Before the Fall

I'm going to have to interrupt the HIV series to address exigent matters. If we must live under capitalism, then we must accept continual destruction as the price of economic dynamism. The Polaroid Corporation used to have its headquarters in that mystical, magical land across the river, The People's Republic of Cambridge. Then one day they woke up and realized they owned a buggy whip factory. Today, I use file cabinets we bought in their bankruptcy sale.

But the determination of the Senate Republicans to allow the U.S. auto industry to collapse invites a resolution of a different order. The death of Polaroid was the price of the rise of a whole new industry. A few thousand lives were disrupted, but there were other jobs to be had and investment losses were soon enough made up elsewhere. What we confront now, however, is very likely the end of an epoch. Karl Polanyi, in The Great Transformation, illuminated the origins of the age in which we have been living, the post-war economic order of the last half of the 20th Century. He describes the system which pertained before, and its end:

The key to the institutional system of the nineteenth century lay in the laws governing market economy. Our Thesis is that the idea of a self-adjusting market implies a stark utopia. Such an institution could not exist for any length of time without annihilating the human and natural substance of society; it would have physically destroyed man and transformed his surroundings into a wilderness. . . .Such an explanation of one of the deepest crises in man's history must appear all too simple. Nothing could seem more inept than the attempt to reduce a civilization, its substance and ethos, to a hard and fast number of institutions; to select one of them as fundamental and proceed to argue the inevitable self-destruction of civilization on account of some technical quality of its economic organization.

And yet, here we are again. Even George W. Bush now appears to get it -- but it is likely far too late. Hang on for a hard ride.

The Plague Years

Doctors noted within a few months after the emergence of what they called GRID that gay men were not the only people affected. The mysterious disease showed up in injection drug users, recipients of blood transfusions, and some people who had none of these evident risk factors. Nevertheless, the epidemic -- which soon came to be called Acquired Immune Deficiency Syndrome, AIDS -- was associated in the public mind with homosexuality for many years.

And indeed, it did highly disproportionately affect gay men, as it still does in the U.S. today, to a lesser extent -- though not everywhere in the world. One of the most notable impacts of the epidemic was the transformation it wrought on gay culture in the U.S., and also on the relationship between the gay sub-culture and communities, and the rest of society.

I'm not an expert on this subject, which is complex and filled with controversy and polemic. I will just say that the community I interacted with at the celebration in 1980 was exuberant and also, for want of a better word, licentious. Released from literally centuries of being forced into the shadows, persecuted, marginalized, and criminalized for being who they were, gay people erupted like volcanoes of sexuality. HIV forced a reappraisal of sexual expression, and its social organization within the gay community. I believe there is a strong argument to be made that it at least accelerated, if not strongly determining, the evolution of gay institutions and activism toward the normalizing and integration of gay life and identity. Back in the 1980s, marriage and commitment and starting families were not high on the agenda. Now the right to marriage is the central demand of gay politics. The community had to confront and reconsider promiscuity, and social and economic institutions that were built around it; and redefine sexuality to include responsibility.

In the meantime, of course, a central focus of activism vis a vis the larger society became biomedical research, care for people living with the disease, and prevention of HIV transmission, all of which required as a necessary condition combatting the stigma associated with the disease, which in turn meant combatting the stigma associated with homosexuality. It was not enough for gay people to be out in their own communities and building their own institutions. They had to be able to draw on the same reserves of communal good will and social solidarity as every one else in the face of the crisis.

As we approach the 30th year of the epidemic in the U.S., we can honestly say that we have come a long way in that regard. The passage of Proposition 8 is a bitter defeat, to be sure, but 20 years ago it would have been unimaginable that it could even be an issue. Here in Massachusetts, that battle is over, and human rights and dignity are victorious. I'm sure we'll get there in the rest of the country in time -- although it is still true that justice too long delayed is justice denied. However, I doubt you'll find many people who will say it was worth it. I have met too many who remember those terrible years, when they buried one friend after another who had died in the awful way that HIV kills.

I myself lost friends, suddenly and cruelly, but my experience was nothing like that of gay men whose entire communities and social networks were devastated. Among my neighbors are a couple who moved from San Francisco to Boston because the associations were too painful to endure. I once interviewed a man living with HIV, one of those rare people called long term non-progressors whose immune system, for unclear reasons, is able to suppress the virus. He told me that living in New York in the 1980s, he had lost every single friend he had, and whenever he made new ones, they would die too. He lives in a kind of survivor's daze, unable to account for or accept his own existence.

Next: Science marches on

The beginning

We now know that HIV originated in Africa, quite possibly as long as 100 years ago based on one recent estimate, definitely before 1959, as HIV has been found in a blood sample preserved from an African man who died in that year.

However, no-one was aware of the disease we now call AIDS until it surfaced in the United States, in 1981. Africans back then got sick and died all the time of who knows what, and nobody outside of their communities even noticed. Here in the United States, however, we had advanced health care and public health systems, and mechanisms for reporting and sharing information about unusual events.

In 1978 and again in 1980, I was in charge of stage security for Gay Pride day in Washington, D.C. Really! Even though I am a person of heterosexuality, this came about because of my friendship with Robert Belanger, a prominent gay activist. Bob, who I have written about here before, was an early member of the Mattachine Society, and he was the society's second president, succeeding founder Frank Kameny after an ideological schism. Despite their differences back in the day, Bob had nothing but respect for Dr. Kameny and always spoke of him with admiration. (Google those names if you're interested in knowing more -- a ton of info will pop right up.)

Anyway, the point is, I encountered the gay movement at a point when the prevailing mood was exuberant celebration. Kameny and Mattachine had at first worked in the shadows, then stepped forward into the light in a small way, in a mode of protest. But by 1980, tens of thousands of people paraded to Rock Creek Park and held, not a protest rally, but a party. The highlight of the day was not a political speech, but a performance by the drag queen Dana Terrell, and the police, who used to beat up transvestites, escorted her(?) into the party.

Then, in 1981, doctors noticed an outbreak of an unusual cancer, called Kaposi's Sarcoma, among gay men in New York and San Francisco, while emergency rooms suddenly saw young men coming in with intractable fevers and a disease seen only in people with defective immune systems, called Pneumocystis pneumonia. The Centers for Disease Control labeled this complex of symptoms Gay Related Immune Disorder. The mysterious gay plague had started.

The worst offense

I'm going to have to briefly interrupt the HIV saga -- and don't worry, I'll get back to it -- for an exigent commentary. Gov. Blagojevich's most egregious misdeed is the worst wig since the days of Moliere. Blagojevich would be summarily drummed out of the Hair Club for Men. Sy Sperling would personally cut the buttons off his jacket and flog him on the way out. I have to disagree with other commentators -- no self-respecting dying rodent would crawl onto a human head and end up looking like that. The anaerobic conditions under that thing must be causing necrosis of the scalp and probably a dangerous build up of botulism. It's a good thing for Blago that he won't be allowed to wear it in jail -- it's a hiding place for contraband. In fact I think that makes him a net winner in this whole thing.

And there you have the key to the mystery: delusional vanity.

Case Study

As readers will have gathered by now, much of my work in public health has concerned HIV. This is partly an accident of timing -- I got into the field in the early 1990s when HIV was the biggest thing going. And I have to admit that HIV exceptionalism -- the perhaps disproportionate amount of funding that goes to HIV-related programs and research -- has helped to keep this particular problem more or less front and center for me. It's certainly not the only focus of my work, and to the extent it is a focus, I think of it as a more broadly instructive example, not a universe unto itself.

But HIV is uniquely instructive, for a medical and public health sociologist. This virus -- a little bit of genetic information that got adrift in the world, a microscopic, mindless, lifeless fragment of chemistry -- brings into sharp relief some of the most important issues in fields as disparate as health promotion and disease prevention, clinical practice, the organization and financing of health systems, and the sociology of science.

A frequently productive intellectual trick is to organize a discussion around a theme that crosses conventional boundaries, so we serendipitously discover linkages and resemblances. For example, a professor might teach a course entitled "Chocolate." Students sign up because they like chocolate, and they end up learning about botany, tropical agriculture, colonialism, African politics and economics, international trade relations, the organization of the food industry, industrial processes, product marketing, and the biology of human sensory perception and psychological reward. These all get fit together to help fill in our picture of the world, and the observed patterns and connections extend far beyond the various meanings of a flavorful bean.

HIV is biologically similar everywhere, but its socially constructed meaning differs radically from place to place, to some extent in a causal dance with the epidemiology but also independently. The sociology of HIV has changed just as much over time, as HIV has transformed the cultures around it, as the epidemic has evolved, and as medical science has changed the nature and context of HIV disease. HIV reveals so much that is central to our interests here, so I'm going to spend some time in the coming days on its story.

The argument from authority

The CBS News web site is headlining the story that Luc Montagnier, who is about to receive a Nobel prize as co-discoverer of HIV, thinks there will be a therapeutic vaccine within 4 to 5 years. The reporter at least has the wit to add "He did not elaborate as to why he believed scientists were close."

