The doctor is out . . .

. . . but it's okay. Many have been viewing with alarm the current shortage of primary care physicians, and predicting that it's just going to get a lot worse. This is one argument advanced against the affordable care act. What's the use of giving everyone insurance if there aren't enough doctors for them all?

Green, Savin and Lu in Health Affairs (at least you can read the abstract) aren't so worried. Although insuring timely access to care -- it can take months to book a routine appointment nowadays -- would seem to make the problem even worse, it turns out that most analyses have been based on an overly simplistic assumption: that the supply of medical services is equivalent to X number of physicians per Y number of people. (1 per 2,500 is the popular choice.)

Actually, physicians nowadays are less and less likely to come as indivisible units; they more and more practice in teams, which makes it easier to match day-to-day demand with an available provider. Yeah, it might not be your regular doc but you don't necessarily need her for an urgent care visit. Even better, you don't need a doctor at all -- Nurse Practitioners and Physician Assistants can do 90% of the visits. It takes much less time and money to produce one than it does to put a doctor through 4 years of medical school and 3 years of residency; and even yet better, their salaries are lower, which is not entirely unjust since they don't need to repay $250,000 in loans or give up 7 years of their lives.

This is just one of many ways we can make health care better and cheaper in this country, while making it accessible to everyone. If we have the will, and if the people get it through their heads that nobody in his or her right mind would ever vote for a Republican.

The Speech

Okay, I'll drop the cynicism for a moment and give the prez some props for delivering the straightforward ideological manifesto he should have provided a long time ago. He's finally stopped believing his own bullshit about bipartisanship and One America yadda yadda, and apparently (although it has yet to be demonstrated) abandoned the strategy of negotiating with himself and pre-caving on every confrontation with the Republiwackos.

Strong words on climate change; direct debunking of libertarianism; repudiation of militarism (rhetorically anyway -- see below); historically correct representation of civil rights and justice as a historically unfinished process, not an inherent feature of American society and -- to many people's surprise -- making the struggle for lesbian and gay equality part of a triumvirate with  the women's movement and the Civil Rights movement of the 1960s; promising to protect the vulnerable and needy; promising to invest in public goods and regulate commerce for the common welfare; some talk about gun safety; immigration reform.

Not everyone on the portside is completely happy, however. No mention of the horrifically destructive and pointless war on drugs and the prison-industrial complex. In fact, he has shown every sign of continuing it and ramping it up. As for the military-industrial complex, he spoke of peace but not of a peace dividend; did not even mention the vast archipelago of overseas military bases; did not mention the undeclared drone war in Pakistan and Yemen and the extrajudicial executions done on his sole authority. No mention of the surveillance state and the absurdly bloated, largely secret national security establishment.

Talk of saving money on health care was vague. The true debate right now is whether we do it by hurting Medicare and Medicaid beneficiaries, or by making health care more efficient and effective by hurting drug and medical device companies, hospital and nursing home chains, and wealthy sub-specialist physicians, all of which are fattening on our own flesh. The entire argument about deficits and entitlements is actually between these two entirely different definitions of the problem, but he failed to clarify that.

Talk of inequality was also vague. We need to tax the wealthy even more, not necessarily by further raising marginal tax rates but by taxing investment income the way we tax wages. We need to insure a full employment economy through our public investments, a goal he did not state. We need universal access to affordable higher education, also not specified. We need to break up the big financial institutions, tax financial transactions, insure workers' right to organize, and strengthen shareholders' rights and create executive accountability. All unmentioned. Corporations are legal fictions, chartered by government; government can take their charters away, after all, but that power is never exercised.

So it's better than what we've been hearing, but not quite there yet. So sez me.

Ignoring the moment

Yeah, it's MLK day, and the inaugural ceremony/speech. I should probably say something profound. But . . .

Call me old fashioned, but back in my day the definition of "girlfriend" included physical connnnnnntact. Let me tell you, it's something you really miss when they aren't around.

Why do we call that thing in the basement the "hot water heater"? That's redundant and repetitive. It's just a water heater, okay?

Okay, I won't ignore the day entirely.

I believe I have previously mentioned my friend who thought Lance Armstrong was being persecuted. Sports heroes are not generally the kinds of people I look to for inspiration -- their accomplishments are essentially arbitrary, the mastery of invented feats. When they turn out to be personally flawed, there's nothing left. (Armstrong of course is more than just flawed - he turns out to be one of the ugliest narcissists ever.) Dr. King was a deeply flawed person in some ways, but it doesn't matter -- his personal life was irrelevant to his greatness. I'm not sure everybody totally gets that distinction.

People is puzzling

The news is dominated today by the chemically enhanced cyclist and the linebacker with the imaginarily dead imaginary girlfriend. Both stories have a certain amount of intrinsic weirdness but it got me to thinking that all the world over, people are obsessed with sports. The popularity of particular games is as definitive of cultures as religion and cuisine; and the civic unity of cities and nations is as much about sporting teams and iconic athletes as it is about political institutions and nationalist mythology.

I don't have any deep explanation of this. It's like music -- nobody really knows why we like it so much or what it really means. I'm as much a fan as anybody, looking forward to the AFC championship game on Sunday even knowing the awful truth about what it's doing to my heroes' cerebrums. Oh well.

American Exceptionalism

All this is old, old news to readers of this blog, but we might as well keep chopping away. The National Academies of Science commissioned yet another panel on the health of the U.S. population compared to civilized countries, and they reach the same depressing conclusion: we're not the Greatest Country on Earth; God doesn't bless America; we aren't a Shining City on the Hill; we aren't Number One. We are the uttermost piece of crap. E.g.

• For many years, Americans have had a shorter life expectancy than people in almost all of the peer countries. For example, as of 2007, U.S. males lived 3.7 fewer years than Swiss males and U.S. females lived 5.2 fewer years than Japanese females.

• For the past three decades, this difference in life expectancy has been growing, especially among women.

• The health disadvantage is pervasive—it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries.

  
  The wise people don't know exactly why, or they kind of do but they're coy about it. We have much more gun violence, we die more in car crashes mostly because we drive more, we have more people who are depressed and addicted and oh yeah -- lots of people don't have access to health care and the health care they do get isn't as good even though it costs 2 or 3 times as much.
  
  A funny thing happens when we turn 65 though -- the life expectancy gap stars to shrink and it goes away by age 75. What else happens at age 65? Oh yeah -- you get, for the first time, universal, comprehensive, single payer national health care.
  
