Guest Post

This is something I haven't done for a while, but I'll be happy to entertain guest posts in the future. Must be on topic, no commercial promotion, and in accord with our overall perspective and values and what not. Author Pat Walling also writes for the Medical Billing and Coding blog. As I told her I would mention, one of the major sources of waste in our current health care non-system that relies on a mess of different insurance plans is the need to spend absurd resources on billing and coding. With a single payer system, we'd do a lot less of it. But, that's the world we live in now, and somebody's got to do it. -- C

Illiterate Fistula Surgeon Brings Hope to Women

Mamitu Gashe is not an ordinary surgeon, at least not in the way most people think of a surgeon. She did not grow up with medical aspirations, but instead assumed the profession as a way to help women deal with a problem she once faced herself. Mamitu's journey started in a remote Ethiopian village when she was 15 years old. She married a local man, became pregnant and eventually lost the baby. Soon after, she discovered body fluids leaking from her vagina.

What Mamitu had was a condition known as an obstetric fistula. A fistula in general refers to any abnormal passageway or connection between vessels or organs in the body that do not normally connect. Fistulas may occur in the lungs, stomach, nose and other parts of the anatomy. Obstetric fistulas specifically refer to damage in tissues of the vagina that cause leaks from the bladder or bowels. This particular condition was a common occurrence in the United States in the 1800s, but improved medical treatments and procedures have made the condition almost non-existent in industrialized nations. Most of the cases today occur in underdeveloped nations, mostly located in Africa.

The young women who suffer from fistula in impoverished parts of the world often lead a lonely life in solitude until they die. They are forbidden from being near community drinking water for fear of contamination. Some of these women commit suicide due to their life of isolation and shame. Mamitu, who was illiterate at the time she was suffering from the condition, found relief thanks to a pair of Australian doctors. Australian obstetrician Catherine Hamlin and her late husband, Dr. Reginald Hamlin, started Addis Ababa Fistula Hospital, located in Ethiopia, in 1974. The couple originally planned on staying in the area for only a few years, but ended up dedicating their lives to helping women in this part of the world receive treatment for a condition that dramatically reduces their quality of life.

In order to make the trip that changed her life, Mamitu spent seven years begging for change at a local bus station to save up the money for the trip to Addis Ababa Fistula Hospital. Dr. Hamlin performed the surgery on Mamitu free of charge. Afterwards, Mamitu ended up working at the hospital changing beds. Eventually Dr. Reg Hamlin became confident enough in her abilities to ask Mamitu to help with removing the stitches of other patients. From then on Mamitu became more involved in the process of repairing fistulas. After observing the surgeries for a few years, Mamitu went to school and eventually became a surgeon and began performing the surgeries herself.

Mamitu is now considered an expert in obstetric fistula surgery. She continues to work side by side with Dr. Hamlin at Addis Ababa Fistula Hospital (nicknamed "puddle city" because of the condition treated there) to provide hope for women who once had no real alternative, except to live a life in isolation while quietly suffering from an embarrassing medical condition. In addition, she provides instruction to other surgeons who travel from around the world to learn the basics of this type of surgery. Mamitu has never forgotten how Dr. Hamlin, now 83, and her husband helped her achieve a productive, healthy life. Addis Ababa Fistula Hospital performs the reconstructive surgery on African girls free of charge. The surgery itself normally costs $300, but many who need it simply cannot afford it or have no way to get to a facility where the operation is preformed. As result, the hospital has helped an estimated 25,000 young women live a better life in the years since it started operations.

In order to help make obstetric fistulas a thing of the past, The United Nations is seeking $750 million to treat up to 3.5 million women who suffer from obstetric fistulas by 2015. Following a successful surgery, many of these women can be integrated back into their communities. Additionally, Mamitu (along with several others) is seeking increased funding to combat the condition. The funding would go to education efforts, as well as providing the surgery to those in need. Treatments for an obstetric fistula will vary based on the cause and extent of the condition, but typically include a combination of surgery and antibiotics. In cases involving younger patients, surgery is sometimes delayed with medications until a certain age is reached. However, it is estimated that upwards of 300,000 lives could be saved with education and medical efforts.

Mamitu has devoted her life to helping others receive treatment for this treatable condition. Her efforts today are focused on raising awareness and funds to help those in need lead a better life. Similarly, Dr. Hamlin appeared on Oprah in 2004 to tell the story of Mamitu and the hospital she operates in Ethiopia. While the appearance did help to raise awareness and bring in additional revenue, there is still much work that needs to be done. Efforts by Hamlin and others will continue until obstetric fistula is a thing of the past worldwide. The Fistula Foundation supports efforts at Addis Ababa Fistula Hospital, and has raised over $3 million to help keep the hospital in operation.

Dr. Hamlin and her colleagues in the field are often frustrated by the fact that a curable condition such as an obstetric fistula remains a big problem in certain parts of the world. The United Nations is assisting with efforts to raise funds to hopefully bring an end to the condition. According to the U.N., about two million women and girls may suffer from the condition. However, success stories like Mamitu’s, are providing inspiration to women around the world. "No woman should have to suffer what I suffered," Mamitu told reporters at a recent luncheon. Mamitu does not normally seek the spotlight, but she hopes that by telling her story other women with the same condition will get the help they need to lead full, healthy lives.

Ineluctable insanity?

Ed Kilgore thinks that even though the Republican establishment will no doubt dispose of risible malignant clown Donal Trump in due course, the hunger of Republican primary voters for a candidate worthy of their delusions is such that they will ultimately get one. Or I think that's what he's saying.

Wacko conspiracy theorists are certainly nothing new in the U.S.A. Joe McCarthy and the John Birch Society were right in the middle of things. Some commentators, such as Andrew Sullivan, who himself vacillates between reasonable Toryism and more than a touch of wackiness, sees equivalence between the current psychosis of the right and academic post-modernism of the late 20th Century, which claimed some vague leftishism.

I really don't see that. The PoMos were never politically influential or even relevant. They were college professors in vague disciplines like "cultural studies" and eclectic departments such as sociology and literature who spent all their time talking to each other in a language even they probably didn't understand. They had no definable political project, but only an amorphous aspiration that undermining the "hegemony" of rational empiricism would somehow be "liberatory" for somebody. About their only impact outside of the academy was to encourage quack medicine and New Age hucksterism.

What we're seeing today is quite different. It's obviously a substantial movement out there among real people, with a majority of Republicans telling pollsters they do not believe the president was born in the United States and large numbers of actual crazy people actually elected to the United States congress. And they have definite, concrete beliefs, such as Dearborn, Michigan, is under Sharia law; the socialist president is plotting a government takeover of Medicare; the best way to solve the unemployment crisis is to stop collecting income taxes from billionaires; and the earth is 6,000 years old. I really don't see any parallel in the history of the left or liberalism in this country.

What I do see, however, is not in fact a spontaneous epidemic of nuttiness. All of this crap was deliberately ginned up by political operatives in order to bamboozle people into voting against their own interests. It's just gotten a bit out of control, and now Donald Trump is the bamboozlers' Frankenstein monster. As ye sow . . .

Now this is interesting

Via PZ, it turns out that there's a passage in the Book of Matthew that for some reason doesn't get read on Easter Sunday:

50 And when Jesus had cried out again in a loud voice, he gave up his spirit.

51 At that moment the curtain of the temple was torn in two from top to bottom. The earth shook, the rocks split 52 and the tombs broke open. The bodies of many holy people who had died were raised to life. 53 They came out of the tombs after Jesus’ resurrection and[e] went into the holy city and appeared to many people.

The fact is that the most devout Christians simply have not read the Bible and do not know what is in it. If you want to keep the faith, you can't just sit down and read the whole damn Bible because you will very quickly discover that it is full of nonsense, self-contradiction, exhortation to evil and injustice, and that God is one nasty, repulsive son of a bitch.

If the preachers weren't embarrassed by the idea that not only Jesus, but a whole lot of other folks, were resurrected, they'd at least mention it once in a while. But even though it's still in the Bible, it's completely censored from the Easter story and is carefully skipped over in church. Next time you get a chance, you might ask your own guy in a dress about this.

Opposite World

This isn't really an original observation but it's worth reminding ourselves periodically that the essential nature of conservative political rhetoric in the United States is inversion of the truth.

A key to the Republican electoral success in 2010 was a massive campaign of TV advertising claiming that Democrats wanted to drastically cut Medicare and deny life saving procedures to old and sick people. Now that their claim to be the protectors of Medicare has gained them control of the House, they propose to do away with Medicare altogether. They don't even want to bother with the death panels, they just want to let poor old people die on the sidewalk in front of the hospital.

Ed Brayton quotes from Glenn Greenwald's new book (no more direct link is yet available it seems). Conservatives crave strong, masculine leaders, so they pretend that their draft dodging chicken hawk politicians are actually macho war heroes -- viz. the draft evading George W. Bush landing on an aircraft carrier with a sock stuffed in his crotch -- while deriding actual war heroes like Max Cleland and John Kerry as weak and effeminate.

Conservatives seized on public outrage about the taxpayer bailout of Wall Street grifters (signed into law by George W. Bush, as we are expected to forget) as additional leverage to win the House, and of course the first thing they did was to block meaningful reform of financial regulations and make sure that the Wall Street grifters had nothing to fear from Congress.