Indeed, that is a puzzle. Montagnier is certainly outside of the consensus of scientific opinion on this question. It is puzzling and a bit unsettling that he would say this, since any statement by him on this subject is bound to become a major news story. Montagnier's current work does focus on approaches to an HIV vaccine, but this doesn't necessarily constitute an endorsement of his views. It is an occupational hazard for scientists to be overly optimistic about the prospects for their own work.

A balanced, in-depth view of the current state of the quest is given by Anthony Fauci in this interview with Scientific American's Nikhil Swaminathan. When Motagnier first discovered HIV, people assumed it would be only a matter of a few years before a vaccine could be developed. Bill Clinton set a goal of developing a vaccine by this year; but in fact we're nowhere close. As Fauci puts it, in a nutshell, vaccines work by mobilizing the body's natural defenses against a pathogen; but humans do not mount an effective immune response against HIV in the first place. You can't boost what doesn't exist.

Actually it's more complicated than that. The immune system does keep HIV in check for quite a while. Untreated people do not develop AIDS for several years, typically a decade. But their immune systems do not prevent the virus from replicating or eliminate it from the body. Rather, the cells that HIV preferentially destroys, immune system cells called helper T-cells, continue to reproduce as fast as HIV destroys them; but eventually, the virus wins the race.

The two major reasons why HIV defeats the immune system are a) its envelope proteins hide, they aren't readily recognized by the cells that normally produce antibodies against viruses; and b) HIV mutates rapidly, so that a vaccine that might be effective against a given strain will not be effective against the multitude of strains that infect any single individual. Another big problem is that there are long-term reservoirs of HIV in infected people that are completely inaccessible to the immune system, or to antiretroviral drugs, from which the virus can continually re-emerge. (By the way, it has been shown that people are initially infected by only one or two viral particles, and early in the course of infection have homogeneous virus; but the virus quickly mutates into multiple varieties.)

Unfortunately, there is no solution to these problems on the horizon. It would be unfortunate if Dr. Montagnier's optimism deflects our attention from what we already know how to do: prevent transmission of HIV by encouraging safe behavior. In this field, many of the most important principles of public health are highly salient. More to come on that subject.

We're Number One!

In addition to state-by-state rankings and statistics, America's Health Rankings, on page, offers some comparisons of the United States with some of the other comparatively wealthy countries. They lifted their data from the WHO, by the way, but they've organized it for us conveniently.

As I mentioned when I redesigned this page, the U.S. does not do particularly well on the life expectancy front. In so-called "Healthy Life Expectancy" -- "Average number of years that a person can expect to live in "full health" by taking into account years lived in less than full health due to disease and/or injury," according to the WHO -- Japan ranks number 1, at 75 years, and the U.S. ranks 28th, at 69 years -- tied with Slovenia.

But there is one category in which the U.S. absolutely blows away the competition, one important health-related area in which we have no peers, no challengers, nobody even threatening to come anywhere close to us in the foreseeable future. We're the top! We're the Coliseum. We're the top! We're the Louvre museum.

Yep, you guessed it, that is fatness. 33.2% of our adult women are overweight, and 31.1% of the men. New Zealand comes in a pathetic second at 23.2% for women, while Malta is lapped by our guys at 25%. Japan isn't even trying -- 3.3% and 2.9% is all the fatness they can muster.

I don't know why you think this is amusing. Obesity -> diabetes -> amputations -> kidney failure -> billions and billions of dollars spent on treatment, and lost to disability, and human misery. Oh yeah, heart disease, strokes, arthritis, cancer -- this is a slow motion public health disaster that will bankrupt this country faster than imported oil and exported military empire. It's a huge, terrifying crisis. It's no joke.

Voting Republican is Bad for Your Health

Okay, I can't really prove that directly. But I'm using the conceit to draw attention to the new America's Health Rankings report. This comes out every year, from the United Health Foundation and big time partners such as the American Public Health Association, and it ranks the states on a wide range of variables related to health outcomes, risk factors, and public health infrastructure. They also compute an overall index so they can put all 50 states in rank order of general healthy goodness. That may be kind of bogus, but you know how it is -- people like contests, so it helps sell the concept.

As I have done in the past, I decided to examine the relationship between each state's ranking and the percentage of the vote that went to the Democratic candidate for president, i.e. Barack Obama. There is a significant positive correlation -- r=.427, p < .001 -- which means that the two variables are somehow related. There are outliers, however -- exceptions. Here's what the plot looks like:



You'll notice that there are three comparatively healthy states that went heavily for McCain, in the upper left hand corner. These are Utah, Wyoming, and Idaho. Utah always ends up being healthier than most factors would predict, because the Mormons eschew tobacco -- and probably to a lesser extent because they don't use alcohol either. Wyoming and Idaho are sparsely populated, rural states. According to the report, Idaho benefits from low rates of infectious disease, clean air, and relatively low income inequality. Wyoming has similar advantages. Take away these three, and the association is much more consistent. (D.C., unfortunately, is not included in the health rankings and would no doubt violate the pattern in the other direction.)

What is it about those unhealthy, McCain - loving states? They have high child poverty rates, low spending on public health, high rates of smoking and obesity, lots of people without health insurance, low average educational attainment -- all problems the Democrats want to do something about and Republicans typically don't. The more things change, the more they stay the same.

That ol' Rule of Rescue

Gardiner Harris in today's Gray Lady has a long piece on Britain's NICE, which we have much discussed here. It's got a lot of good information, but is a bit short on the deep thinking. Unfortunately, here in the U.S. we're going to have to do some of that deep thinking if we're ever going to get our knickers untwisted. Harris begins with a little case vignette:

When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught.
“Everybody should be allowed to have as much life as they can,” Joy Hardy said in the couple’s modest home outside London.

And he ends with the Hardys as well (just like they taught him to do in J school):

Meanwhile, Mr. Hardy waits. In recent weeks his growing tumor has pressed on a nerve that governs his voice. He can barely speak and is increasingly out of breath. The Hardys are hoping that in January NICE will approve the use of Sutent, allowing Mr. Hardy further treatment.

"It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost,” said Ms. Hardy, who now speaks for her husband of 45 years. “What price is life?”

In between is a lot of facts and history (including that Sutent can be expected to buy Mr. Hardy 6 months of life, at a cost of $54,000) but little reflection on Ms. Hardy's moral position. Should "everybody be allowed to have as much life as they can?" Does life have a price? What if we were to answer, as Ms. Hardy would like us to, "yes" and "no" respectively? What would be the logical consequences?

If the British National Health Services -- rather, the British taxpayers -- are obliged to spend the $54,000 to buy Mr. Hardy those six months, what else are they obliged to do? Dare we even ask that question?

And while we're on the subject . . .

of Weapons of Mass Confusion, you have no doubt viewed with alarm the prediction, pulled out of the collective orifices of a government commission, that the U.S. will be attacked with "Weapons of Mass Destruction" by 2013. Now, they can't even predict the weather a week from now, so this is pretty dubious. But . . .

let's talk about biological weapons – pathogens such as anthrax. Anthrax is not contagious. The idea that a small quantity of anthrax spores could kill thousands or millions of people – such as Colin Powell favored us with before the UN Security Council in February 2002 -- is grossly exaggerated. Powell’s calculations assumed that the exact minimum number of spores needed to cause disease could be distributed precisely into each individual's lungs. By the same sort of calculation, 50 pounds of TNT could kill thousands of people because you could divide it precisely into thousands of firecrackers and insert them into thousands of orifices.

If someone were to spray anthrax spores into the air, most of them would never be inhaled and would never harm anyone. (Did you know? Much of the soil in the Southwest United States is already contaminated with anthrax spores.) Only people unlucky enough to inhale a sufficient number, and to be susceptible (susceptibility varies hugely, for unknown reasons) will be affected. Anthrax can be used to sicken or kill a relatively small number of people, in most plausible scenarios. It's scary because you probably won't know you've been exposed until some time later, and if you don’t get the proper diagnosis in time the disease of inhalation anthrax is fatal, although the terror factor has notched down considerably, or should have, since we have learned that it is fully curable.

As we have seen, creating anthrax contamination can cause a substantial economic cost and disruption, as well as kill or harm some people. The anthrax mailer demonstrated a technique of mass disruption that has unique features, no doubt about it. But a truck bomb is a more effective and more certain way to kill large numbers. Even more laughable is the alarm raised by David Kay over a vial of botulism in the back of an Iraqi scientist’s refrigerator. Botulism is anaerobic, which means it can’t grow in the presence of oxygen; therefore the organism is useless as a weapon. The toxin it makes, which is the bad stuff, may be found in refrigerators throughout Beverly Hills, where people inject it into each other’s faces.