  By the way -- it's also a lot cheaper. Even though it's better.

Aaron Swartz

I've written before about open access, perhaps to a degree obsessively, and I try not to repeat myself too much here (which is getting difficult as the years go on, to be sure). But I do have to take this occasion to once again say how very important is this issue, how very fundamental to what ought to be the ethic of science.

Some readers may be fully involved in this issue, may completely understand what was at stake for this young man who took his own life this weekend, and why he did the deed that had MIT and the U.S. attorney pursuing him like the furies, trying to destroy his life and career by imprisoning him for 35 years. Here's his manifesto.

In my own words, subscriptions to scientific journals cost hundreds of dollars a year -- or more. In fact, the library at my own elite Ivy League university has cancelled many of them recently because we can't afford it. Nevertheless, we still have thousands of journal subscriptions and I get to read them all because I have the magical powers of a college professor in a wealthy country at a wealthy university. You, however -- be you the common rabble in our wealthy country, or an academic department chair in Kenya or the Dominican Republic, do not get to read them. Most of the research that they publish was paid for by taxpayers, but it does not belong to the taxpayers. It belongs to people who own for-profit academic publishing companies, that in turn sell it -- for their own profit -- only to those institutions that can afford the exorbitant prices their monopoly power enables them to charge.

This is wrong. Scientific knowledge is the common property of humanity. The right way to do this is to include the cost of publication in the original grant that funds the research. That's how the Public Library of Science, BMJ Open Access, Dove Press, Biomed Central, and other completely legitimate open access scientific publishers work. Yes, we pay them to publish our stuff, but they still have rigorous peer review and high editorial standards -- higher, in fact, than the subscription model publishers in many cases. The reason for that is obvious: they have to spend the money on editorial costs instead of lining their owners' pockets; they have to compete for the best research because the people who do that excellent research are paying for publication; and they have to prove their quality and integrity every day. Best of all, everybody in the world with an Internet connection can read the work.

Mr. Swartz downloaded thousands of copyrighted academic publications from an archive called JStor. But he didn't try to sell them, he just tried to make a point. Knowledge belongs to humanity. For this, the U.S. Attorney and the Massachusetts Institute of Technology hounded him to death. Rapists and murderers don't get 35 years.

Update:  In response to an anonymous commenter, I should also add that I, like almost all researchers, freely share my own work with anyone who asks for it. You can go to my academic web page, see my publications, and if you send me an e-mail, you'll get the PDF. That's just one more thing that's ridiculous about this entire issue.

What Bernie Says

Right here. It's been hard for me to post lately because it feels like biting granite. Our political debates are all completely phony, and the corporate media are making us all live in that phony world. For whatever reason (and I'm not going to get into the Obama mental telepathy game that so many people like to play) the president is not puncturing the fake scenery, he's playing right along.

Yes, we have a spending problem. Specifically, the more than $700 billion a year we're spending on the military, which is more than we spend on Medicare.

Yes, we have a tax problem. Specifically, as Bernie says, federal revenue is a lower percentage of GDP today than it was 60 years ago, and it's somewhere around half of what the rest of the wealthy countries raise -- you know, totalitarian dungeons like Canada and Sweden. We have the most unequal distribution of wealth and income of any developed country, and in fact we're back to where we were in the Gilded Age, just before the Great Depression.

No, privatizing everything and turning it over to profit-making corporations doesn't make it efficient, competition doesn't make the consumer sovereign, and it doesn't make us freer. As Eduardo Porter convincingly demonstrates, in the case of health care it leaves us ripped off, ill served, and unhealthy. You know what does work really well? Universal, comprehensive, single payer national health care. Ask any country where they spend half of what we do, and have healthier people.

Right now, we don't have a deficit problem, we have a problem of insufficient aggregate demand, which means we have a lot of unemployed people. We need to spend money to put them to work. Then, if we want to eliminate the federal deficit long term (not that we particularly need to do that), all we need to do pay taxes the way we did under Ronald Reagan, eliminate the cap on social security taxes, and create a Medicare for All system that is funded by the money people are paying in health insurance premiums now, that pays for results, and not for doing unnecessary, useless and harmful procedures.

If we want to be affluent in 2025, we need to spend money on good quality education and universal access to vocational training and higher education, for everybody; renewable energy, mass transit, a smart electrical grid, and energy efficiency and conservation; and scientific research and development; and less money on the military.

Who the hell is talking about this -- what we absolutely must do. Not Barack Obama, that's for sure.

Money money money

I presume y'all have encountered the tidal wave of blather about the trillion dollar platinum coin. Paul Krugman is for it, in case you need an intro, so it can't be all bad. Most people are having a very hard time grasping this concept, and it I guess it does seem kind of ridiculous. But that's because most people don't know what money is.

It's fairy dust. It's fiction. It's purely symbolic. And that is true, by the way, whether it's made out of gold, or paper, or nothing. The proof? There's a society that already uses money which, like the trillion dollar platinum coin, never leaves the vault. The people of Yap, a real fantasy island, have two-ton rocks, mined from a distant island, which are money. But they never move. They just change ownership. One of them, in fact, lies at the bottom of the ocean, due to a transportation accident, but it still counts. Somebody owns it, and they are accordingly affluent.

The little pieces of paper with dead presidents are just an accounting convenience, as you have learned since you started paying for everything with a credit card. In fact, if you didn't have your wallet on you, or you were between paychecks, in the old days you might write an IOU to your friend or your grocer. Guess what? You printed money, just as surely as the government does. That's all money is -- a symbol.

One of the enduring, and mysterious quirks of conservative ideology is that they just can't grasp this idea. It offends something deep in their psyche, that money isn't actually worth anything but a promise. They somehow believe that gold and silver have "real" value and therefore should be money. But think about it for a second: the value of all the stuff that people buy and sell, all the debt they owe, is far more than the ostensible value of all the gold and silver in the world. All money is backed by real assets, it just doesn't happen to be gold. If I can buy a car or a house or lunch with a sum of money, the sum of money is worth that much, identically as it's worth whatever amount of gold it can buy. There is no difference.

Once Ron Paul gets his tiny brain around that idea, the rest of his nonsensical worldview will melt away like the snows of March.

Ozymandias

That is the famous poem by Shelley, of course. I thought of it when I read this essay by Bill McKibben, which has been reposted just about everywhere in a coordinated cyber-bomb. So if you haven't come across it yet, go check it out.