They claim to be champions of liberty and small government, and of course they are the ones who want to regulate our sex lives and force their religion on everybody else. They seize on the resentments and anxieties of the imperiled working class to insist that rich people shouldn't pay taxes, and that future economic security depends on taking away the very government benefits and services that give them a chance for a decent old age and an education for their children. They claim that Christian values demand that we not guarantee health care for everybody -- that Jesus wants you to be on your own.

What I don't really understand is why this standard procedure of proclaiming the precise opposite of the truth is so consistently successful. Of course the corporate media enables it by declining to assess truth claims, but are people really that stupid? Well, I suppose they must be.

That'd be the butt, Bob . . .

As a classic example of answering the wrong question. (Go here if you don't know what it means, or don't bother if you'd rather not know.)

It hardly seems worth my while to discuss the unanimous vote of the Republicans in the House to do away with Medicare. If you're reading this blog you probably know what I'm likely to say, right? And there are others with much more visible platforms from which to say it. But I do perhaps have a tweak or two to offer.

First, here's James Fallows, making the point that without Medicare, many old people would face ruinous health care costs that would wipe out their estates. That's true, although the implied universality isn't quite right. Some people are lucky enough to die suddenly, without a costly terminal illness. But there's certainly no justice in that random selection.

However, the fact is that this already happens to a lot of people. Medicare does not pay for long-term care -- past six months in a nursing home, people have to spend down their estates and become impoverished, then Medicaid takes over. If you happen not to need long term care, but do need expensive medical care that Medicare does cover, then essentially the taxpayers are chipping in to protect your estate for your heirs. If it just so happens that you develop a long-term terminal illness -- dementia being the archetypal example -- your heirs don't get that benefit.

That doesn't seem particularly just either. To me, what this really invites us to think about is the basic problem of people entitlement to inherit their parents' left-over retirement savings.

The real reason to keep Medicare is not the protection of heirs, as Fallows suggests, but because it is the most cost-effective and just way to provide health care to the elderly that we currently have, and because it could be made even more cost effective and just with some policy changes -- including precisely the policy changes that Republicans decry as "death panels." They don't even want to bother with the death panels, obviously, they just want to let poor people die.

However, Fallows seems to be basing his argument on your right to inherit. That seems to be the wrong question.

But they're junkies, they deserve to die

Those wacky Canadians are at it again, providing injection drug users with a safe place to inject under medical supervision. Whaddya know, overdose deaths in the area went down by 35%, with no ODs occurring in the facility. Also, clean needles, no HIV and Hepatitis C transmission, no needles left on the street, opportunities to offer people substance abuse treatment and other services, and for staff to observe any urgent problems . . .

Sounds great, but the federal government of Canada is against it -- it's operating under British Columbia license. And you can just imagine trying to do this in the U.S. Drug addiction is a moral issue, after all, and this is just coddling people who engage in immoral behavior. Drug addiction is nothing that a year or two in the jug won't cure, right?

Incompleteness

I hope I am paraphrasing Stephen Pinker correctly. In How the Mind Works, he proposes that the great conundrums of the nature and origin of consciousness, free will and moral responsibility, and the infinitely recursive problem of how we know anything might have solutions. . . . But, the solutions are forever inaccessible to humans because our brains have not evolved to comprehend the answers.

It's just good luck that brains that evolved to solve the problems of existence and reproduction on the African savanna, in the particular way ours did, are also equipped to undertake scientific inquiry, including studying human brains. The mechanistic problems of the neural processes that produce sensation and behavior are solvable by us, at least in principle. (Although they are enormously complex and we might not have the time and resources to get anything like a complete picture.) But why consciousness emerges -- why, for example, we experience pain instead of merely having a behavioral aversion to painful stimuli -- is not one our brains are equipped to solve.

As for the epistemological problem, we know the way we know because that's how we came to be. Whether our picture of the world is valid or accurate according to some other way of knowing, well, it's a silly question. If you are really just a brain floating in a vat and all your life is an illusion, so be it. Who cares? Certainly not you.

Religion survives in part because many people aren't satisfied with these dead ends and it feels as though religion supplies answers. Of course it doesn't. If God gave us consciousness, free will, and apprehension of the world, where did God come from and why and how did he do it? There's no answer there either, only censorship of thought.

As for me, I'll keep pondering the deep questions. You never know. I might think of something.

Some of my best friends are doctors . . .

But honestly, what is wrong with these people? These folks tried an intervention to improve infection control in ICUs. It didn't work, but it's not necessarily because it wasn't a good idea -- it's because the providers didn't follow the protocol.

In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts.

Now come on. Almost one third of the time they didn't even wash their hands after contact with a person who was believed to harbor antibiotic resistant bacteria! Yank their damn licenses. I don't know what else to do at this point. WTF?

For the first time ever, MoDo is not a waste of time

She took a day off from mocking Democratic politicians for being effeminate to tell you to speak up when you don't think doctors are being conscientious about infection control. Which, outrageously, they often are not.

Not only that, she diagnoses the real problem, which is the cultural authority of physicians, the deference people automatically pay to them, and maybe the fear that if we offend their hypersensitive egos they won't give us first class attention. It would be a huge win if people would just speak up if they aren't happy with what a doctor says, does, or doesn't do; aren't satisfied with an answer; or don't intend to do or are not doing what the doctor has prescribed. Go ahead and have those conversations. If physicians don't like it, they'll just have to get over it. It's their chance to explain to you what you didn't understand correctly, if that was the problem; or to come up with a recommendation that is acceptable to the physician and which you are also more inclined to follow, which is obviously better than what the physician thinks is a perfect recommendation to do something you aren't going to do. Everybody, including the doctor, will be happier in the end.

And, if they're screwing up, say by not washing their hands, they need to hear about it.

While we're on the subject of infection control, kind of, DON'T USE PRODUCTS CONTAINING TRICLOSAN! Madison Avenue types market all kinds of products, from soap to socks, that contain this antibacterial agent, by claiming, falsely, that it will protect you and your family from germs. Au contraire. It creates cross-resistance with antibiotics, and doesn't disinfect any better than ordinary soap. And -- according to a column in today's JAMA (off limits to the rabble, as usual), exposure to triclosan can actually be harmful to the immune system. Children exposed to high levels are apparently more likely to develop allergies and asthma. It also alters hormone regulation and may be a carcinogen. So don't use it! Ever!

Update: As commenters noted, the verdict in the case of Kristen LaBrie, who did not give her son prescribed chemotherapy, was guilty. First, it astonishes me that they could get 12 people to agree to this. She must have had really lousy representation. And I'm with my readers: the blame here is on a health care system that failed her and her son. The prosecutors have chosen to attack a victim. That's legal malpractice and a serious abuse of office, in my view.

Malicious Prosecution

I am just aghast at the actions of the Essex County, Massachusetts District Attorney who is prosecuting a mother for attempted murder because she failed to administer chemotherapy to her young son, who later died of lymphoma.

That probably sounds pretty awful but here are the facts. She was single, trying to cope by herself with the demanding caregiving regimen for a severely sick child. She observed that the chemotherapy made him much sicker, and she was afraid it would kill him. So she stopped it. She had no support, the doctors weren't communicating with her, she believed he was rid of the cancer, she had nobody to talk to or advise her, so she made a wrong decision. That's all. It's tragic but exactly who is to blame here?

Recently I've been educating myself about pediatric lymphatic cancers. Children who fail chemotherapy are given hematopoeitic stem cell transplants (HSCT) as a last resort therapy. (These are popularly called bone marrow transplants but that is imprecise. It is the stem cells that produce blood cells, not the marrow per se, that is infused.) First they destroy the child's stem cells, then they replace them with donor cells. This means the child's immune system is completely destroyed; it takes up to two years for it to fully reconstitute as the various types of white blood cells start to be produced one by one.

Meanwhile the child has to take a complex medication regimen, including, ironically, immunosuppressives to prevent the donor cells from attacking the child's own body (which is called graft versus host disease). Because the child is highly vulnerable to infection during this time, families have to take extraordinary precautions -- meticulous hygiene, excluding visitors with contagious diseases, limited contact with pets, no houseplants, no playing outdoors, no crowds -- which means no school, no birthday parties, no restaurants or baseball games or parades. The child faces strict dietary restrictions. Caregivers must be alert to any signs of infectious disease and contact doctors if they see any.

Now just imagine -- you've been trying to nurture and comfort this child who has been horribly ill, tortured with chemotherapy and all sorts of painful and terrifying procedures in a strange city (only a few hospitals in the country do these procedures) and a weird alien environment. You yourself have been desperately afraid of losing the child. Now you have to transform yourself into a drill sergeant, and deny the person you love most in the world most of what children desire. Grandma and Aunt Tilly may well have different ideas about what is best for the child. The siblings feel neglected and also deprived in many ways. The doctors are 500 miles away and you have no support.

I expect that something has to give. Complete adherence to these demands is just impossible. I don't know that people are likely to completely understand and remember all the rules anyway, but regardless, they will have to make decisions about what is most important and where they can make an exception or relax one of the rules. Maybe they decide that a certain medication isn't really necessary, or it's okay to go to the sleepover, or to Grandma's house. Whatever.

There is a very high rate of complications and sometimes the kids end up dying of the common cold. But you don't prosecute the mother.

