climate change, and it does contain one fairly egregious error. So, taking those reservations in order:

They cite experts who say the peak happens anywhere from right exactly now, to 2016, plus some outliers who think it's farther away. However, if you read between the lines it's pretty clear that yesterday is probably the best estimate for a few reasons, and more than a year later that's even more clear. First of all, the corporations and governments that have properietary information about existing oil fields all have incentives to highball their estimates of reserves. That brings in investors, increases political clout, fends off conservation efforts, keeps the rabble happy, etc. Second, as they note on page 14, "Because oil prices have been relatively high for the past decade, oil companies have conducted extensive exploration over that period, but their results have been disappointing." Specifically, as shown on page 15, since 1990 that rate at which new reserves have been added has been less than the increase in consumption, at a rapidly increasing rate. And "additions to reserves" doesn't even mean new discoveries: much of it represents increases in calculations of the amount of oil that will be extracted from existing fields based on higher prices, that make more intensive recovery efforts worthwhile. The last so-called "Super Giant" reservoirs were found in the 1960s, and they are now in decline. Since then, only smaller reservoirs have been found. Finally, the price signal that the Hirsch Report says will introduce peak oil may well be here.

The major omission in the Hirsch Report -- the elephant in the bathtub -- is global climate change. Most of the mitigation efforts they discuss consist of making liquid transportation fuel from coal, oil shale, and tar sands. All of these processes pump far more CO2 into the atmosphere than does burning petroleum distillates directly. The major thrust of the report is that if we invest massively in these technologies now, today, we can ameliorate the economic consequences of an oil peak that happens 20 years from now. What they don't say is that we would thereby accelerate global warming. However, if peak oil happens now, or even ten years from now, the economic consequences will be catastrophic, and it's already too late. The technical term is, we are screwed.

They say that greater fuel efficiency can also help, of course, but it takes more than 15 years to replace the auto and truck fleet; and that still won't help all that much. You're burning less gas per mile, but you're still burning it, and of course on present trends humans are driving more and more miles all the time.

(Their egregious error, by the way, is claiming that the U.S. has the world's largest coal reserves. Actually the largest coal reserves are in China and Siberia. But that doesn't matter much.)

Finally, you may have heard that the president has a plan: hydrogen fueled cars. The Hirsch report makes it abundantly clear that hydrogen fueled cars are a) as likely to exist any time in the next 20 years as mobile biological weapons labs are to exist in Iraq right now; and b) hydrogen is not a source of energy, but a method of storing energy, which has to come from somewhere, specifically natural gas. And oh yeah -- that's also about to peak.

Pop quiz:

1) What country is currently the world's largest petroleum producer?

Wrong! It's the United States. But we also consume the most, by a huge margin, and we consume far more than we produce. Saudi Arabia's power comes producing far more than it consumes.

2) Why did the United States invade Iraq?

(Too easy for a hint.)