Now you're back. Let me tell you why neither Barack Obama or anybody else in power is doing anything meaningful about the existential threat facing our civilization. I have a writer friend who got an assignment from Harper's to write about climate change as a kind of eschatology. He kept asking me what it was like to live in the End Times and he got a little bit miffed when I wouldn't buy into the concept. It's not the end times. Civilizations come and go. The world goes on. So far, as a matter of fact, so has Homo sapiens. The collapse of classical Greece, the Roman Empire, feudal Europe and the Kingdom of Ouagadougou haven't even slowed us down.

Industrial civilization is built on fossil fuel, just as Mesopotamia was built on its irrigation system and the Holy Roman Empire on the Catholic religion and steel swords, spears and armor. If some scientist had come along and told them those bases for their civilizations were doomed, and they just had to try something else, what do you think would have happened? I don't know about Mesopotamia, but in Europe, you got burned at the stake.

To say that we have to give up fossil fuel is to say that our civilization must go the way of Ozymandias. It's just not clear to me that it can happen until it all comes crashing down. We are Homo petroleus. Eventually, we won't be any more. The times will be very trying, filled with catastrophe and pain. Then we'll be something else.

Another of those competing liberty things . . .

For what are to me quite mysterious reasons, every year we have these whoop dee doos about health care workers refusing to get flu shots. This particular nurse -- who got fired from a long-time hospital job -- claims it's for "religious" reasons but apparently, at least from what her lawyer seems to be saying, the only religion in question is that it's her religion not to get the flu vaccine. Beyond that, she offers no explanation for her refusal.

Okay. I may get some pushback on this but here's the whole story as far as I'm concerned. Yes, the flu pandemic hoax of three years ago had me foaming at the mouth, and particularly got me up in the face of Daily Kos's Greg Dworkin. Influenza is not, in fact, all that big of a public health issue. Most of the 36,000 people or so in the U.S. who are are officially tagged as dying of flu are already debilitated and it just finishes them off. There is a much smaller number of unlucky folks whose lives are definitely cut short by it, including some children, but it's a far smaller number than are killed from car crashes, or even homicide. Most of the so-called Flu Like Illnesses (FLIs) that people get aren't flu at all, they're other viruses. Also, the flu vaccine isn't as effective as it's been touted to be, maybe about 60% effective, i.e. you can still get the flu even if you've been vaccinated.

All true. On the other hand . . .

The risk of any serious complications from flu vaccine is as close to zero as it can possibly be. It may even be zero. Possibly there is a 1 in a million risk of Guillan-Barre syndrome, or possibly there isn't. Virus for flu vaccines is grown in eggs, so people with allergies used to have a problem, but now there is egg free vaccine. So the worst you can get is a sore arm. Getting the vaccine benefits you personally, because it might let you avoid a case of the flu or have a more mild one if you do get it. That's not all . . .

It benefits everybody else, particularly people who are immunocompromised, pregnant women, and old folks, who are at high risk for flu complications, because by weakening the chain of transmission, it helps prevent other people from being exposed. (That's called "herd immunity," and maybe you don't like that term as applied to people but it's accurate.) So . . .

Obviously there's a basic interest in not forcing people to do what they want, in general, but if you work for a hospital you are obliged to act in the interest of the patients. You aren't allowed to smoke in the workplace, you aren't allowed to come to work while you're sick and know you are contagious, you aren't allowed to slack off and not pay attention to your duties, you may be required to do regular tests to establish that you retain the skills to do your job, you may have to get certain physical examinations -- as pilots and school bus drivers, for example, must do. Flu may not be the biggest problem in the world but it's a big problem for somebody who is already sick and in the hospital. So, if the administrators of the hospital require you to get a flu shot, they are well within their rights. Refusal is irrational, irresponsible, and nonsensical.

I feel no sympathy for this woman whatsoever. Zip. Zilch. Zero. Fire away.

Pleasingly Plump

Sorry for the long hiatus, I was distracted by a (very wonderful) personal matter. It turns out blogging isn't necessarily the most important thing in the world after all.

Anyway, despite the new year and all the ongoing political sturm und drang, I'm going to re-enter the blogosphere with a conventional Stayin' Alive post. Flegal and colleagues in the new JAMA present a very careful meta-analysis of studies linking body mass index with mortality. Their findings confirm what has been the general trend in observations over recent years: the categories of overweight and obesity set by NIH consensus panels may define healthy weight a little too stringently. People in the current "overweight" category (BMI between 25 and 29) actually seem to have slightly lower all-cause mortality than people of ostensibly "normal" weight, and people in the lowest category of "obesity" (BMI 30-34) do not appear to have higher mortality rates. Above that, however, obesity is most definitely associated with sharply higher risk of mortality.

But . . .

It's complicated. Underweight individuals have elevated mortality, probably mostly because the reason they are underweight is that they are already sick. Mildly overweight people may have good cardiovascular fitness and good muscle mass, or not: being both overweight and unfit is probably bad. Also, staying svelte in youth is probably a good omen for your later years. People tend to gain weight with age, but very few young people die, so when we're talking about mortality risk, we're talking about older folks who are naturally a little bit more zaftig than their younger selves.

Anyway, the point of all this is, if I were a real doctor, I'd tell you to pay more attention to being physically active and fit, and eating a well-balanced diet, than whether you're five pounds overweight by the standard measure. However, if you're much more overweight than that, you should try to trim down. And how can you do that?

Well, this one is abstract only for the rabble, but: the high fructose corn syrup and table sugar thing is probably real. It turns out that fructose -- of which there are similar amounts in both of the above-named products -- is the worst form of calories. Not only does it have a high glycemic index, it doesn't satisfy hunger, in fact it appears to make you hungrier. That's the crap in soda and supermarket sweets and the sugar bowl on your table. It's increasing prevalence in the American diet may have a lot to do with the obesity epidemic. Do not eat it! Have a piece of fruit.

Back to a normal schedule now, I hope.

Riiiiiiggghht!

As Noah says to the Lord in the famous Bill Cosby routine. As I may have mentioned before, I'm a lifelong -- well, since age 13 -- subscriber to Scientific American, which is probably why I'm such a know-it-all, even though they've been assiduously dumbing it down for the past few years.

Anyhow . . .

Michael Dettinger and Lynn Ingram this month tell us that once every couple of hundred years, California has been visited by the real, diluvean deal. Starting on Christmas eve in 1861 it rained not for 40 days and 40 nights, but for 43, after which the Central Valley was "an inland sea 300 miles long and 20 miles wide." Sacramento was 10 feet under. It took 6 months for the water to drain.