A new bookmark

It's a busy day for me, so let me just turn you on to a good on-line magazine, Miller-McCune. I'm surprised I haven't heard about it sooner, and that it doesn't get more attention. In particular, if the Huffington Post health coverage makes you sick, the way it does me -- Ariana just loves her some of that voodoo -- their health and health care section is totally reality based and written for people who can think critically.

I particularly draw your attention to the work of Michael Scott Moore on drug control policy, and also here.

Check it out!

Trick Question

Quick, what country exports the largest amount of oil to the U.S.? (Hint: Most of them speak a version of English.) Yep, watch out for flying hockey pucks, it's Canada. But as my old friend Ellen Cantarow tells us, that stuff isn't exactly oil after all, it's bitumen, a corrosive, sticky, nasty substance obtained from the so-called tar sands. We're already importing almost a million barrels a day of this dreck, and the projection is more like 3.5 million barrels by 2025.

It has to be diluted with natural gas and pumped through pipelines at high pressure. It corrodes the pipelines and there have been spills -- including a big ugly one near Kalamazoo. They're building more pipelines to haul more of it. And it is very carbon inefficient -- with the energy needed for extraction and refining, about 50% more C02 winds up in the atmosphere than we get from using petroleum.

Wait there's more! Who is the biggest corporate player in this depravity? Koch Industries, which according to Ellen, handles 25% of imports to the U.S. and is one of the biggest U.S. refiners. Sweet!

I'm not going to talk about politics,

I'm not going to talk about politics, I'm not going to talk about politics. ...

Plenty of people are on the case, and anyway it's just gone beyond comment. Are we really talking seriously about repealing Medicare and Medicaid?

So, I'll bet you didn't know that today is World Health Day. Okay, that's kind of a made up thing, like National Pickle Week, but the WHO does it every year and this year, they've got an important theme, which is preserving the effectiveness of antibiotics.

You've probably heard about MRSA -- staphylococcus that is resistant to penicillin-like drugs. That problem concerns the so-called gram positive bacteria (named for a guy who invented a way of staining bacteria for viewing under a microscope). But there's another resistance problem affecting the gram-negative bacteria, called Klebsiella pneumoniae carbapenemases (KPC), which are enzymes produced by enterobacteria that confer resistance to all the beta lactam antibiotics, including penicillin-like drugs. This is a huge worry because gram negative bacteria exchange genes very readily, and because these organisms are often resistant to other antibiotics as well. Basically, we may soon be seeing a whole lot of untreatable infections.

WHO Director Margaret Chan isn't pulling any punches:

In the absence of urgent corrective and protective actions, the world is heading towards a post-antibiotic era, in which many common infections will no longer have a cure and, once again, kill unabated. The implications go beyond a resurgence of deadly infections to threaten many other life-saving and life-prolonging interventions, like cancer treatments, sophisticated surgical operations, and organ transplantations. With hospitals now the hotbeds for highly-resistant pathogens, such procedures become hazardous.

The actions we can, and must take are actually not all that hard, but they are urgent. Number one, most important, easiest to do in reality and apparently hardest to do politically, is top feeding antibiotics to livestock! Just outlaw it. Boom. Done. Of course this means that livestock will have to be raised more humanely, under less crowded and more hygienic conditions. It will take away our God-given right to fatten cattle and pigs while they wallow in their own feces, making the country a totalitarian dungeon. So be it.

Second, physicians must stop prescribing antibiotics inappropriately. This apparently will require some sort of intervention by payers, because they seem incapable of doing it on their own.

Third, everybody must get the message: don't ask for antibiotics, let your doctor decide if you really need them. If you do really need them, and you do start taking them, finish the entire course even though you already feel better. That is your duty to humanity.

Fourth, we need to improve infection control measures in hospitals and other health care settings. Equipment and facilities need to be designed so they are more readily cleanable. Microbes can obviously hide in every crack and crevice, so there mustn't be any. We have to get cleaner, make fewer holes in people, and enforce stricter policies on hospital visitation. Sorry.

Fifth, we can adopt better hygiene habits in our own lives. Keep washing those hands. But don't use those antibacterial cleaning products, the bugs just get resistant to them. Keep a clean house. Bleach and alcohol do disinfect and can't produce resistance, but they usually aren't really necessary.

Stay home if you're sick.

Do your part.

Well said, Dr. Ludwig!

JAMA truly annoys me by keeping the stuff behind the subscription wall that the general public really ought to read. (NEJM has heard my exhortations and fixed its policy.) I wish I could give you my password but I would be severely castigated, so here's a link to the first paragraph of David Ludwig's commentary, and I'll summarize the key points for you.

Back in the good old paleolithic, life might have been nasty, brutal and short, I don't know, but our ancestors actually ate pretty well, it seems. With the benefit of stone tools and fire, they were no longer limited to fruits and insects, but they could kill large animals, cook tubers and coarser parts of plants, and pretty much eat anything and everything. The agricultural revolution may have seemed like a good idea at the time, but it got people eating mostly grain which meant less protein and less of those great micronutrients from the other parts of plants, so people actually ate worse and got shorter. (There were other reasons for this as well -- check out Jared Diamond for a big discussion.

Comes now the Industrial Revolution and the advent of "ultraprocessed" foods. Ludwig gives the example of "Strawberry Splash Fruit Gushers," which "has only a trivial amount of strawberries (from concentrate)," but 7 kinds of sugar plus partially hydrogenated fat. Ultraprocessed foods ultimately derive almost entirely from corn, wheat and soy -- much of it processed through animals. It is high in energy density, low in fiber and micronutrients, has the wrong kind of fat, high glyemic index, and a lot of salt, sweetness and other flavorings to trick us into eating too much of it. E.g., 10 ounces of strawberries have 90 calories, 5 grams of fiber, vitamins, minerals, and all kinds of phytochemicals; 1 ounce of Strawberry Splash Fruit Gushers also has 90 calories, and basically none of that other stuff.

Eat that crap and you're likely to get fat, get diabetes, get heart disease, and die. But it's cheap, abundant, easy, heavily marketed, and addictive. So all of the above is happening to us.

I think I may have written about these issues one or two times previously, sorry if it gets old. But there are public policy responses to this disaster. One excellent start would even cut federal spending and reduce the deficit! That would be ending subsidies for corn and soybeans. Have I heard the Tea Party mention that one?

I didn't think so.

By coincidence . . .

PZ Myers posted a link to this cartoon which illustrates my post of April 1. Just thought I'd let you see that.

Let your congresscritters know

that you oppose cuts in the budget of the National Institutes of Health, which in case you didn't know the Republicans want to seriously trash. The Association of American Medical Colleges has made it easy, go here.

The more we know the less we do

This has got to be a trend. Last week it was prostate cancer screening, now coronary artery bypass grafts and pills for autism. Stuff we spend a lot of money on that doesn't work, that is.

Getting a "triple bypass" is almost seen as a rite of passage for older men, and of course parents want to do something for their autistic kids so they let doctors feed them pills, although there was never really any evidence for benefit. I've spent however many years on this blog primarily arguing that the biggest problem in medicine is that we do too much, and that we could go a long way toward solving a lot of problems -- including providing universal access, having more to spend on public health, and just plain being healthier -- if we could fix that. So is it harvest time for all like-minded people?

More of the necessary research and meta-analysis is being done, to be sure. But this isn't just an issue of knowledge. The affirmative evidence was never really there to support population-based prostate cancer screening, or CABG surgery, or feeding pills to kids with autism, or COX-2 inhibitors, or rosiglitazone, or ...

Instead, we did all that stuff because of the financial incentives, with a little bit of cultural proclivity thrown in. Getting more and better evidence is important, but we still need to reorganize our health care system to properly take advantage of the evidence we do have, and to avoid wasting money and doing harm.

But it's a conversation we aren't even having. Instead we're talking about repealing Medicare and replacing it with vouchers to buy private insurance. Which is insane. Our entire political discourse these days is insane, in fact. The most basic truths are no-where to be found, and nobody -- most egregiously, not the president -- is articulating them. This is a well educated society, by the way. I'll retire to Bedlam, as they say.

I told you so . . .

In a population based randomized controlled trial, "After 20 years of follow-up the rate of death from prostate cancer did not differ significantly between men in the screening group and those in the control group."

If you read my previous post, you know that "significantly" doesn't mean "significantly." The 95% confidence intervals for the screened and unscreened groups overlapped, but actually the most likely interpretation is that screening did result in a slightly lower risk of ultimately dying from prostate cancer, (although of course you'll still die of something!) "To prevent one death from cancer, 1,410 men would need to be screened and 48 treated." That means 47 men who got no benefit but who underwent surgery and/or radiation therapy and risked incontinence, erectile dysfunction, and bowel symptoms. And maybe even that single beneficiary who got a slightly longer lifespan is fictitious.

No thanks.

Here's some boring wonkery . . .

. . . to give you some relief from all the April foolishness.

Xin Sun and a cast of thousands reviewed 469 clinical trials reported in both high impact and lower impact journals. Okay, here's the wonkish part. It's actually kind of important and profound, in ways that go well beyond the current context. So I'm using this as an occasion to talk about a big issue.