The hysteria over botulin toxin is similar to the hysteria over ricin. Ricin is not really a "biological weapon," although for some reason it’s often called one. It's a toxin that happens to be derived from a plant, as are most common poisons. Cyanide, atropine, all the good murder mystery poisons, come from plants. Ricin’s claim to fame is potency by weight, but it's not outstandingly useful as a military or even terrorist weapon (however defined). As a dry powder, it’s not volatile, not easily dispersed. You could open a 50 pound bucket of it in the subway and it would just sit there. However, during the WMD hysteria leading to the attack on Iraq, the federal government and the corporate media had a grand time creating immense conniption fits about ricin. It's easy to make and various common criminals and nut cases have been found with it, so regular yelping about ricin helped maintain the desired atmosphere of fear and hysteria. But there are plenty of perfectly good ways to poison people, available at your corner hardware store.

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

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

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

So what about nukes? Those are definitely Weapons of Mass Destruction, by anybody’s definition, including mine. Well, it's okay for us to have them, and Israel, China, Russia, France, UK, and now Pakistan and India. It's just not okay for anybody else to have them. So let's be clear about the terms of this discussion.

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

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

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

Your Liberal Media: Lazy, Incompetent, or Dishonest?

Today:

WASHINGTON: The outgoing US President, George Bush, says his biggest regret in office was US intelligence that incorrectly stated Saddam Hussein had weapons of mass destruction.

"A lot of people put their reputations on the line and said the weapons of mass destruction is a reason to remove Saddam Hussein," Mr Bush said in an interview with the US ABC TV network.

"It wasn't just people in my Administration. A lot of members in Congress, prior to my arrival in Washington DC, during the debate on Iraq, a lot of leaders of nations around the world were all looking at the same intelligence. I wish the intelligence had been different."

A little over a year ago:

By Sidney Blumenthal Sept. 6, 2007 | On Sept. 18, 2002, CIA director George Tenet briefed President Bush in the Oval Office on top-secret intelligence that Saddam Hussein did not have weapons of mass destruction, according to two former senior CIA officers. Bush dismissed as worthless this information from the Iraqi foreign minister, a member of Saddam's inner circle, although it turned out to be accurate in every detail. Tenet never brought it up again.

Nor was the intelligence included in the National Intelligence Estimate of October 2002, which stated categorically that Iraq possessed WMD. No one in Congress was aware of the secret intelligence that Saddam had no WMD as the House of Representatives and the Senate voted, a week after the submission of the NIE, on the Authorization for Use of Military Force in Iraq. The information, moreover, was not circulated within the CIA among those agents involved in operations to prove whether Saddam had WMD.

On April 23, 2006, CBS's "60 Minutes" interviewed Tyler Drumheller, the former CIA chief of clandestine operations for Europe, who disclosed that the agency had received documentary intelligence from Naji Sabri, Saddam's foreign minister, that Saddam did not have WMD. "We continued to validate him the whole way through," said Drumheller. "The policy was set. The war in Iraq was coming, and they were looking for intelligence to fit into the policy, to justify the policy."

Now two former senior CIA officers have confirmed Drumheller's account to me and provided the background to the story of how the information that might have stopped the invasion of Iraq was twisted in order to justify it. They described what Tenet said to Bush about the lack of WMD, and how Bush responded, and noted that Tenet never shared Sabri's intelligence with then Secretary of State Colin Powell. According to the former officers, the intelligence was also never shared with the senior military planning the invasion, which required U.S. soldiers to receive medical shots against the ill effects of WMD and to wear protective uniforms in the desert.

Instead, said the former officials, the information was distorted in a report written to fit the preconception that Saddam did have WMD programs. . . .

We don't bother to report: you decide.

A day of mixed feelings

I do feel obligated to do a post for World AIDS Day. I laid out some of the basics about the global HIV epidemic while I was in Mexico City for the IAS conference in August. It's obvious that while almost everyone in the rich countries who needs them has access to antiretroviral drugs, there is a major injustice in that 2/3 of the people in poor countries who should be getting these drugs are not, and we're falling further behind every day, as more people become infected. Actually, based on the latest indications for treatment, the gap is even bigger than that, more like 3/4 who are not being treated who should be. The cost of first-line regimens in the poor countries -- due to agreements wrested from the pharmaceutical companies with great difficulty -- is $95/year per person, which means it would cost about a billion dollars a year to buy the meds for people who currently aren't getting them.

It would cost a good deal more than that to actually deliver them to places that currently lack basic health care infrastructure, and many people argue that "HIV exceptionalism" -- placing HIV ahead of other important public health problems -- is distorting spending on global health and making it less cost-effective. It costs much less, for example, to provide people with insecticide-treated bed nets to prevent malaria -- just a couple of bucks -- and the payoff is at least as great. But that's a false comparison, because what matters isn't an abstract cost-effectiveness analysis of existing spending, what matters is what is politically possible. There is vastly more than enough money available to do both, and a lot more than both, if we had the political will.

The powerful movement and infrastructure to combat HIV and AIDS in the poor countries is of immeasurable strategic value. This infrastructure exists in large part because people living with or affected by HIV in the U.S. and Europe, after campaigning for universal treatment, prevention programs, and client care services in their own countries realized that it would be hypocritical of them not to work just as hard on behalf of people less fortunately situated, particularly in Africa. Rather than get into a squabble with this movement over the allocation of resources, advocates for broader public health measures need to support it in exchange for leverage.

Building public health and health care infrastructure in poor and remote places will do a lot more than facilitate the delivery of ARVs. The same distribution routes and workforce that dispense ARVs can provide immunization, health education including not only HIV prevention but practices to provide safe drinking water and otherwise promote community health, midwifery services, and the other basics. These programs can employ women and combat gender, ethnic and caste discrimination. We can build on HIV care to find and treat tuberculosis and parasitic diseases.

So, my mixed feelings are whether we should have a World AIDS Day and not just a World Health Equity Day. But I'm willing to take the situation where I find it. Let's build on the movement to combat HIV and AIDS, eliminate associated stigma and discrimination, and elevate the principles of justice in HIV prevention and treatment, and extend those values and that energy to global justice in every realm.

Gracias . . .

• for the prospect of a president who generates syntactically well-formed utterances.


• An adequate supply of firewood for the winter. And the true miracle is that the people who got through the New England winter before the era of fossil fuels didn't have chain saws either.


• Charles Darwin and Edwin Hubble, who between them discovered the universe and what we truly are. Which is absolutely nothing, except to each other, which ought to be enough. Get over it Misters Dobson and Ratzinger.


• John Coltrane


• Bayes Theorem. I don't know why I said that, I guess it's just good to know that our intuitions are often wrong.


• The evolution of the gut. Imagine having to live like a cnidarian, without an anus.


• Peace in our time. Yes we can.


• Hitting that sweet spot, 93 million miles out.

I expect to be disconnected from Your Intertubes until Sunday. Remain thankful until then.

Dope

When I was a youth, use of certain psychoactive drugs -- specifically cannabis and hallucinogens -- was associated with a rich countercultural movement that posed a radical, moral challenge to the political establishment; set out to reinvent social relationships and the individualistic and material values of the dominant culture in the U.S.; and to create new forms of spirituality based on metaphysical exploration. The drugs were not seen as mere recreation or escape, but as tools for insight and rediscovery of the relationship between perceptions and the world. Of course this was ultimately misleading for many people. Nevertheless, I still believe that the potential of hallucinogens to contribute to positive emotional development and mental health, if used under properly controlled conditions, is substantial, and has not been investigated as it should be due, essentially, to prejudice. There is good, though incomplete, evidence that LSD-like drugs can be highly effective in treating alcoholism, palliating terminal illness, and otherwise benefit people.

People I knew, at least, recognized a sharp distinction between these kinds of drugs, which have very low potential for addiction, and opiates, barbiturates, and other drugs of abuse. To a typical hippie, the idea of using heroin was repulsive.

Nowadays, adolescent drug use, of any kind, is not associated with any potentially progressive or even particularly interesting cultural movement. It's about alienation, but with no place to go. Adolescent opioid use and addiction is increasing. According to the National Survey on Drug Use and Health (available here if you want to wade through some tables) 3% of 8th graders used hydrocodone (Vicodin) in 2007, and the prevalence went up to 10% by the 12th grade. Forty-three percent of people admitted for treatment for opioid dependence started before they were 20, according to the Treatment Episode Data Set (also available from the SAMHSA web site.)

Because illicit prescription opioids are very expensive, young people commonly move on to heroin, which is, believe it or not, comparatively very cheap -- thanks to the U.S. invasion of Afghanistan, which created conditions under which poppy cultivation and the heroin trade exploded. 77% of injection drug users acquire Hepatitis C infection within a year, and many of them also acquire HIV infection. Unfortunately, opioid dependence is highly intractable. The vast majority of people only succeed with long-term maintenance therapy using methadone or buprenorphine -- opioid substitutes. Recent studies which tried weaning young addicts off of these drugs within a short time were failures.