The most incredible fact about all that is that I had never heard of it before. Cal was relatively sparsely populated at that time, nevertheless thousands of people died. If that were to happen today . . .

Guess what. It will. They've been able to trace the record of such events in the sediment going back to 1150 or so, and they have convincing evidence of 5 of them. It turns out that great rivers of water vapor form in the atmosphere and west coasts generally are vulnerable to these events. And of course you know the kicker . . .

Global climate change should make them more frequent, by increasing the amount of water vapor in the atmosphere. If you thought Katrina and Sandy were exciting, well now. Words fail. A simulation of a lesser event -- only 23 days of rain -- found that 1.5 million people might need to be evacuated, with total economic costs of $700 billion. Given that nobody's getting 1.5 million people to high ground very quickly, again, well now. You figure it out.

That's why I'm not making any predictions for the New Year. Shit will happen.

Merry Christmas

Really. I believe I posted many moons ago about Richard Dawkins's idea to make "Atheists for Jesus" T-shirts.

I was just talking to a friend yesterday about the ascendancy of I-got-mineism in our politics, and the delusions that come with it -- that everything you have you deserve, nobody and nothing outside of yourself contributed to your deserved fortune, and every penny you pay in taxes is stolen to give to lazy parasites. That's not so weird in itself, but the alliance of this philosophy with the predominant form of Christianity in the U.S. is pretty strange.

My uncle was a preacher -- the pastor of Trinity Church on the Green in Branford, Ct, which is a national historical landmark. My mother was a Sunday school teacher. I got several perfect attendance medals for Sunday school, and I was talking about getting confirmed when I got old enough to figure out for myself that religion is bunk, i.e. thirteen years old.

But, the Christianity they taught me was the exact opposite of Rich Warren and Pat Robertson and Franklin Graham. They claim to interpret the Bible literally, and live by it. So how do they interpret this?

Matthew 25:31

³¹ “When the Son of Man comes in his glory, and all the angels with him, he will sit on his glorious throne. ³² All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats. ³³ He will put the sheep on his right and the goats on his left.
³⁴ “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. ³⁵ For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, ³⁶ I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’
³⁷ “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? ³⁸ When did we see you a stranger and invite you in, or needing clothes and clothe you? ³⁹ When did we see you sick or in prison and go to visit you?’
⁴⁰ “The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’
⁴¹ “Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels. ⁴² For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, ⁴³ I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me.’
⁴⁴ “They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’
⁴⁵ “He will reply, ‘Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.’
⁴⁶ “Then they will go away to eternal punishment, but the righteous to eternal life.”

Or this?

^{Mark 12}

¹³ Later they sent some of the Pharisees and Herodians to Jesus to catch him in his words. ¹⁴ They came to him and said, “Teacher, we know that you are a man of integrity. You aren’t swayed by others, because you pay no attention to who they are; but you teach the way of God in accordance with the truth. Is it right to pay the imperial tax^[b] to Caesar or not? ¹⁵ Should we pay or shouldn’t we?”
But Jesus knew their hypocrisy. “Why are you trying to trap me?” he asked. “Bring me a denarius and let me look at it.” ¹⁶ They brought the coin, and he asked them, “Whose image is this? And whose inscription?”
“Caesar’s,” they replied.
¹⁷ Then Jesus said to them, “Give back to Caesar what is Caesar’s and to God what is God’s.”
And they were amazed at him.

Or this:

Matthew 19

¹⁶ Just then a man came up to Jesus and asked, “Teacher, what good thing must I do to get eternal life?”
¹⁷ “Why do you ask me about what is good?” Jesus replied. “There is only One who is good. If you want to enter life, keep the commandments.”
¹⁸ “Which ones?” he inquired.
Jesus replied, “‘You shall not murder, you shall not commit adultery, you shall not steal, you shall not give false testimony, ¹⁹ honor your father and mother,’^[c] and ‘love your neighbor as yourself.’^[d]”
²⁰ “All these I have kept,” the young man said. “What do I still lack?”
²¹ Jesus answered, “If you want to be perfect, go, sell your possessions and give to the poor, and you will have treasure in heaven. Then come, follow me.”
²² When the young man heard this, he went away sad, because he had great wealth.
²³ Then Jesus said to his disciples, “Truly I tell you, it is hard for someone who is rich to enter the kingdom of heaven. ²⁴ Again I tell you, it is easier for a camel to go through the eye of a needle than for someone who is rich to enter the kingdom of God.”

Now, I know that the scammers have all sorts of arguments as to why these passages don't actually mean what they appear to mean. But why don't we ever hear from other Christians who do believe in the words attributed to Jesus in the Gospels? Why do they cower under the pews? Just askin'. 

Not all massacres are alike

Via Balloon Juice, I came across this essay by Mark Ames, who apparently is something of an expert on rampage murder. His main focus in the linked piece is on the NRA, and I recommend it for that reason.  Basically, he argues that by being batshit crazy, the NRA actually insures intense loyalty and passion on the part of its members, because it reinforces their tribalism and paranoia.

That's worth thinking about, but the point I want to make for this post is that the Newtown tragedy was not typical, in that the perpetrator had no evident connection to his targets. I have mentioned previously the socially isolated men who shoot up their workplaces when they are in one way or another robbed of their only source of dignity through their employment. The kids who attack their own schools also typically, in one way or another, feel humiliated or socially excluded.

Now we find the question of access to mental health services entering prominently into the post-Newtown debate. I'm afraid that while I agree we have problems with mental health services, that's largely an irrelevant distraction. The typical workplace or school shooter would not have contemplated getting mental health services. Workplace shooters often erupt after being fired, or disciplined, or having a conflict with their supervisors. There is seldom any indication in advance that they ought to get mental health treatment, and even if somebody thinks there is, there's no way to make them do it. Similarly, the school shooters are generally entirely unpredictable.

Now, it just so happens that Jared Loughner and James Holmes were recognized in advance as having serious mental illness, in both cases as it happens by school authorities. And their respective institutions reacted by expelling them and washing their hands of the matter. Loughner already has an official diagnosis of schizophrenia and obviously, Holmes will get one too. The Newtown shooter was also manifestly somehow wrong in the head, although we'll never get to slap a specific label on him. It's this run of bad luck which has apparently made mental health a big player in the current debate.

However. None of these people sought treatment. Putting a free psychiatry kiosk on every street corner would not have helped. The only thing that would have helped is making it impossible for them to acquire large capacity ammunition clips.