It is conventional in clinical science to consider results to be valid when they have an associated "p value" of .05 or less, the jargon for which is "statistical significance." The term is misleading, in both directions. Findings with p values <.05 aren't necessarily "significant" in the sense that they actually matter; and "statistical insignificance" doesn't mean that an association doesn't exist, or is trivial, it just means you haven't established it to the satisfaction of an arbitrary convention. Most people misunderstand what a p value really means. It's usually interpreted as the probability that your result is not real, but arose just by chance. If the p value is less than .05, then you would say that there's a 95% chance your result is real. But that isn't what a p value means. It is the fallacy of the transposed conditional. The p value is actually the probability of getting your results given the hypothesis, in this case the null hypothesis that there is no real association. But, obviously if you make a lot of comparisons you'll see a lot of low p values that are spurious. The true probability that the drug is effective depends not only on the results of your study, but on the probability that the drug is effective based on what you knew before you did the study. If it is extremely unlikely -- say because there is no biological plausibility -- then a p value <.05 doesn't make it likely after all. It's probably just a coincidence. That's why, in order for p values to make sense, they have to be used to test plausible hypotheses that are specified before you undertake your trial. You always have a lot of information about clinical trial subjects, so even if the results of the trial are negative overall, you can comb through your data and look for "significant" results for some group that you didn't define ahead of time - say, women, or people of a certain age range, or people with a particular severity of disease, whatever you like. Chances are, you'll find some. And guess what -- people publish results of that kind. But they're basically BS. They might constitute hypotheses worth testing, but they aren't findings.

What Sun and the gang found is that when trials are funded by drug manufacturers, that did not have significant results for the pre-specified primary outcomes, they are much more likely to report sub-group analyses than trials that aren't funded by the manufacturer. What this means is that they are trying to find a way to sell their product, even though it apparently doesn't work, by inventing some specific category of person for whom they claim it does work, when in fact they don't have credible evidence for that conclusion.

Whoo. Sorry about that. Anyway, we need to do things differently. Industry funding of clinical trials must be totally isolated from the conduct and reporting of the trials, not just because of this finding but because of a vast record of deception, spin and scandals going back decades. There are probably several plausible ways to organize medical research to bring this about. We could establish a government sponsored institute to which the drug companies would transfer the funds for clinical trials. The institute would then accept competitive proposals from researchers, and award the funds to the most credible investigators, who would carry out the trial with no contact whatsoever from the interested parties.

Doesn't look exactly like the Free Market™ of conservative corporatist fantasy. But it would be a better world.

Can't anyone tell it like it is?

Here's an editorial in Nature, which bills itself as an international journal but is basically British, so it's probably best understood as a view from across the pond. From any distance, really, the United States right now is looking like the Land That Time Forgot, specifically in about, oh, 1372 or thereabouts. The proximate cause of the editors' growing contempt for our once great country is the Republican's witch hunt hearings on climate science of earlier this month, occasioned by an effort to prohibit the EPA from regulating emissions of greenhouse gases:

[T]he [proposed] legislation is fundamentally anti-science, just as the rhetoric that supports it is grounded in willful ignorance. One lawmaker last week described scientists as "elitist" and "arrogant" creatures who hide behind "discredited" institutions. Another propagated the myth that in the 1970s the scientific community warned of an imminent ice age. . . It is hard to escape the conclusion that the U.S. Congress has entered the intellectual wilderness. . . .

That's all fine, but then they just have to say this:

Fred Upton, the Michigan Republican who chairs the full Energy and Commerce Committee, once endorsed climate science, but last month said . . . that he is not convinced that greenhouse-gas emissions contribute to global warming. It was yet another blow to the shrinking minority of moderate centrists in both parties.

Is there something in the water? Or is there legislation I haven't heard about, that forbids anyone to criticize the delusional far right that has taken over one of the two major parties in the U.S. without pretending that somehow the Democratic Party has become a far-left mirror reflection? What would constitute "moderate centrism" on this issue? Agreeing that greenhouse gas emissions contribute to global warming, but only half as much as scientists say they do? And by the way, who exactly are those "moderate centrists" in the Republican party in the first place? Not a single Republican Senator -- not one -- will publicly state that human-caused emissions of greenhouse gases are causing dangerous climate change.

On the other hand, there are plenty of Democrats who are global warming skeptics, or who don't want to do anything about the problem. Update: Plenty of them. Presumably they aren't "moderate centrists," so what exactly are they?

Listen up, Nature editors. When one side is right on the facts, and the other side is wrong, there isn't any "moderate center." There is only truth and falsehood. Can we please, please, for all time abandon this idiotic fetish of "balance." It's killing us.

Drive-by posting

I'm in Baltimore, where I've been at a training all day (as an observer, not a participant -- it's part of a study I'm doing). I have maybe some half-way serious issues to write about so I want to do it correctly, and I don't have time right now. So, just for the heck of it, here's a weird government funding opportunity I came across. Anybody care to apply? Anybody see any worrisome implications here?

Defense Advanced Research Projects Agency: Chronicle of Lineage Indicative of Origins (CLIO). DARPA is seeking innovative research proposals that will reduce biosecurity restriction on genetic engineering and synthetic biology research by ensuring biosafety and biosecurity at the level of the pathogen (rather than a research facility). The CLIO program specifically seeks to enhance biological security and the protection of genomic intellectual property in the global biocommodities community by developing safe and secure systems for encoding non-hereditary events into the genome of viruses and prokaryotes. The funding is intended to establish the technical precedence for the use of genomic, epigenic or biophysical taggant systems to record information and potentially to report on environmental events during research or commercial activites.

Deadline: Abstracts due 4:00PM ET, April 21, 2011; Proposals due 4:00PM ET, May 25, 2011

Andy Rooney has always been pointless . . .

But here he does a public service by embodying a ubiquitous form of willful obtuseness. Rooney thinks he should ignore all the advice we hear about healthy diets because "they" keep changing their minds and he's always ignored them anyway and he isn't dead.

If I were you, I wouldn't even bother clicking the link because his essay is so banal, but it's good form to offer it. How this clown earns a salary is incomprehensible. Anyway . . .

"They" have refined "their" understanding of human nutrition over the years, just as our understanding of every area of biomedical science has advanced. But the only really major change that I can think of as far as dietary advice is that "they" used to emphasize a low fat diet, and it's now clear that the issue is not really how much fat you eat, but what kind of fat. Unsaturated cis-fats are good to include in your diet, because they slake hunger without causing a glycemic spike and can actually improve your blood lipid profile. Other than that, "they" have been recommending fruits and vegetables, legumes, whole grains, and if you must, lean meat since I was a child.

There have been two major sources of confusion. First, the official FDA recommendations were heavily influenced by lobbyists for decades, so they were somewhat unclear and they leaned against much of the scientific wisdom by promoting meat and being overly tolerant of junk food. In the latest incarnation, that has been fixed.

Second, there were a lot of hypotheses about the health benefits of nutritional supplements, particularly anti-oxidant vitamins, which have not panned out. So don't bother with the vitamin pills as long as you haven't been diagnosed with a deficiency. (Vitamin D supplementation is still controversial though it's looking less and less like a good idea for most people. Folic acid supplementation is a good idea for pregnant women who don't eat a lot of veggies, but it's now added to wheat flour so you're already probably getting it.)

Rooney may do a public service by providing the platonic ideal of an idiot, but he does a disservice if anybody is foolish enough to pay attention to him. Sugary drinks are a plague upon the land, shortening our children's lives and promoting an epidemic of diabetes that is starting to overwhelm the health care system. This is a public health disaster compared to which radiation releases are utterly trivial. Andy Rooney should be ashamed of himself.

Elementary, my dear Watson

As you know if you've been paying attention, it turns out that the really difficult tasks for artificial intelligence aren't the ones that people think of as the provenance of human geniuses, such as playing championship chess or proving mathematical theorems. It's the ordinary stuff we do every day, such as building a picture of the world around us from the photons hitting our eyeballs, or understanding how to obtain a double tall latte in a strange city (or even a familiar one) that are horrifically difficult.

It turns out the philanthropists [Hah!] at IBM aren't the only people trying to build a database of real world knowledge for the benefit of our future computer overlords. The MIT media lab is doing it too, and they're asking the world to play. If you go to the Open Mind web site, you can contribute to the common sense database yourself. That may or may not interest you, but seeing what kinds of statements constitute the body of real world knowledge, and comprehending how vast is your own store of commonplace facts, will (perhaps) be something of an eye opener.

The quantity of information and the processing power stuffed between your ears is just unbelievable. Check it out, you might have fun.

That said . . .

Yes,the Fukushima nuclear reactor complex has been spraying radioactive particles into the atmosphere and as a result they are destroying a lot of produce and the people in Tokyo aren't drinking the water. That's bad news to be sure -- although the fact is if you did eat the spinach or drink the water nothing bad would happen. If it all stayed as radioactive as it is now, or maybe got a bit worse, which it probably will, then if you kept on eating and drinking for a while you would eventually increase your risk for cancer and possibly other health problems. But it would take a lot more radioactive contamination over quite a long time for this to have a major public health impact.

But while people are freaking out over this rare though certainly disturbing occurrence, coal fired power plants are spewing non-radioactive (or more accurately, scarcely radioactive) particulates all the time. And they kill people! So does motor vehicle exhaust. As a matter of fact, it is estimated that air pollution contributes to 2.5% of all deaths in the high income countries. You can look at all the global health risks here. (Warning: pretty big PDF, from the World Health Organization.) Radioactivity isn't anywhere on there, and it still won't be even after recent events. It's just trivial.