I can't tell you exactly why this is happening. Adolescents have always experimented with the forbidden, and have never had terrific judgment. The adolescent brain is uniquely vulnerable to addiction; the psychological and biological risk is nothing new, and opioid drugs were certainly available when I was in high school and in college. It just never would have occurred to me or my friends to try them. We knew they were dangerous, we associated them with losers and criminals, and we weren't looking for oblivion, we were looking for experience. So the difference is cultural. What does this say about the state of our society?

Cleaning out the attic

I just came across a memo I wrote concerning the curriculum for a course for first year medical students about everything that isn't biomedicine. I thought I'd clean it up a bit and post it here, just to give a sense of the complexity of the field of medical sociology. This is just the What part -- then there's the who, how and why of it all.

What
§ Disease, disability, and suffering -- Medicine addresses these starting from a focus on individual biology; has historically been less concerned with social and environmental conditions. Debate over appropriate boundaries for medicine – is more interest by medicine in social and environmental conditions a progressive reform, or an oppressive "medicalization" of society?

§ Well-being and health. See above. Also, medicine has historically been less concerned with promoting and maintaining well being than with intervening to treat disease. Again, what is the appropriate boundary of medical interest in public policies and individual behavioral modifications to promote well being and health, vs. historical role in treating disease?

§ Patients, clients, consumers, people. Interest by the medical profession in non-biological properties of patients is, again, greater now than in the past. Former model was hierarchical (or patriarchal, if you like) – physician told patient what was wrong, and what to do – "doctor's orders." Patients' attempts to introduce non-biomedical ideas into discourse were rejected. Now, more patient participation in decision making, physician interest in social and psychological dimensions of patient well-being and their relationship to treatment decisions, is encouraged -- at least that's the normative discourse. Whether it really happens is another question.

§ Medical Education. Comment: Medical school focuses largely on biomedical science; clinical skills are normally taught starting in the third year, but teaching, and evaluation, concerning the physician-patient relationship, communication, and support for healing is highly underdeveloped. These subjects aren't very well understood either.

§ Professionalization. This is a process that nobody controls, which happens largely ad hoc. It's an apprenticeship model, in which medical students and interns learn how to be a doctor by observing their preceptors. What they end up learnind depends on who those people happen to be, and the settings in which they work. Nobody is in control of the process, and it just keeps reproducing the same evils, generation after generation.

§ Regulation. Medicine is a regulated profession, requiring that practitioners meet licensing standards, and that they perform within certain limitations and according to certain generally accepted, though vaguely defined, standards.

§ Health Expertise: Scientific knowledge Gets top priority at medical school. Is there enough room for everything else?

§ Care. What does this really mean? What is the appropriate stance of the physician toward the patient – boundaries, limits of emotional involvement, what the physician can best offer in terms of emotional support.

§ Healing. Still largely a mystery, in spite of all our scientific knowledge. The most powerful source of healing we dismiss as the "placebo effect" and work very hard to find ways of eliminating and/or ignoring it in our research. Does this really make sense?
§ Health promotion/disease prevention. Again, where are the proper boundaries of the physician's role in this? What other kinds of professionals and institutions are concerned here?

§ Health Care Delivery Institutions: Ambulatory care can be offered by any of the below institutions, except I guess for nursing homes. The list gets confusing because of the trend toward vertical integration as well, i.e. academic health centers now include hospitals, ambulatory care centers directly associated with the hospital, affiliated physician practices, affiliated community health centers, and various other services including, in some cases, nursing homes and home care services (which by the way you left out.) It's hard to know exactly how to organize this but I would suggest that one way to do it is from the standpoint of the physician as a member of the labor force. What are the kinds of relationships physicians have with these institutions? They can own a practice or be partners in a group practice; work for a staff model HMO; work for a community health center or hospital based outpatient clinic; work for a hospital inpatient service; be full-time faculty doing research and teaching; and, not untypically, combinations of the above. If they are practice owners/partners, they will probably have various kinds of contracts and relationships with some of these other institutions as well.

§ Ambulatory Care
§ Offices,
§ Hospitals
§ Public Health Clinics
§ Nursing Homes
§ Academic Health Centers

§ Pharmaceuticals and Durable Health Care Products. Private, for profit corporations, motivated solely by greed.

§ Federal and State Policy Process and Regulatory Agencies Again, not in the curriculum previously – we're talking CDC, FDA, AHRQ, HCFA, state DPH, etc. – this is a lot, most of it thoroughly captured by the regulated interests.

§ Financing: I think we need to divide financing into the source of the money – govt., employers, individuals – and then the structures through which it is spent – indemnity insurance, HMOs of various kinds and variations such as PPOs – and finally the relationship of the provider to the payer, noting that the payer is not necessarily the entity that pays in the first place, but rather the entity that directly purchases the services – or provides them itself, as in a staff model HMO in which payer and provider are in fact the same entity. Any kind of insurer can be for-profit or non-profit, as can employers for that matter, and any kind of provider. I.e., both Aetna and Blue Cross/Blue Shield offer both HMOs and indemnity insurance. Does their organization as for-profit or non-profit companies matter? Why?

§ Not-for-profit
§ Medicare
§ Medicaid
§ Managed care organizations
§ For-Profit

And that's just the gross outline of the structural issues in U.S. medicine. I'll keep on unpacking them as we move -- we hope -- toward fundamental change next year.

We are fools

ABC News reports the obvious: in the United States, when people lose their jobs, they also lose their health insurance. If they don't have major health care needs, they may be able to skate for a while. If they really need insurance, they can continue to buy into their employer's group plan for 18 months, if they pay the full cost, including what the employer used to contribute, plus 2%. But since they're out of work, that might not be possible. (This is because of a rider on a 1986 "Christmas tree" bill, the Consolidated Omnibus Budget Reconciliation Act, COBRA, in case you've run across the term.)

So, that's straightforward. A lot of lucky duckies doubly or triply shit outta luck. But because of our fragmented system of private health care plans, it gets worse. The people who have least need of insurance will stop paying premiums. The people who will take advantage of the COBRA option are the ones who have most need for health care. That means the insurance plans lose revenue faster than they shed costs, which means they have to raise premiums for everybody else. That means businesses will either be under greater financial strain, or they'll stop providing health insurance, or they'll raise the employer share and more people will opt out -- and the people who opt out will tend to be the healthiest people, which means -- you get the idea.

This is called the death spiral. And of course, it will just accelerate our economic collapse as the health care sector, about 17% of the economy, faces contraction. Now, consider a country whose people are smart enough to have established single payer national health care. None of the above happens. They weather the recession with much less human cost and shorter and shallower economic damage, because they have a huge automatic stabilizer built into their economies.

Uwe Reinhardt is a very prominent health economist. He has this to say about us:

As someone who grew up in Germany and lived for some years in Canada and got used to portable, life-cycle health insurance, I have always been amazed that Americans preferred the ephemeral health insurance that comes with the job at a particular firm and is lost with losing that job. Now, the foolishness of that preference is becoming clear to many middle-class Americans who spent their life denigrating 'government' health insurance.

Well, I don't know whether it's becoming clear to them or not, frankly. But maybe it will finally be clear enough, to enough people, that the Redistributionist in Chief will finally be able to usher the United States into the community of civilized nations.

We need universal, comprehensive, single payer national health care. Desperately. Now.

Bazz Fazz

Nuriel Roubini is not a happy camper, and neither am I. I'm knocking off early for the weekend, needing to decompress, so I won't say much today and you won't hear from me again until Sunday. But I will tell you that I am very much worried.

Cold and hungry people tend to make trouble. They can make good trouble, and we can come out of this with a new New Deal; and they can make bad trouble, and we can come out with fascist uprisings and World War Last. We might get a little bit of both but it's hard to envision what's on the other side of that.

No U.S. president for the next two months while our chins sink below the quicksand. Ugh.

Real artificial intelligence?

This web site claims to be able to analyze the language used by a blogger and spit out a description of the writer's intellectual style. Here's what it says about Stayin' Alive:

The logical and analytical type. They are especialy attuned to difficult creative and intellectual challenges and always look for something more complex to dig into. They are great at finding subtle connections between things and imagine far-reaching implications.

They enjoy working with complex things using a lot of concepts and imaginative models of reality. Since they are not very good at seeing and understanding the needs of other people, they might come across as arrogant, impatient and insensitive to people that need some time to understand what they are talking about.

Right on? Or equivalent to an astrological reading -- they're always sufficiently vague and flattering that we fall for them. A related site guessed, correctly, that I am male, but since a majority of bloggers are male, that is not particularly impressive -- it made the same guess for Digby.

Still worth reading the NY Times

Two articles today that grabbed me by the eyeball. (You may get a pop-up ad but I don't begrudge them an income.) The first you have no doubt heard about elsewhere, some geniuses (by dint of 99% perspiration and 1% inspiration) have largely sequenced the genome of a woolly mammoth, and the kicker is, they believe that with a modest investment - equal, say, to occupying Iraq for an afternoon - they could actually create a woolly mammoth embryo, implant it in a mama elephant, et voila.