QED

Update: An armed society  is a polite society, right Mr. LaPierre?

About that Second Amendment

Jeffrey Sachs is of course correct. The amendment has to do with an archaic debate about federalism. It protects the state militias, not some bozo who wants to walk around the shopping mall with a gat on his hip so he can shoot any black kid who looks threatening, or a bunch of louts who think they can resist "tyranny" by taking on the United States army. The state militias are now the National Guard. That's the well-regulated militia. Back in the day, the militia members owned their own muskets, and kept them at home, which is why the amendment reads as it does.

The Supreme Court, in decreeing that a) this has anything to do with a "right" that pertains to individuals and b) has any application at all in the United States post about 1800, is legislating from the bench. This "interpretation" has nothing to do with conservatism or "original intent" or even jurisprudence. It's just a fraud. There is no such thing as gun rights, or gun owners rights, or a right to bear arms, deriving from the Constitution of the United States.

None. It's all nonsense.

On Liberty

It's not exactly a revelation that you get a huge political advantage from attaching a label with positive associations to your cause. Rights, liberty, life, freedom,choice -- who could be against any of those? Respecting the right to bear arms gives us more liberty, more freedom, more choice, and we can defend our lives and our property. If you want to restrict that right, you want to take away my freedom. Obviously.

What's wrong with this picture? I shouldn't even have to point it out, yet somehow our public discourse can't arrive at the obvious.

People walking around with guns on their hips may feel that they have liberty and freedom, but they diminish the freedom of others. Who would dare to offend a belligerent character with a gun in his hand? Are the people of Newtown, and every other school district in this country, freer because their neighbors own high powered rifles with 30 round magazines? Of course not. They are forced to take all sorts of measures that restrict freedom in order to protect themselves. They have to make their schools, libraries, town halls and court houses less accessible. They have to tax themselves more to pay for police and security systems. Even so, sometimes their children get murdered.

I could play this argument out at greater length but others have done so better. The point is, liberty is always a problem of balance. Whatever liberty is granted to one person may take away from the liberty of another. Your liberty to dump your waste in the river deprives me of the liberty to swim in it.

Here's another powerful example. Banning smoking in public places turns out to have a huge effect on the incidence of heart attacks and acute respiratory distress. Huge. A twenty-one percent decrease in hospital admissions for acute myocardial infarction. That means smokers aren't poisoning other people, and the rest of us don't have to pay as much to take care of people who have heart attacks.

Libertarianism is sophomoric nonsense. Rand Paul and Ron Paul and everybody associated with the Cato institute are mindless. We must root this delusional thinking from our political discourse. 

Why?

Connecticut is a relatively small state in geographic extent, but Newtown is pretty far from me in Connecticut terms. I have never been there, and I had to look it up on a map. As it turns out, though, my brother-in-law's niece attended Sandy Hook, and her baby sitter's daughter was killed. And seeing my governor and senator on TV talking about it makes it seem somewhat close to home anyway.

As for why the guy did it, the answer to that is easy: he was batshit crazy. Nobody is worried about asking Jared Loughner, for example, why he shot the congresswoman and all those other people, because we know he can't give a meaningful answer. As this story by AP's Helen O'Neil discusses, we can't say there has been an increase in these rampage killings recently. The first one I remember was Charles Whitman, who climbed a tower at the University of Texas in 1966 and shot 45 people, killing 13. I was 12 years old at the time. When I was in college, a woman in combat fatigues shot up a nearby shopping mall, and 16 year old Brenda Spencer shot up a school yard in San Diego in the "I don't like Mondays" assault. Usually they're men of course: the Luby's cafeteria massacre, the McDonald's in San Diego, that Vietnam vet who attacked children in a schoolyard, the epidemic of postal service massacres, and more recently Columbine, Virginia Tech  . . .

(As I write this, my neighbor is emptying a 12 round magazine. He needs to do that every morning.)

So these keep happening. The distribution in time may not show any obvious pattern, but the distribution in space does. The U.S. seems to be where it happens most often. Sure, there have been massacres in New Zealand, Scotland, and Canada in my memory, but each of them is unique in its particular country. (I'm leaving politically and economically motivated crimes, such as the Mexican drug cartel massacres, for another day. I'm just talking about rampage killings by unconnected individuals.)

Is it something in the culture? I don't really see any evidence of that. Charles Whitman, on autopsy, was found to have a brain tumor. Many of the perpetrators, including Loughner and James Holmes, are manifestly psychotic. We don't understand psychosis well at all; it isn't clear how the zeitgeist influences psychotic fantasies. Obviously you have to know that the CIA exists to believe it has implanted a chip in your brain, or to have heard of Alpha Centauri to believe that extraterrestrials are beaming messages at you from that particular location, but otherwise the form of the delusion is probably sui generis, in other words you could believe you were possessed by a demon. Same idea. So whether violent movies or video games actually make psychotic people violent is far from proven.

There is a pattern of workplace rampages by socially isolated men whose work is their only claim to dignity and who react when something goes wrong there, but I don't know that that is unique to the U.S.

But we all know what is unique to the U.S. The only time I have fired a rifle was at boy scout camp. The weapon had a bolt that you pushed up and pulled back to open the chamber. Then you inserted a single cartridge, pushed the bolt forward and down, and took your one shot. Guess what? If you're hunting deer, that's just as good as a semi-automatic Bushmaster with a 30 round magazine. You only get one shot and if you miss, and try shooting again at the fleeing animal, you are an irresponsible idiot. There is absolutely no reason for people to own semi-automatic weapons or large capacity magazines. They have nothing whatsoever to do with hunting or sport of any kind. They are designed for exactly one purpose, and that is to kill humans. That is the only purpose they are good for.

The arms which the well-regulated militia had the right to keep and bear were muzzle loading muskets. You'd pour black powder down the barrel from your powder horn, then shove a wad of paper down the barrel with a rod, then drop in a ball. Then you could aim and fire, once.

If I want to shoot the chuck that's eating my garden, or bag a turkey for dinner, the most I need is a double barreled shotgun. Break it at the breech, put in two shells, and you're good to go. If I had one, and I lost my marbles, I could maybe shoot two people. Not 26. It's that simple.

You might want to play with this

An on-line app from the Guardian that let's you look at death rates globally or regionally, by age, from various causes, in 1990 and 2010.