Coal -- from mining it, but mostly from burning it -- kills people by the tens of thousands every year. So does petroleum. (You will be interested to know that the most important health consequences of fine particulate pollution are heart disease and stroke, not pulmonary consequences or cancer as you might imagine.) But this is all just totally fine. Nobody is freaking out about it. Y'all just go on breathing the air like nothing is happening.

Y'all are nuts, basically.

The Horse's Mouth

In the case of the present unpleasantness in Japan, that would be (what else?) the Bulletin of the Atomic Scientists. They have conveniently posted links to all of their Fukushima coverage on one page.

These are people who know what the heck they are talking about, think rigorously, write in a cautious and dispassionate voice, and are seeking the truth, not setting out to prove a preconceived conclusion. They don't necessarily come into this as nuclear power abolitionists, but they are all realists. And one reality is that government and industry have been relentlessly lying to the people about radiation safety since the Manhattan Project. Here's Barbara Rose Johnston:

During the Cold War, scientific findings on health effects to nuclear fallout that contradicted the official narrative were typically censored. Scientists were not only punished for their work, they were also blacklisted -- one example of this was American anthropologist Earle Reynolds whose work for the Atomic Bomb Casualty Commission was censored in 1953 by the US government. His research showed that Japanese children who were exposed to fallout were not only smaller than their counterparts, but had less resistance to disease in general and were more susceptible to cancer, especially leukemia. The consequences of this censored history was examined in 1994 by the US Advisory Commission on Human Radiation Experimentation, which concluded that the radiation health literature of the Cold War years was a heavily sanitized and scripted version meant to reassure and pacify public protests while achieving military and economic agendas.

She notes that the "hydrogen gas" TEPCO reported venting from the damaged reactors in fact included radioactive tritium.

There are many other strong essays there. If you want to understand these issues better -- the Fukushima situation specifically, and the broader issues surrounding nuclear power -- check it out.

You don't have to take it from me

I thought Time magazine was extinct, but no, they're still around, and apparently, worth something. Michael Grunwald:

Since 2008, proposed reactors have been quietly scrapped or suspended in at least nine states — not by safety concerns or hippie sit-ins but by financial realities. Other projects have been delayed as cost estimates have tripled toward $10 billion a reactor, and ratings agencies have downgraded utilities with atomic ambitions. Nuclear Energy Institute vice president Richard Myers notes that the "unrealistic" renaissance hype has come from the industry's friends, not the industry itself. "Even before this happened, short-term market conditions were bleak," he tells TIME.

Around the world, governments (led by China, with Russia a distant second) are financing 65 new reactors through more explicit nuclear socialism. But private capital still considers atomic energy radioactive, gravitating instead toward natural gas and renewables, whose costs are dropping fast. Nuclear power is expanding only in places where taxpayers and ratepayers can be compelled to foot the bill.

Okay, so why is nuclear socialism so popular, particularly with Republican free market fundamentalist radical libertarians who think Barack Obama (who also happens to just love nuclear power) is a Communist?

Of course, Obama is great buddies with the CEO of General Electric. I'm sure the Nuclear Energy Institute has some money to spend on bribing politicians, but I doubt they're a major player on K Street. There's something more primal about this, I think. Back in the day, it was cannabis-saturated hippies, not Wall Street investment bankers, who were emblematic of the anti-nuclear movement, and I think the resonance of past culture wars is still with us. Nuclear power also has a kind of machismo, a testosterone scent of technical hubris. But above all, it offers a tempting escape from harder choices that we need to make.

Many have argued that a renewable energy regime will be less centralized and more democratic -- you can own your own solar panels, conservation can put money in your own little pocket, mass transit is a great equalizer, and other arguments along similar lines. Nuclear power is the most capital intensive technology imaginable, and it can only exist within a pervasive security state. Some people actually like that, on purely aesthetic grounds.

The alternatives also require investment, but a a different kind of investment, to be sure. The research and development will be expensive, but the dissemination of renewable energy and conservation technology can happen in small packages -- as I say, you may be able to buy your own -- while the expensive packages, such as mass transit, represent universally accessible public goods. And it's a benefit to live near a train station. Yes in my back yard, please!

Why we can't just do this is incomprehensible.

Prescient Ignorance

Andrew Bacevich hasn't made a blog post since April 30, 2010. But if you read it, you'll think he made it today, until you get close to the end. He declares,

The problem with the clichés of the Information Age is that they are entirely bogus. Worse than bogus: They are pernicious. All the yapping about our supposedly fast, flat, and wired world fosters bizarre expectations. Computers, we are told, possess and confer power. Out of power comes mastery.

Don’t believe it. The fact of the matter is this: We live in a world characterized not by ever-greater speed but by never-ending surprise. No one—not the pope, the president, or even a fast-world guru like Thomas Friedman—knows what’s going to happen next. Those who pretend otherwise are frauds.

The Information Age has not notably enhanced our ability either to anticipate the future or to respond to the problems that catch us when we are looking the other way.

It turns out these musings were not inspired by any of the shit which has hit the fan in the past couple of weeks, but by the oil well blowout in the Gulf of Mexico. Remember that?

So. I can understand how folks got all excited and happy about the prospect of people power deposing the supremely odious Muamar G/K/Qadd[h/~h]afi; and how they got a sick feeling when it looked like he was going to successfully slaughter his way to a secure future of despotism. So I guess they figured they had to do something. On the other hand, they didn't feel like they had to do something about, say, Robert Mugabe or Laurent Gbagbo. Or the 3 million little kids who die of hunger every year.

Not that it has anything to do with that black goo under the sand. Oh no no, of course not.

But even stipulating the righteousness of the motivation, is this really such a great idea? Nobody has the slightest idea how it will turn out, and in fact nobody really has a plan. I can imagine a lot more unpleasant outcomes than pleasant ones, frankly, and although I'm by no means an expert on Libya I haven't come across anybody who is an expert who even tries to convince us otherwise.

And that's more or less where we stand in general today. We're at a historic moment that feels like -- well, a tsunami. Vast currents are pouring out of their banks, sweeping all before them and cutting new channels that lead no-one knows where. It all has, one way or another, to do with the fossil-fueled industrial age hitting its limits. Just about everyone claims to have their own personal crystal ball, and is happy to tell us what's coming and what to do about it.

I'm just foolish enough to be humble.

The Nationtwit is on your . . .

I was contemplating whether to buy my insurance from a lizard, a duck, a beagle, or one of the world's two most annoying humans -- a harsh and barren choice, to be sure -- when word came that the duck had been fired for making tasteless jokes about the unfortunate Japanese people. So naturally I was moved to deep sympathy for the most unfortunate Japanese insurance industry.

Not to worry, as it turns out. In the first place Japan, like the U.S., has a distinctive form of anti-socialism or whatever you want to call it for the nuclear power industry. "Under the Japanese Nuclear Act of 1961, operators of nuclear plants are not liable for any damage resulting from a "grave natural disaster of an exceptional nature." So if you or your loved ones get irradiated, or your property is rendered uninhabitable for a thousand years, tough shit. In the U.S., liability for nuclear power plant catastrophes is limited to $12.6 billion, beyond which the federal government is responsible.

Most Japanese have government-sponsored earthquake insurance as well, and total liability -- for both public and private insurers -- is capped. Beyond $60 billion in total claims, people get only partial compensation. Obviously, that doesn't come close to the total cost of this disaster.

In the U.S., floods are more common and more costly than earthquakes, so guess what? In places where you can't get flood insurance on the private market, the government will sell it to you, cheap. The result is a whole lot of development in places where there shouldn't be any, and we all pay for it.

Still, private insurance executives worldwide, even though they aren't complaining out loud about the Koch brothers and Senator Inhofe, know damn well that climate change is happening and that it's increasing their risks. One more reason you know Republicans and teabaggers don't actually care about the deficit is because they deny anthropogenic climate change, which is going to cost the National Flood Insurance Program oodles of dough -- actually it has already -- among other large costs to the federal budget.

As I have said recently, the public health consequences of nuclear power, even given what is happening right now, are actually pretty minor compared with the cost of fossil fuel burning. I expect I'll have more to say about that. Nevertheless, nuclear power is not economically viable without major distortions in the market created by government fiat. Building in flood prone areas is also encouraged by policy in the U.S. and Japan, for no defensible reason that I can see. There's a political dynamic here that cries out for examination.

The Red Mountain State?

Vermont and New Hampshire are identical, but totally opposite states. While the New Hampshire legislature is working on a constitutional amendment to ban income taxes, repealing same sex marriage, and, here's a list of all the craziness in wingnutistan, which includes having New Hampshire raise it's own army* --

The hippies next door in Vermont hired some pointy-headed libruls from that commie university on the Charles to figure out the best way for them to save money on health care and cover everybody. After doing some of that satanic science stuff, they decided that Vermont should have a single-payer health care system, just like the hoseheads to the north. They'd only save 25% in costs over 10 years, create thousands of new jobs, and give 100% of the people good quality health insurance. Obviously, Vermont will become a totalitarian dungeon.

* How do you know the toothbrush was invented in New Hampshire? Otherwise, it would be called the teeth brush.

Que será, será

I've discussed here more than a few times the problem of low probability, high impact events. To be more precise, we are often talking about events that are nearly certain to occur, but at unpredictable times that might be far in the future. It also so happens that without even trying, I've learned a little bit in the past few days about U.S. Pacific coast geology.