This sounds like fun and they could definitely recoup their investment with ticket sales to Ice Age Park. However, Nicholas Wade, probably wisely, buries the lede: it is possible to do the same thing with neanderthals. He acknowledges there might be a wee bit of ethical reservation about the required procedure: modifying the genes of a Homo sapiens, creating an embryo by replacing the nucleus of a Homo sapiens ovum, and implanting said embryo in a Homo sapiens female for gestation. It's not exactly human cloning but it's sorta kinda like it.

Fortunately, there is an alternative which some of Wade's informants find less troubling: start with chimpanzee DNA, modify it to make your neanderthal, and have a chimp mother do the gestating.

Time out!

Ethically, I don't give a FFOARD about either process, what I care about is the result, an issue which nobody in this discussion appears even to contemplate. You will have brought into the world a being very similar to us, presumably with a consciousness and self-concept which is similar in many ways, but which, as far as we know, would have very limited capacity for Homo sapiens style language and no ability to survive in our world as anything but a freakish curiosity. I suppose we could make two or more so they would not be utterly alone but I mean, come on now.

I'm not really worried about it, I'm sure it will never happen -- or am I?

The other news is the death of Jay Katz, which for some reason they covered as a local, rather than national story. Dr. Katz was indeed an important national, in fact an important international figure. He is best known as a fierce advocate of the ethical conduct of research on human subjects, whose legacy includes those incredibly annoying, nit-picking, bureaucratically obtuse and dull-wittedly stubborn entities called Institutional Review Boards. Even though they drive us nuts, may they forever keep on doing it. It's the job of the IRB to be a maddening pain in the ass, and to always err on the side of too much protection and too much paperwork generating precaution. If they don't, somebody is once again going to feed radioactive cornflakes to kids with cognitive disabilities, or let poor black men die slowly and horribly just so they can watch, both of which actually, truly happened before Dr. Katz and his colleagues came along to put a stop to it.

But to me, he's even better remembered for his book, The Silent World of Doctors and Patients. Getting them to talk to each other -- as partners, not adversaries or daddy and child or prisoners tapping on the pipes in separate cells -- is what I'm all about, since I have to concentrate on something. Thanks to Dr. Katz for noticing the problem.

Quackery and leftery

Two pieces in the new JAMA - one of which, on a RTC of Gingko biloba extract for prevention of demention, is actually open access - crashed together to get me thinking. The other is a report by Bridget Kuehn on the establishment by various medical association and public health advocacy organizations of a new Immunization Alliance, to combat the misinformation which is causing some parents to refuse vaccinations for their children. Although the Immunization Alliance per sehas not gotten around to creating a web site, a largely overlapping group of organizations has established the National Network for Immunization Information, which summarizes and debunks the outstanding BS about immunization here.

The sad news is that Gingko biloba is totally ineffective -- does absolutely nothing, zip, zilch, nada -- to prevent or delay dementia or improve cognitive functioning in old folks. That's too bad, because I'd sure like some insurance that I won't eventually lose my own marbles, but there it is.

Now, here's why these seemingly disparate items came together for me. If you go to the hippie dippie food store where I often shop, there is a whole aisle filled with herbal extracts and nutritional supplements which are marketed to prevent or cure every ill known to humanity, nearly all of which have never been shown to do a damn thing for you and many of which have been conclusively shown to be worthless. I haven't done a survey, but I will be happy to make a decent size wager that the same people who buy this garbage are disproportionately likely to believe that vaccinating children causes autism and other harmful effects and is all a big scam by the evil medical establishment, along with antibiotics, statins, and the rest of their poisonous potions.

I can also tell you that for many people, these beliefs are associated with a broadly progressive stance which views powerful institutions as oppressive and promotes cultural transformation and egalitarian social policies. The fundamental, and really gross error here is to biomedical science as an instrument of social control and domination, and pseudoscientific nonsense as somehow liberatory.

Robert Kennedy Jr. is a prominent living example of this intellectual perversion, and he is personally largely responsible for creating the necessity to invest resources which are badly needed elsewhere in combating the widespread delusions about vaccines. His essential stance that public health and medical science constitute a conspiracy against humanity is reminiscent of Lyndon LaRouche, not ML King or Gandhi as he apparently fancies himself. But it is typical of a certain subset of people who consider themselves progressives.

Now, there are biases that enter into the scientific enterprise. I'll be the first to tell you so, and I devote a lot of time here to exposing them. Yes, pharmaceutical development is motivated by profit, not the human interest, and a lot of drugs are overhyped, oversold, and overprescribed; while there is considerable underinvestment in developing treatments which are badly needed, but less likely to be profitable. (That includes vaccines, by the way.)

But these biases can be discovered and exposed. In the end, there are scientific standards for truth which really do work and really should guide our decision making. Denying that HIV causes AIDS, making unsubstantiated claims about the health effects of herbs, or making false claims about the dangers of beneficial medical interventions is not liberal, or progressive, or empowering of ordinary people: it is fraud. The cause of science is the cause of progress.

The doctor is out?

You may have come across this report that says half of U.S. primary care physicians want to leave the profession. Actually, I would pay approximately zero attention to this survey -- the response rate was less than 10%, and it's likely that the docs who were motivated to answer are the ones who are the most angry and unhappy. I don't think half of all primary care docs are about to quit.

Nevertheless, primary care in the U.S. is in crisis. We have a shortage of primary care physicians, with long waits for appointments, visits that are too short, and docs feeling hassled, overworked, underpaid compared to their specialist colleagues, and unable to give sufficient attention to their patients. In some parts of the country, it's difficult for people to find doctors at all, especially if they depend on Medicaid, which pays less than private insurance. The situation looks poised to get worse before it gets better, as too few graduating medical students go into primary care residencies, while a lot of primary care docs are nearing retirement.

NEJM recently hosted a round table discussion of this issue and they once again did the right thing by making it open access. Here Barbara Starfield, a physician who is also a highly regarded investigator into effective medical practice, lays out some of the issues. The entire suite of essays is on the NEJM front page right now, although unfortunately they haven't given us a permalink. (This Intertube thing is fairly new to them, evidently.) In my view, there are five major areas where we can look for solutions. The last three are not high on the panelists' agenda, so consider this a contribution to the discussion.

1. Pay more for primary care services: Right now, doctors are paid a lot for doing tests and procedures, but not paid enough for office visit time and not really paid at all for all the paperwork they have to do and informal consultations with colleagues and patients (as by phone and e-mail). By undervaluing time spent with patients, we make it very difficult for primary care physicians to sustain effective healing relationships and truly understand and meet their patients' needs. We also discourage young physicians from going into the field. Yes, as Starfield says, if we pay more many doctors will choose to see fewer patients rather than increase their incomes. That's good, as far as I'm concerned.


2. Develop new models of primary care in which M.D.s don't do everything: The idea is to have R.N.s, physician assistants, and counselors of various kinds spend time with patients on health education, support for medication and diet adherence, routine physical exams, etc., and have the expensive and scarce M.D. time reserved for services where it's really needed. I'm only partly into this. I think the physician-patient relationship benefits from having physicians involved with all aspects of patient care, but maybe there's a decent compromise position.


3. Use information technology to streamline paperwork: This mostly means electronic medical records, linked to Electronic Order Entry and billing systems. If we can really get this to work, it will make Marcus Welby's life considerably easier, but there are obstacles, including cost-effectiveness for small practices (not there, subsidy needed); the need for standardization so all the systems can talk to each other; and cutting down the hassles a lot of physicians experience with pop-up warnings, elaborate paths to get to what they need, etc.


4. An equivalent of the U.K.'s NICE, with real power: Evidence based guidelines that are respected by insurers, patients and the courts can cut down on unnecessary tests and procedures and make decision making easier. That's a long discussion which I'm not going to get into here.


5. Improve doctors' communication and time-management skills for patient encounters: I've listened to hundreds of hours of tapes and read thousands of pages of transcripts of physician-patient encounters. Sadly, few physicians are skilled at communicating effectively and efficiently with their patients. While I don't think 12 minutes is enough for most visits, doctors could get a lot more out of the time they do have -- and hopefully, some day, it will be enough. Medical training is barely beginning to address this, and the evidence base is inadequate. (Dear NIH: Give me lots of money. Thank you.)


6. Universal, comprehensive, single payer national health care: Right now, primary care physicians spend a whole lot of time figuring out what is and is not paid for by their various patients' various insurance schemes, managing complicated businesses that require infrastructure to bill multiple payers, and negotiating with their patients over what expenses they can and cannot pay out of pocket. If everybody has the same insurance, and everything is covered, all of that goes away. And oh yeah, we all save money.

So, whatever reforms we get in the coming year, these need to be in there. Let's make it happen.