Worldwide, heart disease and circulatory disease are by far the leading cause of death. No surprise there, but you might be surprised by the importance of chronic respiratory diseases in carrying off the old folks. Unintentional injuries -- falls -- aren't way up there in the rankings but they're pretty important. A broken hip is very often the beginning of the end.

There have also been some big changes since 1990. HIV of course has jumped way up, while other communicable diseases have tended to go down in rank.

Anyway, you get to visualize it all sorts of different ways -- try it, it's very informative.

Big Gummint

Jonathan Chait has justly won a wanker of the day award or two, but I'll give him props for this. (No endorsement of the Puffington Host implied or intended.)

I'll put a slightly different spin on it, but the basic idea is correct. The reason the weeping orange man won't specify the spending cuts he's demanding in return for the revenue increases he also won't specify is that he cannot. The United States has a far less generous social safety net than other wealthy countries, our infrastructure is crumbling, our regulatory agencies are underfunded (and they spend little money anyway) -- the one place where we can actually find substantial savings is in the bloated military, while the Republicans have been running around screaming that it's dangerously underfunded since Obama took office. They also campaigned against Obama for cutting Medicare, and now they're complaining that he doesn't want to cut it enough. Not that simple logic ever mattered in political discourse but . . .

The fact is that at some point, Congress is going to have to sit down and pass appropriations bills, and reauthorize the major entitlement programs. Fiscal cliff or not, debt ceiling or not, Orange Julius's House of Representatives is going to have to specify how much the federal government will spend on each and every one of its functions. They can cut funding for stuff they don't like, such as the EPA, but that will have a trivial impact on the budget deficit. They can cut spending on Medicare, but there are only two ways to do that:

1. Payment reform and cost-effectiveness guidelines. They claim that is equal to "death panels," so they won't do that.
2. Reducing benefits. That's not going to win them any love in 2014. 

 They could try cutting Medicaid benefits and tightening eligibility standards. That won't pass the Senate and if they did it, they would get the blame for horrendous consequences. At some level, the sane among them know that.

And they can cut the military budget, but they won't do that.

So they're stuck. The low IQ members may not understand that, but Boehner does. He knows it perfectly well.

When everything changes

Our new article in Patient Preference and Adherence is now available open access. (I try to publish open access when I can, but don't always have the funding.)

I really like this piece because we gave voice to people who have been through really tough times and in most cases, overcome. But it required fundamentally changing how they thought of themselves and how they related to the world.

This is one of the consequences of a chronic disease diagnosis -- in this case HIV, but it happens to some extent with heart disease, chronic kidney disease, cancer. The doctor pronounces the word and the world changes. You are still the same person, but in a sense your identity is altered, where you are in the world is different.

Most of these folks, ultimately, made the most of it. But I don't know what the magic pixie dust is that can get people to successfully incorporate the new reality and move ahead courageously. Nor can they say what it was. At some point, it just happened.

Not really the end of the world

While it is true that only a few people are convinced that the apocalypse will occur on a specific, known date, it is tragically also true that there are a lot of people -- I don't specifically remember the polling on this and maybe somebody can come up with a number, but it's close to half of Americans -- believe that it will happen sometime soon, they just can't say exactly when.

You may be old enough to remember that Ronald Reagan's Secretary of the Interior, James Watt, believed that, and said so publicly. He said that environmental conservation was pointless because the environment wasn't going to be around much longer anyway. Yes, that really happened. And maybe that's one reason among several that the looming catastrophe of climate change is largely ignored.

The failure of the Doha climate conference ought to be the top headline in every media outlet. It was buried in a small item inside the NYT this morning and is basically nowhere to be seen on the web sites of the major news networks. But the Reuters story (linked above) gets it right.

At the end of another lavishly-funded U.N. conference that yielded no progress on curbing greenhouse emissions, many of those most concerned about climate change are close to despair. . . .

The conference held in Qatar - the country that produces the largest per-capita volume of greenhouse gases in the world - agreed to extend the emissions-limiting Kyoto Protocol, which would have run out within weeks. But Canada, Russia and Japan - where the protocol was signed 15 years ago - all abandoned the agreement. The United States never ratified it in the first place, and it excludes developing countries where emissions are growing most quickly.

Delegates flew home from Doha without securing a single new pledge to cut pollution from a major emitter. . . . A series of reports released during the Doha talks said the world faced the prospect of 4 degrees Celsius (7.2F) of warming, rather than the 2 degree (3.6F) limit that nations adopted in 2010 as a maximum to avoid dangerous changes. According to the World Bank, that would mean food and water shortages, habitats wiped out, coastal communities wrecked by rising seas, deserts spreading, and droughts both more frequent and severe. Most impact would be borne by the world's poorest.

No, this is not the end of the world. It's not the end times. The universe will go on. But it will be hard times indeed, harder than we have ever known, and that includes World War II and the Dark Ages. Wake the fuck up.
 

What with the end of the world approaching . . .

. . . in just a couple of weeks, my curiosity has again been awakened about why so many people believe in this particular category of balderdash, continually through the ages. This story about the followers of Harold Camping casts a bit of what little light there is to be found, but leaves me unsatisfied. (The on-line magazine Religion Dispatches, from which this is taken, is a good resource, BTW. They write about religion from the outside, without hostility but with appropriately critical thinking.)

As you may recall, Camping was the radio preacher who convinced thousands of people that the apocalypse would occur on May 21, 2011. They quit their jobs, spent their savings promoting the truth to the world, left their kids without college funds, abandoned their homes . . .

Spoiler alert: It didn't happen. The universe sailed on as serenely or tumultuously as ever. But why did they believe this? They weren't just betting on it. They were absolutely certain, as certain as the sun would rise on that day, the earth would be devastated by massive earthquakes, and then the rapture and the end of the universe would occur in October. Which also didn't happen, by the way.

It turns out that many of them are engineers or otherwise mathematically trained. They figured it out, by elaborate reconciliation of scriptural passages. The numerological and textual relationships they found in the Bible could not possibly have been coincidences, they were irrefutable evidence of the truth of the prophecy. Well, okay, but you really have to try very hard to get to that conclusion. Confirmation bias can't happen until you already believe. There's still a piece missing here.

But come to think of it, the same can be said of all religious belief. It's just that much of it doesn't smash to pieces against observable reality quite as hard. Anyway, I'm puzzled.

Unpopular Legislation

As you have no doubt heard, while Americans tell pollsters they like various specific provisions of the Affordable Care Act, the act as a whole still gets less than 50% approval.

Maybe this is why. (PDF -- scroll down to page 8.)