It seems the Cascadia fault runs offshore near Washington and Oregon, much like the fault that just broke near northern Honshu. It is right now a little bit past the historically average interval for a major rupture, which would likely produce a tsunami. Fact.

So what should be done? I use the passive voice advisedly because the first problem is thinking of who it might be who might do something. Suppose the governor of Washington, Christine Gregoire, decided to write to everybody who resides, owns a business, or owns property near the Washington coast, and that would include Seattle. She might say something like, "You should know that geologists believe it is likely that sometime in the next 100 years or so, an earthquake and tsunami will devastate a large stretch of coastline in Washington and/or Oregon. It might happen tomorrow, it might happen long after you are dead. It might hit right where you are, or it might be centered far enough away to affect you less severely. But everything in the path of the tsunami will be destroyed and anyone who fails to evacuate (and you might have, at most, 30 minutes warning) will die. So, do whatever you think is wise."

She would become an Enemy of the People. She would be universally excoriated for sowing panic, damaging property values, giving little children nightmares, and probably being nuts. But, all this does happen to be true. Yet, obviously, nobody is going to do anything about it. Yes, they have toughened building codes so new construction in the area is more earthquake resistant, but as we have seen, absolutely nothing can be made tsunami resistant. When you are all of a sudden in the middle of the ocean, that's just not a place your house and minivan can be.

People are not going to abandon their communities, and they certainly aren't going to abandon Seattle. So, there you have it. And by the way, Mt. Vesuvius will probably destroy Naples. Some day. Maybe tomorrow. Too bad, huh?

What not to do in a crisis

Number one: Do not withhold information from the public, and above all don't just tell people not to panic, or not to worry, without fully and openly explaining exactly what is happening, including what you don't know.

People generally speaking do not panic in an emergency. Obviously if you're in a building that's on fire there can be a stampede to get out, but that isn't the situation in Japan. People actually have been told to evacuate from a large area, and to remain indoors in an even larger area, and that hasn't caused any counterproductive behavior, as far as I know. What does cause fear and anger is the reactor operator not telling us what the situation is. All sorts of rumors and speculation are flying around the world, but we don't exactly know the truth.

Naturally, that leads everybody to suspect that the most dire possible scenario is the truth. Maybe it is. If so they need to tell us. That would be a ruptured pressure vessel in at least one of the reactors, and possibly a breached containment structure as well, inability to keep water on the core, and ongoing fuel damage and melting with a high probability of a full core meltdown and breach of the containment. Is that happening? Is it possible? I do not know. That is worse than knowing that it is true, if it is true. If it is not true, why don't they say so and tell us what is true?

It's long past time.

Update: And Robert Alvarez gives us one more thing to worry about, the spent fuel stored at the site. Again, they need to answer this. What exactly is going on?

Things fall apart

There is just too much going on right now. It's impossible to know what is most consequential, what short term outcomes will ensue, and what good or bad will result for the long term. This is not a time for confident prediction, and while we are always drowned in data-free analysis by non-experts, this would be a particularly propitious time for most pundits to shut up.

One of the few certainties about the world is that our actions have unintended, unforeseen, and largely unforeseeable consequences. With hindsight, they always appear foreseeable, but that's a fallacy that ought to have a name. (Maybe it does.) Japanese engineers and regulatory authorities protected their nuclear reactors with seawalls high enough for the tsunami that might be expected from a magnitude 8 earthquake, but they got a magnitude 8.9. They assumed a magnitude 8.9 earthquake was impossible because otherwise, it would not have been feasible to put the plants where they wanted to put them.

Dick Cheney and Ronald Dumsfeld (oh, did I just make a typo?) assumed that all they had to do was kick over the Baathist regime in Iraq and goodness would flower, because if they made any other assumption, they would have needed a plan for what the heck to do next and they didn't have one, but they really wanted to invade Iraq.

I really want K/G/Q/[h/~h]addafi [okay, you decide how to spell it] to be standing in the dock in The Hague while Libyans create a secular democracy, but I sure as hell don't know whether that is even possible, let alone the best way for the U.S. to help make it happen. I don't know what's going to happen with the damaged nuclear reactors in Japan, and I don't know what the consequences will be politically for nuclear power there and elsewhere. I know I want the U.S. and the world to dramatically reduce use of fossil fuels, but I'm also really not sure whether nuclear power -- perhaps in the form of a safer basic design, which does exist -- can or should be part of the path. It may well be counterproductive even granted acceptable safety, because of the enormous investment of fossil fuels required to build nuclear plants, the encouragement of energy-intensive and capital-intensive, centralized economic structures that they promote, and the diversion of political energy into the inevitable debates around them.

I could go on. But the point is, we all need to work very hard these days to generate more light and less heat. We need to be humble about what we actually know, not get dug into positions that seem right at the moment, and try to create a public discourse that's more about working together to find the right conclusion than yelling at each other until we get our way.

That doesn't mean I'm advocating for "civility" or "centrism" or "bipartisanship." Not at all. Sometimes my values are offended, and sometimes people just have the facts wrong. I'll say so, in no uncertain terms, when that is clear to me. My point is, there's a whole lot I don't know and it behooves us all to keep that in mind. Most of the professional gasbags, most of the time, don't know what the hell they are talking about, but they are paid to sound authoritative, or to engage in mindless shouting matches, because that seems to be the cultural norm. We need to get over it.

Nukular Follies

See Update Below

See second update

One way I misspent my youth was by working for Ralph Nader's Critical Mass Energy Project (in a very lowly role). I helped to organize the Critical Mass '78 conference, where I had a chance to meet Hazel Henderson and to hear Ted Kennedy and Rep. Leo Ryan speak. Ryan was murdered just a few months later by followers of Jim Jones, in Guyana. So I took that kind of personally. Then I helped to organize the huge march on Washington following the Three Mile Island debacle. Along the way I learned quite a lot about nuclear power and the issues surrounding it.

I haven't had much to do with energy policy since then, at least not professionally, but I haven't forgotten anything. Accordingly, the truly crappy job your corporate media are doing explaining the situation with the reactors in Japan is really frosting my pumpkin.

These are good old fashioned boiling water reactors, the same kind as TMI and the standard model back in the day. I heard an "expert" on CNN claiming that the control rods had gone in as soon as the earthquake alarm sounded, so there was no danger of a core melt down. Not even close. The control rods stop the fission chain reaction involving U-235 which is the main way the reactor produces power (i.e. heat). However, the problem comes from other, much shorter lived but therefore much more highly radioactive species that are created as a byproduct of the U-235 chain reaction. If the cooling system fails, which is what has happened, the heat produced by the decay of these isotopes builds up until the entire mass of fuel melts its way through the pressure vessel and lands on the floor of the concrete containment structure. (I use the present tense, but this has never actually happened yet. It's hypothetical.) From there, if it eats through the containment, it could hit groundwater, resulting in a steam explosion and widespread dispersal of radioactive particles, or simply migrate in groundwater or otherwise get to all kinds of places.

The Japanese engineers, having evidently lost all of their designed options to cool the cores at two reactors, are using seawater. It is not clear how they are doing this or if radioactive water is being discharged back to the ocean, but in any case, as you know, seawater is corrosive and will destroy the pumps and pipes in due course. So it seems pretty desperate.

A Chernobyl type event cannot occur with these reactors. Chernobyl was graphite moderated and the graphite caught fire, which is what produced such wide dispersal of radioactivity. It's quite unlikely that a high level of contamination will spread very far. However, these reactors are now totally destroyed. In addition to the dead loss of the power plants -- which cost billions -- clean up costs will be enormous, as is the cost of the necessary evacuation, which will likely have to be enforced for a long time.

There are many objections to large-scale use of nuclear power, but unfortunately, in my view, the politics of the issue have focused almost entirely on concerns about safety, mostly championed by NIMBY constituencies. The risk of a large scale public health catastrophe is quite low, and we accept an ongoing but 100% certain catastrophe from burning fossil fuels with seeming equanimity. However, nuclear power is not a good bet economically, because individual plants are extremely costly -- as they must be to be acceptably safe -- and when things go wrong, they can go very wrong. And, when their useful life is over, even if they get there safely, they cost a fortune to clean up.

Therefore, investors won't pay for them without government subsidies in the form of liability limits and cheap insurance, tax incentives, and dumping the cost of decommissioning and part of security onto the public, whether as ratepayers down the road, or taxpayers today. As much as we all would like a painless way out of the environmental crisis caused by our fossil fuel based economy, nuclear power ain't it.

Update: First, a bit more information. Apparently what they are doing is pouring in seawater and then venting the steam. This would obviously result in a low-level, but continuous release of radioactive particles to the atmosphere. That does appear to be what we are seeing. Although the authorities continually downplay this, it's certainly not good. So far the wind has been carrying the plume out to sea, where a U.S. navy task force encountered it, causing them to leave the area. When the wind shifts onshore, it will waft over the land.

The public health and moral issue here is complicated. The consensus belief is that there is no safe level of ionizing radiation -- we are all exposed to ionizing radiation all the time, but slightly more means a slightly higher life-long risk of cancer. On the other hand, although I don't know precisely what degree of contamination we're talking about from the current situation, for people living nearby this is probably less than the risk people experience from living near a major highway. On the other hand they didn't know about it when they decided to live there. It is troublesome that they don't seem to have a plan B. If they have to keep pumping in seawater and venting the steam, this could continue for months, until the hot isotopes cool down enough.