Perverted Priorities

You probably haven't heard of the World Health Organization's Commission on the Social Determinants of Health, but that's because your liberal media would rather spill tanker loads of ink telling you all about the latest heroic medical breakthrough by Godlike biomedical scientists -- you know, the one that will bring billions in profits to a drug company and maybe buy a few months of life for a lucky few people for a several tens of thousands of dollars apiece -- rather than telling you about how we could avoid a whole lot more sickness and suffering and death for billions of people really cheaply, although unfortunately there isn't a specific company that will profit from it so we don't do it. (Just thought I'd go with a Faulknerian sentence for the heck of it.)

I can't give you a link because the only report I've found is in subscription-only BMJ, but Deborah Cohen of that august publication reports:

The sudden global reduction in credit may lead to opportunities to rethink and improve global strategies to reduce health inequities, an international conference heard last week.

Michael Marmot, chairman of the World Health Organization’s commission on social determinants of health, said, "During the crises [the first and second world wars] there was social solidarity and the thought that we have to do things differently. The credit crisis is an opportunity to say are we going to do things differently." He was speaking at a conference entitled Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.

Professor Marmot pointed to the fact that Western governments had recently found hundreds of billions of dollars to support the banks and that the commission’s report early this year had put the cost of upgrading the world’s slums at $100bn.

"For one ninth of the money we put into saving the banks, every urban resident in the world could have clean running water," he said, although the will to tackle health inequity was lacking.

Indeed. But is the professor perhaps a bit naive? Here in the U.S.A. we managed to find a couple of trillion dollars to invade and occupy Iraq. We could have given every urban resident in the world clean running water for one twentieth of that amount. But is there even a remote possibility that an American president would make such a proposal, and is not the possibility even more remote that an American congress would approve it or the American people support it?

On the front page of the Commission's web site you will find the following statement: "(The) toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible," the Commissioners write in Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health." The report is available there free of charge. What is biologically possible, alas, seems to be socially impossible. I would be interested to hear what our Christian friends who are so committed to a Right to Life think about that.

Let 'em break rocks?

I get a lot of e-mail from publicists, and in case you're one of them and you're thinking of sending me some, let me tell you it's pretty tough to make it to the show here. However, the Restorative Justice Community makes the cut. They're trying to use web-based tools to build networks and provide resources to support ex-offender re-entry. Here's something I wrote about the subject a few years back:

Substance abuse is closely associated with recidivism. For example, 39% of jail inmates with first-time convictions have regular drug use histories, compared to 61% of those with two prior convictions. The majority of jail and state prison inmates have been regular drug users, and this group tends to have a history of unemployment, limited formal education, and to have associations with people who also abuse drugs and commit crimes. These factors all pose challenges for successful reintegration and prevention of recidivism. It has been shown that substance abuse treatment can be effective in reducing recidivism.

However, according to a CSAT consensus panel, “Release presents offenders with a difficult transition from the structured environment of the prison or jail. . . . Many offenders are released with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to access available resources for adjustment to life on the outside.” Hence the early release period is one of particular vulnerability to relapse. Substance abuse treatment becomes more effective with continuity and duration. For released offenders, treatment is much more likely to succeed if it is integrated with other essential rehabilitative services including education, job skills development, housing, family counseling, etc. However, service systems are generally fragmented and linkages between the institution and post-release services tend to be weak.

Transporting inmates back to the community and receiving referrals from probation and parole on the very day of release are critical to an offender’s success in establishing a law-abiding life. Most offenders will live within five miles of where they lived before being incarcerated, retaining in most cases the same associations they had previously. Many inmates also have untreated, and often undiagnosed, mental illnesses, and they disproportionately suffer from physical illnesses including HIV and hepatitis C infection, which are associated with injection drug use.

As I assume y'all know already, we incarcerate a higher percentage of our population than any other (putatively) democratic country, and the vast majority of them are not violent criminals but the unfortunate sorts of people I describe above, who suffer from substance use disorders and just haven't managed to build successful lives. Locking them up does none of us any good, and dumping them back on the street without a plan to get them a life just makes matters worse.

While I commend the RJC, private efforts are not enough. We need a radically transformed public policy approach to addiction, drug trafficking, and the troubled and thwarted people among us. I won't even get started on the racist nature of the system -- white people who are caught with drugs get treatment, Black and Latino people go to jail. One more item for your long, long list President Obama.

The S Word

If you'll glance at the map at the top of this page, you will see that the United States is not the darkest shade of green. That would be the land of flying hockey pucks to the north, and most of that big peninsula sticking off the western edge of Asia. (It's called western Europe, Governor Palin.)

John McCain and the geographically challenged governor called Barack Obama a socialist because he wanted to slightly increase marginal tax rates on wealthy people. Unfortunately, Obama is not a socialist. However, by the definition of the term generally accepted in the United States, those dark green countries do indeed all have socialist systems. They all have much higher tax rates on wealthy people than we have here in the U.S. By a variety of mechanisms, their governments assure that 100% of their citizens have comprehensive health care, for which they pay little or nothing out of pocket, and that the cost is affordable to everyone. Access to higher education is based on admission by merit, not family wealth. Many of these countries provide subsidized child care for working parents. Pensions are generous, worker protections are strong, vacations are long.

Now, if you take an economics course here in the U.S., the professor will tell you that all that taxation and gummint interference in the economy necessarily means slower economic growth and a lower overall standard of living. George W. Bush said that tax cuts stimulate economic growth and tax increases stifle growth -- "It's economics 101!" And indeed it is. But it is not true. Those European countries in recent decades have had growth rates comparable to or better than the United States, and their standard of living is, in many ways, better than ours, because, well, they get all that free good stuff that we don't get. Larry Beinhart reveals that the historical comparisons in the U.S. show the same thing. High taxes are good for economic growth, and low taxes are bad.

Beinhart also says -- but I said it first, many times, as long-time readers know -- that economics is not a science, but a form of theology. Crack open that economics textbook and you'll see some lovely curves, making elegant intersections and carving the plane into graceful shapes. They look just like the curves in real scientific journals!

But there's a difference. In science, the curves are made by plotting data points. They are representations derived from reality, empirical observations. In economics, they're just something somebody made up. They look all scientific and stuff, but they're just icons, like the glass in church windows -- images to focus our faith, visions of an imagined realm.

Now, one might think, as we stare into the abyss of an economic collapse that the consensus of economists told us was impossible and cannot really be happening, that these frauds might finally be laughed out of town. But it won't happen. Ten years from now, they'll still be drawing those silly curves on the blackboard.

Beating a horse I had hoped was dead

Naturally there's a lot of buzz about possible appointees to important positions in the new administration, and naturally most of it is probably either manufactured by people who are campaigning for jobs, or just hot air. But one rumor is so disturbing that I feel the need to address it. I don't like giving it credence even by condemning the idea, but I have to speak out. (Or write out, I should say.)

The rumor is that Robert Kennedy Jr. is being considered for Administrator of the EPA. One of the most important pledges Barack Obama has made is that he will restore respect for science. The world is on the brink of disaster in part because the Republican Party generally, and the Bush administration in particular, have substituted ideology and political interests for scientific truth -- denying anthropogenic global warming, the health effects of mercury pollution and other environmental contamination, and even supporting the notion that children should be indoctrinated with long-discredited ancient fables in science classes.

Robert Kennedy Jr. is equally an opponent of science and a champion of faith against reason. I have written extensively about his mendacious and absurd campaign on behalf of the preposterous, thoroughly refuted claim that a preservative used in childhood vaccines, called thimerosal is a cause - in fact, he seems to claim that is the cause, of autism. You are encouraged to read what I have written on the subject, which is in four installments, here, here, here, and here. I conclude:

Here's why this matters. A lawyer, who is famous for being the son of a murdered politician, has gained a very prominent public platform -- including a lengthy article in a high-circulation magazine, op-eds in the nation's leading newspapers, and appearances on many of the big-time TV yackfests -- to claim that "they" -- the secretive, corrupt, unaccountable cabal of public health scientists -- are all conspiring to conceal from the world the horrifying truth that the entire medical institution -- drug companies, the FDA, the CDC, physicians the world over, medical journal editors, academic researchers -- have collectively inflicted a devastating disease on millions of children the world over; and what is more, they are continuing to do it in poor countries where thimerosal is still used. What is most remarkable about this conspiracy is the absolute unity and the inviolability of the oath of silence taken by all those hundreds, or probably thousands, of co-conspirators.

Maybe you've been home sick some time, or channel surfing between innings of the big game, and seen those informercials with the guy selling a book about the miracle cures "they" don't want you to know about. It turns out there's a simple, natural cure for cancer; heart disease; arthritis; you name it. The reason people have these diseases is because they are caused by prescription drugs. Statins are the cause of heart disease. But just send this guy money, and he'll tell you the cures "they" are keeping secret.