Two and a half years after the law’s passage, six in ten Americans either believe that the health care law establishes a government panel to make decisions about end‐of‐life care for Medicare beneficiaries (39 percent) or are not sure whether or not this is a provision of the ACA (22 percent). The numbers among seniors are very similar: 32 percent of seniors believe the law sets up such panels, 28 percent are not sure. Two in three seniors say the law cuts benefits for people in the traditional Medicare program. In fact, there are no actual cuts in benefits for beneficiaries in the traditional Medicare program, though those enrolled in Medicare Advantage plans may see fewer supplemental benefits once reimbursements to those plans are reduced.

A lie is half way around the world before the truth gets its boots on. The Republicans have succeeded in lying to people, and the corporate media have enabled their lies. This must end, or there is no hope for us.

It's Open Access Time!

The new policy at NIH is that all publications resulting from NIH funding have to be posted to a repository called PubMed Central for open access after one year. Here's one of mine, that went live today.

Many people -- both doctors and patients -- complain that there isn't enough time in a standard medical visit. In order to make their boat payments, doctors typically average 12 to 15 minutes for regular outpatient visits. In fact, there isn't much evidence that visits used to be a lot longer, but medicine, and life, have gotten more complicated, and that amount of time seems less adequate than it used to. Of course a higher percentage of patients are older and sicker than in the past, and of those who are sick, there's usually more to be done. In addition, we're managing diagnoses that didn't used to exist - "pre-diabetes," high LDL, and so on.

The people in our study all had HIV, and they were visiting HIV specialists, but for these patients, as for most people with HIV, the HIV doc is also their primary care doc. Most of them were doing reasonably well, so these visits, on average, weren't a whole lot longer than 15 minutes. But, they varied a lot. Using a coding method of my devising, we found that longer visits tended to appear to be more "patient-centered" -- less physician verbal dominance (i.e., doctors normally talk more than patients but it was more even in longer visits), more patient questions, more patient expressive utterances, that sort of thing.

As you will often find with me, there's a "but" -- when we looked directly at the really long visits, many of them seemed more patient centered because a lot of what went on wasn't really medicine. In one, the patient spent most of the time griping about his siblings who were squabbling with him over his mother's estate. In another, the doctor spent several minutes teaching the patient about the history of South Africa. In another, the doctor tried to recruit the patient to go to church with her.

So it's not that simple. We're there on business. Most of us expect efficiency and likely value quality over quantity when it comes to interacting with our doctors. In fact, my own mother happened to volunteer to me the other day that she really appreciates how her ophthalmologist concentrates on business and doesn't get into a lot of chit chat. She adores him, but it's because she trusts him to take care of her eye (she only has one), not because he's all up in her stuff. That makes sense to me.

The end of football?

Okay, this study, partly paid for by the National Football League, has gotten a lot of attention. The NYT has a more lay-friendly discussion, but the Times coverage, like most media reports on this, is a bit misleading. Let me first unskew it, and then discuss it.

In a nutshell, the researchers sliced up the donated brains of a bunch of football and hockey players, and some combat veterans (many of whom had played football) and found most of them had brain damage that looked kind of like Alzheimer's disease. They were able to correlate what they saw under the microscope with reported symptoms that they maintain define four stages of traumatic encephalopathy.

Now to unskew. This is actually what we call an existential or phenomenological study. It does not give us information about the prevalence  of this sort of damage among football or hockey players. True, this sort of damage was not found in the (fairly small) number of controls they looked at, but these guys' brains were donated in the first place because the families were worried that something was wrong. What this study is telling us more about what can happen to people who suffer repeated blows to the head, but it does not mean 68/85 of football players (or hockey players or combat veterans) actually have this sort of damage.

We still don't know that number, and we don't know a whole lot about the details of what puts people at risk. Maybe some people are more susceptible for reasons of underlying physiology. Maybe particular patterns of injury -- with respect to frequency, age of occurrence, severity and specific physics of the blows, etc. -- are much more dangerous than others. Conceivably, growing awareness among coaches and policies to prevent repeated concussions in a short time have already reduced the risk. We don't know . . .

But. Clearly there is a risk. It seems based on casual observation at least to be quite substantial for professional football players but it also seems to be more than most parents would tolerate even for high school, and certainly for college players. This is quite unpleasant for me to face up to because I am a lifelong pro football fan. They're giving us cheap entertainment and yeah, some of them get fame and fortune but a lot of them only last a couple of years and end up with battered bodies, little in the way of marketable skills, and a few bucks to show for it. Then this disease -- first headaches and depression, then personality changes including angry outbursts, then loss of ability to plan and motivate, then dementia.

You can argue that grown men who take on this risk voluntarily can do what they want. Maybe. But if mothers won't let their sons play, the game will fade away. What other people think doesn't matter. That will be the end of it.

What I'm doing right now

Just in case people are curious about what I do for a living, here are my recent and current activities.

1. I just got a paper accepted and revised the page proofs. It's a focus group study of people living with HIV about their experience communicating with their doctors about adherence to antiretroviral medications. It's an open access journal so as soon as it's on-line I'll give y'all a link.

2. I revised and resubmitted another paper, about a new system I developed for coding and analyzing clinical encounters. The system is also part of the basis for . . .

3. An award from the Patient Centered Outcomes Research Institute to study how features of clinical communication in chronic kidney disease and heart disease are related to patients' understanding and recall of the information they get and the treatment decisions that are made in a visit. Right now we're finishing up the interview guides and protocols and waiting for IRB* approval.

4. I finished drafting a paper on racial and ethnic differences in patient-provider communication in HIV care, based on our system for coding and analyzing interactions, and sent it to a co-author.

5. I'm in the middle of a study called Explanatory Models and Decision Heuristics in HIV Care. I did a whole bunch of semi-structured interviews with people living with HIV, to find out what they understand and believe about HIV and HIV treatment, and how that affects whether they take their pills and so on. Now my mission is to develop a structured survey that can be given in waiting rooms to find out what conversations people really need to have with their docs and/or nurses. (It turns out, BTW, that people who tried this with kidney disease found out that 1/3 of people living with chronic kidney disease  do not know that the kidneys make urine. Really.)

6. I'm supposed to be analyzing data from another survey I was involved in, concerning people's perception of risk from near-highway pollution. Need to get cracking.

7. I'm working on a proposal about communication between providers and families, and how well families follow medication and infection control protocols, for kids who have hematopoetic stem cell transplants (AKA bone marrow transplants, although they don't literally transplant bone marrow.)