But, the situation could certainly get worse. They are now admitting that there have been partial core melts in at least two, and probably three reactors. If the pressure vessels are damaged, and a pressure vessel is ultimately breached, they have much bigger problems. That would mean there is no way to keep the core immersed in coolant and you'll have a mass of molten material on the floor of the containment. From there, more substantial releases of radiation would be probable. So this is a big mess.

On the subject of corporate media idiocy, I switched on CNN yesterday afternoon to get an update on the situation. Don Lemon was interviewing a doofus in a bow tie. Don said, "And here's Bill Nye, who you probably know as a science guy." Then he asked the doofus to explain what a meltdown means.

The guy said -- I can't quote exactly but the substance is guaranteed 100% accurate -- that uranium is really heavy, it's the heaviest naturally occurring element. When you get U-235 in a certain configuration (really, that's as specific as he got) it gets really hot. So it's really heavy and therefore when it melts it goes down. That was the answer of the science guy.

To reiterate, a reactor core meltdown is not caused by the uranium. Uranium -- no matter how highly enriched with U-235 -- is only very slightly radioactive. You could actually carry a piece of it around in your pocket and it would be minimally dangerous. It doesn't get hot. It is a fission chain reaction that generates heat, and that has been shut down. The heat is generated by other radioactive isotopes which contaminate the fuel as a byproduct of fission.

So the Science Guy is an ignorant idiot who hasn't the slightest idea what he is talking about. Why on earth such a fool gets such a platform is incomprehensible.

Update 2: Apparently the pressure vessel in one of the reactors is leaking. That is a very serious situation. Stay tuned.

Krugman is once again shrill

It's a habit with the guy. Apart from noting that it's obvious he's been reading Stayin' Alive or otherwise why would he think the same way I do, let me give you my value added.

The Republicans -- and Krugman singles out Huckabee as a paradigmatic example, which is a good choice -- have done a profound disservice to the country, and especially to our children, in their cynical and dishonest tactics to win the votes of old folks. They positioned themselves as the defenders of Medicare and patients' rights by saying that end of life counseling and comparative effectiveness research are a disguise for "death panels" that will judge the lives of the sick and old not worth preserving; and by labeling policies to promote effective, evidence based and efficient medical care as a "government takeover" that will put "bureaucrats between you and your doctor." They don't actually believe any of this, and what they really want to do is simply to cut Medicare and Medicaid benefits without doing anything to get more benefit from the remaining resources. They are the ones who really want to murder your grandmother.

So what we have is the inversion of reality. Unfortunately, the "journalists" who talk about these issues on teevee don't understand them and do absolutely nothing to sort out the truth. Even worse, as Krugman appropriately tells us, Democratic leaders, including the president, don't even try. They just accept the underlying premises of Republican disinformation but make a half-hearted effort to resist their conclusions.

As Jerome Kassirer writes in this weeks BMJ, in this case discussing the FDA (subscription only, here's the lede:

And here may be the most serious problem of all -- namely, the failure of many to appreciate and understand the rigors of science. Too few people trained in science are serving in state and national legislatures. Too few judges are adequately versed in science. Too many people believe that science is just another belief system. Too many regard evolution as a theory, believe in creationism, and reject the evidence that global warming may [sic] be of human origin.

The assault on FDA practices is falling on the susceptible ears of those who believe that economics should rule major decisions; that what is good for the prescription drug business is good for patients; and that public perceptions and company marketing decisions yield self-correcting errors and so serve to eliminate faulty products. Such notions are a callous deception.

In fact, business is amoral, and when it dominates, people can get hurt.

Indeed. There is a conspiracy behind the assault on science and reason. It is a conspiracy of obscenely wealthy psychopaths whose only purpose in life is greed. They spend a part of their fortune to poison our political discourse with ignorance and lies, and Mike Huckabee is their servant. Huck, there's nothing Christian about that.

Makes sense to me

I won't bore you with a lengthy recitation of what's wrong with the drug development process. If you've been reading Stayin' Alive for very long you've heard all about it. Basically, drug companies want to make money, and the way they do that is by getting patents and marketing exclusivity which lets them charge big bucks for pills that cost a couple of cents to make. On the other hand, it costs a lot to get a drug approved, so they aren't nearly as interested in products that they only sell you once -- ones that actually cure your problem -- as they are in products that you have to keep taking forever. And how serious your problem is pretty much doesn't matter -- baldness is just as profitable as multiple sclerosis.

The results are that poor people -- which means most of the people on planet earth -- can't afford drugs that could save their lives; badly needed drugs, such as new antibiotics, get little investment; and drug companies pour a lot of their revenue into marketing for drugs for diseases that probably don't even exist, or brand name drugs that are no better than cheap generics.

Joseph Stiglitz (the dirty commie) has an idea. The government already pays gazillions of dollars for brand name drugs. Instead of rewarding drug companies with patents, why not just hand them the money up front, and then make them sell the drugs cheaply? The amount of money they get depends on priorities set by criteria of public need. So there would be a big prize for a new class of antibiotics, or really effective treatments for autoimmune diseases. (A cure for type 1 diabetes anyone?) and much smaller prizes for baldness and restless leg syndrome.

This could be completely spending neutral -- the money the government spends now to buy brand name drugs could be diverted to the prize fund. Neither Stiglitz nor I nor anyone has actually done a formal analysis, and maybe it isn't really possible to figure out ahead of time, but I'd be willing to bet that you could actually spend less and get a better public payoff than we're getting now from drug development. And even better, the drugs would be cheap for everyone, including people in poor countries. The world would become more egalitarian, at no cost to either the federal treasury or the pace of new drug development. The companies incentives to invest could be made exactly the same in magnitude, but directed toward more socially productive ends.

Easy! Sensible! Contradicts free market fundamentalism! Not going to happen!

An epistemologically dangerous man

That would be Mike Huckabee. I don't know if he really has any chance to become president, but he obviously thinks he does. It will be bad enough if he becomes the nominee of a major party and his world view becomes further legitimized in our political discourse.

You have no doubt heard about his fictitious biography of Barack Obama. In Huckabee's alternate universe, Obama grew up in Kenya, raised by his father and grandfather who taught him to hate the British. This was not a "gaffe" and it did not cost him any support among his target population. Here's why.

Huckabee has often said that the country wants someone like him, because he is a "vertical thinker." Follow the link to learn more about vertical thinking, but here's what it means in a nutshell.

I'm a horizontal thinker. Horizontal thinking is the procedure of science. We observe the world and based on what we see, we create theories to explain associations and causes. Then we test those theories, using experiments or further observations to see if they continue to explain what we see, or if they need to be corrected, augmented, or replaced. We keep going around and around like that until we understand more and more about the universe -- and we also find ourselves rewarded with ever more and more mysteries to solve. It's fun, but it's also scary and disorienting as we keep finding out that we used to believe is wrong.

Vertical thinking goes like this. The truth has been revealed. You already know it. So you just have to fit whatever you observe into your framework. If it doesn't fit, you didn't really see it. If you are a Christian fundamentalist, like Huckabee, that means that cosmology, biology, geology, and climatology are all false, because the Bible has already explained all that stuff and that sciency stuff doesn't fit. QED.

The alternate universe Obama biography was generated by the same process. Dinesh D'Souza had revealed the truth about Obama, that he hates America because of his African ancestry. That doesn't actually make any sense if you know that he met his father only once. In fact he wrote a whole book about not knowing his father. He actually grew up in Hawaii, raised mostly by his white grandparents, and in Indonesia, with his white mother and Indonesian step-father. Indonesia, by the way, in case you didn't know, is a former colony of The Netherlands. That biography doesn't fit with the vertical thinking, so another was required. QED.

So it isn't just that I don't like Mike Huckabee's policy proposals. I don't like his mind, at the most fundamental level. The 12th Century is so over.

My back pages

As I believe I have mentioned here, I am in the process of moving out of my home of 25 years. This is a bit painful, but it's a healthy process as well. Perhaps we should all turn our lives upside down and shake them out every once in a while.

I had two file cabinets, a couple of those old fashioned milk crates, and some shelf space full of papers: everything from old school work, including materials I had collected for my master's thesis and my dissertation but also going back to undergraduate days; to files from my consulting business that got me through grad school; to my repeated, always short-lived attempts to keep a journal (blogger has at long last allowed me to conquer that block, but writing for public consumption is very different); to clippings and articles I collected on subjects that happened to interest me, from the Iraq Weapons of Mass Destruction™ hoax to Ted Kaczynski's manifesto; to my old letters. Yes, people used to correspond by writing out fairly substantial essays on paper and mailing them to each other.

Probably the biggest revelation is how much of my life I had forgotten. I often could not place events in the journals and letters. Did that person really spend a year in Phoenix taking care of her mother during which we had an elaborate correspondence? I have no memory of that whatsoever. It's probably just as well that I've forgotten many of the preoccupations of my tortured youth. I embarrassed myself reading some of the old junk. It's enough to know that I have managed to grow up, at least partially, and that quite literally, I am no longer the person I once was.