What Kennedy is doing is utterly reprehensible. Apart from the exploitation and abuse of families coping with the heartbreak of having an autistic child, he is attempting to cause severe damage to the culture. (Fortunately, despite the podium he has been given by irresponsible corporate media, he hasn't gotten much traction.) As I have said a thousand times, the democratization of science is critical to the future of democracy, indeed the future of humanity. That means we need to expose corruption and self-dealing in scientific enterprise, to be sure. But it also means that we must have respect for the cause of science, the quest for truth using human senses and reason, and the norms of honesty, openness, and intellectual integrity which the large majority of scientists and physicians try to honor.

Science is conducted by flawed human beings, working in flawed institutions. But it is not a conspiracy against the public. Kennedy deserves no respect, and no hearing, from anyone, ever again.

Now here's why it really, truly matters. According to the CDC, the incidence of measles in the United States so far this year is the highest since 1996. "Low vaccination rates among children whose parents are religiously or philosophically opposed to vaccination are responsible for the increase in measles cases that occurred between January and July 2008." Many parents have chosen not to vaccinate their children because of the lies spewed by Mr. Kennedy. Measles can cause permanent brain damage, deafness, and even death. None of the children in the U.S. died, but several were hospitalized. I don't know how many of these parents were influenced in their choice not to have their children vaccinated by Kennedy's crusade, but if it was even one, he is morally responsible for that child's illness.

President Obama, you are certain to make mistakes. We all do. But here's one you don't have to make.

Pills pills pills pills pills pills pills

Commenter MAM on the previous post points us in the right direction, toward a fundamental issue that the breathless corporate media reports on the JUPITER trial completely miss. C reactive protein is indeed a general marker of inflammation. You can knock it down with a statin, but if you do that, you are ignoring the underlying cause of the inflammation.

CRP is not, itself, a causal factor for heart disease. That was shown in a study published just a couple of weeks ago, also in NEJM, which found that people who have elevated CRP due to a genetic predisposition are not at elevated risk for heart disease. It's chronic inflammation that's the culprit, CRP is just an indicator. Rather than just writing prescriptions for statins, physicians who find elevated CRP in their patients ought to try to find out why, don't you think? First of all, if it's applicable, the people need to quit smoking. The doctor and patient would want to work together to determine if the patient is chronically exposed to other sources of air pollution, whether from living or spending time near a highway, a nearby factory, occupation, lack of a working range hood and exhaust fan, you name it. Does the person have gum disease? Good oral hygiene and regular dental care might be the answer. And oh yeah, universal, comprehensive insurance that includes good dental coverage is part of the policy solution. And yes, believe it or not, dental care and stopping gum disease are associated with reduced cardiac risk, it isn't speculative.

Some people have chronic inflammation due to autoimmune disorders with poorly understood etiology, such as rheumatoid arthritis. They are typically already taking powerful anti-inflammatories, and maybe statins on top of the rest couldn't hurt. When all is said and done, pills are going to make sense for some people, but our problem is that we don't bother to say all and do all first.

This is just a single example. Statins were originally prescribed for elevated plasma LDL, but why do people have that symptom? It's because we don't eat the way our ancestors did -- mostly whole grains and veggies and some very lean meat. Instead we eat unnaturally fatty meat, grain with the bran and germ stripped out, refined sugar, dairy products, and even synthetically altered oils -- trans fats -- that couldn't have been better designed to kill us if somebody was trying. Instead of walking everywhere and running after game and away from predators as our ancestors did, we travel around sitting inside a ton-and-a-half of fossil fuel-powered steel. Instead of digging and pounding and building and throwing things, we sit on our lard butts all day staring at electronically generated images. That's why we have hypercholesterolemia.

That's also why we have diabetes, but all we do about it is take pills.

I've been bummed out for the past eight years by the gang of murderous thieves who took over my country, but if I'd been foolish enough to mention it to a doctor, he just would have given me pills to make me feel better.

Not that pills are bad per se. Our ancestors didn't usually make it to an age when they even had to worry about heart disease, because infectious diseases or parasites got them first. To be sure, those tiny critters get a better shot at us because of the way we live, crowded into cities, drinking our own excrement, and oh yeah, eating wrong and being out of shape, but still, even the most stringent public health measures can't eliminate infectious disease. Antibiotics and immunization have definitely changed the basic parameters of our existence.

No matter how wise we are about how we organize our societies and how we live our lives, we're going to get sick sometimes and scientifically designed chemicals are sometimes going to be part of the answer. But we make a big mistake by always assuming that they are the answer, that all our problems can go away if we just swallow a magic pill. We've gotten to this point because it is in the commercial interest of drug companies to shape the culture that way, and we've let them do it. Just one more power we've got to fight.

Take more pills?

The big medical breakthrough news of the day is the so-called JUPITER trial, which you can read all about here thanks to NEJM's increasing open access practices. It's all the rage these days to give clinical trials snappy acronyms -- in this case it's Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin. The reason for the clever branding is that this trial was paid for entirely by AstraZeneca, the manufacturer of and patent holder on rosuvastatin, which they would prefer we call by the brand name Crestor.

Okay, here's the background, the study result, and what I think it means. As usual, we are not dispensing medical advice here. Inform yourself, consult your doctor, make a decision you are comfortable with.

Statins were originally developed and tested, and subsequently prescribed, based on the observation that high levels of Low Density Lipoprotein, aka bad cholesterol, are associated with vascular disease leading to heart attacks and strokes. They block the action of an enzyme involved in the synthesis of LDL, hence lowering LDL levels. Ergo, they have been prescribed for people with elevated levels of LDL.

For quite some time, they were prescribed even though there was little or no evidence that they actually prevent heart attack or stroke in people who haven't already had one. Some people objected to this practice on the grounds of monetary cost and the risk of side effects. The latter concern was amplified when one statin was found to pose a substantial risk of a very serious side effect called rabdomyolisis. That particular drug was withdrawn from the market, and others have proven to be much less likely to cause that particular problem.

Evidence has been growing that statins can indeed reduce the risk of cardiovascular and cerebrovascular disease and serious events in otherwise healthy people with high LDL levels, and so they are increasingly prescribed. However, it turns out there is another marker for risk of vascular disease, called C Reactive Protein, CRP, which is a sign of inflammation. It so happens that statins also have an anti-inflammatory effect and lower CRP.

So, AstraZeneca paid the patent holder of the CRP test to do a large scale trial in which people who did not have elevated LDL, but did have elevated CRP, were given rosuvastatin. The trial was stopped early, because treatment reduced the rate of hospitalization, angioplasty or bypass surgery, heart attack and stroke by about half, and the death rate from all causes by 20%.

Slam dunk, right? Maybe, but these questions often look different when you look at absolute risk, rather than relative risk. Another way of stating these results is that 25 people would have to take the drug for 5 years to prevent a single adverse incident. In other words, if you are in the low LDL-high CRP group, there's a 4% chance you would actually get a noticeable benefit by taking this stuff for 5 years. It's a big benefit, to be sure -- who wants to have a heart attack? Still, if you put it that way, you're more likely to think about the cost and possible risks. Side effects were not a big problem in this trial -- the only notable concern was an increase in the diagnosis of diabetes, although blood tests for the effects of diabetes didn't show a meaningful difference.

Still, the trial was halted after less than two years, and while there is some longer term follow-up available, we've had lots of experiences with adverse effects of medications emerging only after long experience with large populations. In particular, people who start out with normal LDL levels end up with abnormally low levels when they take statins. That does seem at least intuitively suggestive of a concern.

As for cost, there are generic statins available at 1/3 or less the cost of rosuvastatin. They all work the same way, so I personally see no reason for anybody, anywhere, to be prescribed a brand name statin, including Crestor. That's purely a waste of money. Take a generic. Of course, AstraZeneca would not have paid for a trial of a generic chemical.

Second, it will require considerably more information and analysis to understand the cost effectiveness of such an intervention at the population level. There is an opportunity cost -- there are other ways to spend the health care dollar. For one thing, a very good way to get elevated CRP is to have gum disease. Maybe universal dental care would do more than prescribing statins, and have other benefits as well. (Yep, it's true -- having your teeth cleaned prevents heart attacks.)

CRP is also raised by spending time near highways, breathing ultrafine particles from motor vehicle exhaust, and other exposures to air pollution. It so happens that a disproportionately popular place to put public housing is near highways, because the land is cheap and people who can afford not to don't want to live there. Maybe we could achieve a population health benefit, not to mention justice, by choosing to build affordable housing in safer locations, and reducing other sources of air pollution.

So think about it. Do we really want to view pills as the answer to every problem? Or is it worth considering other options?

Political Science

On Monday I opened up my fake closet of anxieties, but of course I have a real one. Pretty high on the list is something we aren't supposed to talk about, the fear that dare not speak its name. Since the McCain campaign whipped its crowds into a murderous frenzy, calling the Democratic candidate a communist, a terrorist and a traitor bent on surrendering the nation to its enemies, the Secret Service informed the Obama family of a blizzard of vile threats. Since the election, some intrepid explorers with the asbestos eyeballs needed to venture into the far precincts of Wingnuttistan (which are disturbingly not very far at all) have found the tide of hate is only rising.

Now, Mr. Obama is well protected, and I'm sure they know what they're doing. I don't really think we should lose sleep over his safety. Nevertheless, the question has made me think about the peculiarities of human social organization. One might think that a socio-political system as large and complex as the United States would be far too robust to be deeply affected by the removal of a single individual. But we know this is not so. The basic structure of modern republics always includes a large lawmaking assembly, in which the incremental importance of individuals is generally small; but all nations embody the leadership and execution of government in a single individual. Typically they symbolically embody the state in another, either an anachronistic hereditary monarch or a ceremonial presidency established to emulate the monarchical role. We, however, combine the functions in a single individual.

Historians argue vociferously over the significance of the Kennedy assassination to policy. Some believe he would have avoided the Vietnam disaster, while others say that Johnson only continued a trajectory he had already set. It is arguably the case that Johnson was in a better position to achieve the Civil Rights Act than Kennedy would have been. But would a two-term Kennedy presidency have brought about the chaos in the political culture that gave us Richard Nixon, and ultimately the rise of the abominable late Twentieth Century conservative movement?

Who knows? But we do know that the hope of the world now rests on one untested young man. So far he seems to bear it easily enough, but he has a long, steep road ahead, lined with determined enemies behind every rock and tree. Good luck to us all.

And don't forget to visit: The web site of the President-elect.

This was not a big issue in the campaign . . .

. . .but it's certainly been a big issue here. Somewhere on President Obama's lengthy agenda is the question of foreign aid. In case it isn't already obvious (and I suppose I should add a caption) the world map at the top of the page shows life expectancy at birth. It is stolen from the Global Education Project, and one of the tasks I still need to do in building the new site is to add the credit and link. I have recommended the site here before, I reiterate it now.

As you can see, your chances of stayin' alive are worst in much of Central Africa and a few places in Asia -- for Americans, it's important to note that Afghanistan is among them. Iraq is probably also doing worse than the map shows, but we don't have good up to date information.

One of the few initiatives for which the soon-to-be former administration has gotten widespread credit is PEPFAR, the President's Emergency Program for AIDS Relief. The $3 billion a year we spend on PEPFAR is a bit less than the president originally promised, and it has been compromised somewhat by idiotic conditions regarding condoms and abortion, but it has certainly made a big difference, especially in Africa. PEPFAR has provided antiretroviral treatment to 1.45 million people, and is credited with preventing 10 million babies from being born with HIV.

However, as Colleen Denny and Ezekiel Emanuel point out in the Nov. 5 edition of JAMA, there are many other far less expensive interventions that we do not fund adequately, which could save even more lives and prevent more disability. For the $3 billion a year we spend on PEPFAR, providing antiretroviral therapy yields a benefit of somewhere in the range of 5 million Disability Adjusted Life Years. (I talked about that concept recently, and promised to get back to it. So here we are.)

But providing insecticide treated bed nets to prevent malaria, for the same money, would provide more like 200 million DALYs. Just providing the standard set of immunizations for kids would yield 429 million. A community based support program for pregnant women, using trained lay midwives and inexpensive supplies, gets us 333 million DALYs.

PEPFAR has support in the U.S. because we are familiar with HIV and its ravages, and there is a strong advocacy community in the U.S. for HIV prevention and treatment. But the many other deadly afflictions of poor countries, for which we could have an even greater impact at less cost, are comparatively neglected. Given the hard times we'll be going through here -- hard by our standards but not hard at all by the standards of the poor countries we're talking about -- it will be difficult for the new president to increase spending on foreign aid. Alas, Denny and Emanuel seem to argue for allocating funds away from PEPFAR and toward some of these other problems.

I can't support that because the last thing we need to do right now is divide people who support assistance to the poor countries. But there are compelling reasons for us to do more. Yes, Africa does not need an increase in it's human population. But we know that when infant mortality goes down, and the status of women improves, birth rates go down and population stabilizes. So the right strategy can work.

Just one more item on a long, long list.

Oh yeah: For the benefit of our Alaskan readers, Africa is that big continent to the south of Europe. If you aren't sure where Europe is, leave a comment and we'll tell you how to find it on the map.

This "Deep Thought" thing is apparently fashionable

So I might as well have a couple.

Lean years are ahead for cartoonists and satirists. Let's face it, Obama is a hard man to mock. He's cool, calm, pragmatic, smart, articulate and physically graceful. He has big ears but that's about all you've got to work with. We'll see what they come up with but SNL may struggle for ratings.

John McCain's concession speech was extremely gracious, appeared to be entirely sincere and reflective of a genuine commitment to the national interest. In other words, it was like he had a brain transplant. Where has that guy been for the past few months? That John McCain might even have won. Has the senator been kidnapped and replaced by a clever impostor? Or did he suddenly start taking his meds again? WTF?

Blogger was supposed to move over all the links and what not but, as I should have known, it didn't. I'll gradually be restoring them and building the site in coming days. Comments and suggestions are more than welcome. I don't know what this "follower" thing is exactly, it's a new one on me. I haven't checked out all the followers yet, but come one, come all, it's liberty hall. However, I take no responsibility.

Hope the new look isn't too much of a shock

But hey, a whole lot can change in one night.

It wasn't quite as good a day as we hoped for. Proposition 8 apparently passed in California, which is truly terrible news. The collective wisdom of Alaska was reflected in their returning two felons to high office, Michelle Bachmann, Saxy Chambliss, and some other truly revolting people managed to get re-elected. Obama's win, while decisive, was not really a blowout and it is evident that there are a lot of people in this country who respond to tribalism, divisiveness, and ugly, empty rhetoric.

But I'm still not going to sell this moment short. Go ahead and hold onto that glow for a little while, at least. But now the really hard work begins. We will never have a truly democratic society if we just depend on touching a screen or filling out a paper form every couple of years. We will never overcome the profound challenges we face if we just elect some people we like and walk away. It's great that we will have a talented president who can inspire people, but you need to get inspired enough to act, to be continually involved in politics, public policy, and community activism. What the Obama victory means is that we're all in this together. Now let's be there.

What else is there to say?

Nothing to do but wait. The polls in Massachusetts open at 7:00. When I got in line at 8:00, it stretched around the block. The polling place was very well organized and efficient, I only waited about 45 minutes; but the line wasn't getting any shorter behind me. Later this morning, I walked by a polling place in Chinatown, and the line was also around the block, so it wasn't just people trying to get their vote in before work -- the traffic has been steady, and the lines substantial, all day.

It's a gorgeous fall day here. The mood was calm, determined, and mildly festive. Of course our vote doesn't matter. Now that Diane Wilkerson has found an unusually expensive method of stuffing her bra there are actually no meaningful electoral contests on the Jamaica Plain ballot, although there are 3 ballot questions that draw considerable interest. But the main thing is, people want to be a part of history.

Am I worried? Not really -- it doesn't seem as though we should be. But after two stolen elections in a row, and knowing the utter amorality and ruthlessness of the opposition, it's hard not to be. Not to mention the horrific consequences if McCain is somehow declared the victor. American democracy has never been all it's cracked up to be, but it would be very sad indeed to see even the pretense die before our eyes.

Well, that's very unlikely. Tomorrow we will wake up knowing that we at least have a chance. After the oppressive weight of the past eight years, that will feel awfully good.

The World's Still Turning

It's hard to get down to regular business today. The election tomorrow will be one of the most significant in our history, right up there with 1860 and 1932. That's not to say that Barack Obama will necessarily be remembered alongside Lincoln and Roosevelt. The challenges he faces are equal to theirs, but whether he can achieve greatness is up to all of us. Nevertheless, the coming moment may be the most important of my lifetime. Truly, I did not believe I would live to see this day.

In spite of all that weight of history upon us, we still have our own work to do. I'm happy to say that my colleague Kari White and I had our article Role Exchange in Medical Interpretation published on-line today in the Journal of Immigrant and Minority Health. Sadly, although the journal is on-line, it's not open access.

I will tell you, however, that when people who are not professional interpreters are called upon to interpret in health care settings -- as often happens -- disaster is likely to ensue. We observed nurses and social workers who were called upon to interpret substituting their own judgment for that of doctor and mother (these were pediatric visits) and making up false translations accordingly. We observed social services staff who were asked to interpret but who had limited training spending significant time socializing with mothers, giving their own medical advice, and editing mothers' and doctors' remarks for what they considered to be the medically relevant content.

So one important element of the universal, comprehensive, single payer national health care that President Obama is going to give us -- or even the more limited regulated insurance market we can actually expect -- is that it includes adequate reimbursement for high quality, professional interpretation when doctors and patients don't share fluency in a common language. That includes deaf people as well as immigrants, by the way.

Ultimately, as well, we need to promote bilingualism in this country instead of treating it as some sort of a threat. Learn another language -- you'll have access to twice as big a world.