I wound up tossing 90% of it. The lost autobiography is no big tragedy. If I do ever write one, it will be largely imagined memory and self-justification, like most of them. But there are a few themes that define what I held on to, persisting interests that I am glad to have discovered as consistent themes in my intellectual life.

The most succinct statement I can make, that encompasses much of what preoccupies me, is the problem of human progress. We're absurdly smart animals, but are we too smart for our own good? The prevailing view is that obviously we're better off than our primitive ancestors. We learned to sow and to reap, to build warm dry houses, to weave strong supple fabrics, to cure disease, to speak with people thousands of miles away, to fly. We have discovered the universe and the secret of life. We are the crown of creation, and we ought to be damn happy about it.

But, it's not so simple. We've bought a lot of pain and trouble for our triumphs, and we may be feeling smug only because we're in a little bubble of time and space that feels just right for a lot of the people who have the leisure to create the zeitgeist. How to turn intelligence into wisdom is the essential problem I continue to pursue. It has been said that we are too soon old and too late smart. Maybe that applies to us as a species as well.

The Big Three

One reason religion is appealing, obviously, that it offers some consolation. The fact of an indifferent universe, the finality of death, the inconsequentiality of humanity in the vast darkness -- it's just too hard.

But people are also unsatisfied with the limitations of science. We don't have all the answers, and some people feel compelled to fill in the blanks. There are an infinity of questions we haven't answered, big and small, which is what keeps science in business, but there are three that most people find uniquely consequential and difficult, each in its own way.

These are the nature and genesis of consciousness; the origin of life; and why we find ourselves in this particular universe. The latter is a two part question: Why does the universe exist at all? And why does it happen to have its particular history and properties?

The problem of the origin of life is difficult in a simpler way, if you will. It isn't metaphysically challenging, it's just an ordinary puzzle. We may never know for sure how it got started because it was just so long ago, but we may well come up with highly plausible scenarios that we can reproduce. It doesn't pose any fundamental challenge to the philosophy of science.

Consciousness is a deeper problem, however, because the only person who can observe your consciousness is you. People say that they have something they call conscious experience, and that it is absolutely compelling that it is a stuff, a reality, an entity, that transcends the material. We see red and green, we feel hot and cold, happy and sad, love and anger -- and these are tangible, somehow real in a way that is far beyond the observations others can make of the link between sensory inputs and behavioral outputs. Something essential happens in between that cannot be measured or observed by anyone else. That challenges the fundamental philosophy of science.

The problem of the origin of the universe may be insoluble in principle, because if the universe is defined as everything observable, then either something outside of it accounts for its existence, meaning we can never observe it; or we confront an infinite regress, in which every solution is a new puzzle to be explained.

As far as I'm concerned, none of these problems challenges the credibility of the rest of science. But they -- or at least the last two -- do mean that we have not come to the end of metaphysics. Religion, on the other hand, is no answer. It is just the invention of one arbitrary mystery to substitute for the real ones.

Just do it?

My old friend (really) Dr. Sean Palfrey wants doctors to go lower tech and higher wisdom. He sees his colleagues ordering up too many tests, and treating too aggressively, because they don't trust their clinical judgment and they fear doing too little more than they fear doing too much. The wasted resources make medicine much too expensive, which means that lots of children (Sean is a pediatrician so that's where he's looking) don't have continuity with a primary care provider. Which means we're hurting the most vulnerable when we waste resources on the more fortunate -- and we aren't actually making them better off either.

All this is true, as anyone who has been reading your humble and obedient servant for any time knows I would say. However, the situation isn't going to get any better just because Sean's editorial hits some doctors like a diamond bullet, right between the eyes.* It's going to require policy changes, not just exhortation.

That begins with medical training. Unfortunately, right now, it is almost impossible to reshape the way physicians learn how to be physicians. The four years of medical school is just an introduction, heavy on the basic sciences and light on clinical practice. Even so, nobody is really in charge. The dean is just a mediator among departments that jealously guard their "contact time" (the class hours they essentially own within the curriculum) and traditions. Physicians learn the trade through an apprenticeship system after they graduate, and essentially, what they learn depends on the luck of the preceptors who they draw. Nobody is shaping what their role models do so nobody has any real leverage to control the experience.

Then, they go forth into a world tightly constrained by financial and career incentives, and the organization of medical practice. They will likely become sub-specialists because there's more prestige, more money, and less demand on their time than going into primary care. If they resist all that and do enter primary care, they will have heavy caseloads, long hours, and lots of paperwork and administrative crap to deal with. They will get paid for throughput and doing procedures, and paid very little to talk with patients and families, counsel them, and urge restraint. If their patients are depressed, or anxious, or have behavioral problems, just about all they can do is push pills. They will be heavily influenced by the culture around them and the allure of shiny, magical machines.

In order to really get control over this mess, we need universal, comprehensive, single payer national health care. In the meantime, the Patient Protection and Affordable Care Act does offer some openings to get started. The Republican campaign to thwart it, and leave us stuck with the present disaster, is a crime against humanity.

* Yes, it's from Apocalypse Now. I intended that you recognize it.

Still not a good enough explanation . . .

As we in the Reality Based Community grow terminally frustrated over ostensibly real news that is mostly fake, while ostensibly fake news (e.g., The Onion, John Stewart) is essentially real, this essay by David Roberts has been getting some blogospheric attention. I commend it unto you, but I wouldn't be Cervantes if I didn't at least have a quibble.

Roberts concludes:

There's one thing we haven't learned from climategate (or death panels or birtherism). U.S. politics now contains a large, well-funded, tightly networked, and highly amplified tribe that defines itself through rejection of "lamestream" truth claims and standards of evidence. . . .

Politicians and the political press have tried to accommodate the shibboleths of the right as legitimate positions for debate. The press in particular has practically sworn off plain judgments of accuracy or fact. But all that's done is confuse and mislead the broader public, while the tribe pushes ever further into extremity. The tribe does not want to be accommodated. It is fueled by elite rejection.

At this point mainstream institutions like the press are in a bind: either accept the tribe's assertions as legitimate or be deemed "biased." Until there is a way out of that trap, there will be more and more Climategates.

Excuse me, but if they just go ahead and label these people as crazy, then why should they care if the same people deem them "biased"? They've already said those people are nuts, get it? So at that point, who is in a trap?

The reason they don't do it is not because they don't want Rush Limbaugh and Sarah Palin to call them "biased." It's because their corporate masters won't let them.

Dear Mr. President: No more pre-emptive caving

For reasons that probably have something to do with his toilet training, Barack Obama's consistent negotiating posture is to accept the underlying premises of his opponents, give them a big chunk of what they are demanding, and then sit back and expect them to shower him with gratitude and drop the rest of their demands.

As you may have noticed, it doesn't work.

As you also may have noticed, he's done it again. Now, he apparently thinks that by offering the states the chance to design their own systems before the provisions of the PPACA are fully implemented, he does an end run around the states' rights ideologues and forces Republicans to put up or shut up when it comes to expanded coverage and affordability. Sadly, no. I got this e-mail:

Health Care Compact Alliance's Statement On Change To Obamacare

Alexandria, VA – Eric O’Keefe, Chairman of the Health Care Compact Alliance, released the following statement regarding the news that President Obama announced today that he supports amending the 2010 health care law to allow states the option to opt out of some of the laws' requirements three years earlier than currently permitted.

“We welcome the President’s admission that the states may well be able to do a better job with health care than the federal government. However his small step in the right direction is well short of what is needed to restore citizen control over health care, and fiscal sanity to Washington.

By easing the health care law mandates and giving states the earlier option to opt out, President Obama is pushing responsibility and authority down to the states, where it should be. However, even the President's new changes still keep too much authority and regulation with the federal government. Health care is simply too large and complex to manage at the federal level and that is why several states have introduced the Health Care Compact. The Health Care Compact is a comprehensive state-based solution, which takes health care regulation away from the federal government and leaves it to the states and their citizens.”

So they just say "See, you're endorsing our premises, but not following them to the logical conclusion." Give 'em a mile and they'll take a parsec. If I may get wonky for a minute, it is impossible to solve the problems of health care affordability and coverage at the state level because you just end up with a race to the bottom. If you allow insurance to be sold across state lines, and states to establish their own regulations, then it is impossible to create community rated risk pools. It is impossible to get negotiating power with drug and device suppliers, or with regional medical centers for that matter, at least in much of the country.

Canada managed to get its single payer system installed one province at a time, but that was because a) the provinces are a much bigger chunk of Canada than the states are of the U.S., b) the times were different and the idea was extremely popular, c) the vested interests in opposition were much less powerful than they are today and d) the federal government passed legislation to facilitate and push the provinces into doing it. And oh yeah, Canadians are sane.

Mr. Obama, you must lose the habit of anticipatory surrender. It does not work. It has not worked, it will not work, it is the wrong approach. Unless you are actually a mole. I am starting to wonder.

There is an alternative point of view on this, that it's a shrewd move which allows for a push to create state-level single payer systems. For the wonkish reasons I stated, I don't think that can really work, unless maybe California and New York took the lead, along with other large states. However that may be, the problem is with how it is presented -- that the states are really smarter than the federal government, it's wrong for the federal government to design a system for the whole country, and there is probably something wrong with the PPACA so we should let the states do something better. It's the failure of rhetorical and ideological leadership that I'm objecting to, not necessarily Ron Wyden's political strategy.