8. Two more papers I'm supposed to be writing . . . will get a round tuit.

I probably forgot a couple of things. In fact I know I did. Anyhow if anyone has questions about any of the above, or would like to learn more, let me know.

* Institutional Review Board. They're supposed to protect the rights and interests of human research subjects, but they can often be a source of petty bureaucratic annoyance.

Some worthwhile propaganda

Check out Science works for us, a web site created by a consortium of research universities to explain why threatened cuts in federal funding for scientific research will be bad for the economy, and bad for you. (They even have a map you can click on to see what will happen to funding that comes to your state.)

Yeah yeah, federal spending on scientific research is soshulism. Here's the problem Sen. Paul: knowledge is a public good. That means that even according to the bogus Economics 101 theory you embrace, it won't be produced in sufficient quantity by private enterprise. Of course, you don't believe in scientific conclusions anyway, you prefer that we remain ignorant.

If congress doesn't act affirmatively before January 1, federal funding for scientific research will be reduced immediately by 8%. It's already the lowest it's been in a decade, in real dollars. Funding for research (and that includes the military, BTW) is only 2% of the federal budget, but it generates huge profits for society, part of which is returned to the treasury in taxes.

Making these cuts will be absolutely nuts. Write or call your representatives in congress and tell them to make sure it doesn't happen.

The varieties of crankery

Okay, the most obvious reason why people sell bunkum is just that -- to obtain money. Pat Robinson has managed to get very wealthy by conning the rubes, but every preacher is out to make a living. True, you don't have to be a creationist to get people to put money in the plate but having your own special truth to which those smart people who laugh at you are hostile builds tribalism and loyalty and helps shake out your pockets.

The same motive applies to homeopaths and naturopaths and chiropractors. They couldn't get into medical school or didn't want to make the serious effort it requires, but this way they get to pretend they are doctors and get a fee.

Most con artists start believing their own bullshit -- it makes them more effective a the con and lets them live with a clear conscience. So they also get to believe they are actually helping sick people or saving souls. It makes the money even sweeter. So these cases are not hard to explain.

Climate change denial is rather similar -- it's mostly financed by the fossil fuel industry and associated tycoons. Just follow the money.

But that doesn't entirely explain why lots of people who aren't making money off of these schemes become passionate believers. These frauds sell in large part because the truths they deny are inconvenient, uncomfortable to downright distressing, or take some hard work to really understand. It feels better, at least for many people, to believe the bunkum, and once they start believing, confirmation bias, tribalism and just avoiding the conclusion that you've been duped all reinforce and maintain the belief against all evidence.

That doesn't explain, for example, Peter Duesberg, the virologist who to this day maintains that HIV does not cause disease. It's cost him career advancement and the respect of his colleagues and gained him nothing, as far as I can tell. But here's what seems to have happened.

When the HIV hypothesis was first proposed, like any hypothesis it took some work to confirm. At the early stages of any emerging scientific idea, it's appropriate to question it, push back, and really make the proponents of the hypothesis prove it. Indeed, most of the time they turn out to have been wrong. If the hypothesis holds up, and the critics say fine, you have overcome my objections, they shouldn't pay any price, in fact they should gain respect. But the dynamic doesn't always work that way, either within the relevant community or the individual critic's psyche. In the process of arguing with his colleagues, Duesberg evolved from a friendly critic to an adversary, and came to see conceding that HIV causes AIDS as a personal defeat. His self-esteem just wouldn't allow it. In other words it was a case of confirmation bias run amok.

The problem is what to do about it. Presenting people with ironclad evidence and irrefutable logic that says they've been just plain wrong all along doesn't work with most folks, most of the time. It just makes them resent you and dig in even deeper. Viz. Duesberg. So we come to an impasse.

My colleague Steve Sloman has an idea. Most people have what he calls the illusion of explanatory depth: they think they have a very sound basis for their belief but it turns out they really can't explain why they believe it or defend their belief effectively if you ask them.  Don't tell them they're ignoramuses or dupes, ask them to explain it to you. They may suddenly find they can't.

Catching up wit h the news

I'll get back to the deep epistemological thoughts soon, but a couple of noteworthy studies have come out over the holidays, in the general vein of less is more.

First, I'll bet your doctor has you come in for an annual checkup, assuming you are fortunate enough to have health insurance. Don't bother. Based on a systematic review, some Danish folks whose names I won't repeat because I don't know how to make the "O" with a / through it conclude that "General health checks [i.e. checkups] did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although they increased the number of new diagnoses. Important harmful outcomes were often not studied or reported." In other words, they don't make you any healthier or make you live any longer, they just get you more diagnostic labels. And, obviously, cost money. Maybe we wouldn't have such a shortage of primary care providers if they weren't busy wasting their time and ours.

See the doctor if you have a good reason to, such as symptoms you're worried about or you need a certificate or something. And of course, if you have a chronic disease that requires ongoing management. Otherwise, find something better to do.

And yet another analysis that should prompt second thoughts about screening mammography. Basically, based on data from the U.S. cancer registry called SEER, Bleyer and Welch conclude that somewhere close to 1/3 of the cancers found by routine screening would never have caused clinically significant disease; and the vast majority of the rest could have been successfully treated even if they were diagnosed later, after a palpable lump or other symptoms appeared. The basis of this conclusion is essentially that after screening became widespread, the rate at which early stage cancers were diagnosed went way up, but diagnosis of late stage cancers went down only a tiny bit. Simple arithmetic tells you that most of those cancers diagnosed by screening would not have ended up being diagnosed at a late stage. Also, this means that something like 70,000 women a year are "overdiagnosed," i.e. they are told they have breast cancer and treated for it, even though nothing bad would ever have happened to them if the "cancer" had not been found.

Again, I'm not a real doctor and I'm not giving medical advice. Certainly if your mother or sister had breast cancer, if you've had estrogen therapy, if you have never had children, you are at higher risk and have a stronger argument for getting a screening mammogram. But make your own decision -- don't let anybody pressure you to do it.

That said, this finding is not anti-medicine. Au contraire. The death rate from breast cancer has fallen a lot in the past two decades. But that is because of better treatment. Advances have been incremental so they haven't been much noticed, but they have been substantial. The contribution from screening to the lower death rate, if any, must be quite small. And by the way, better treatment is probably why screening doesn't turn out to be so valuable after all -- catching it very early isn't as important any more.

A few thoughts on science denial

Now that the election is over, we can finally start to talk about stuff that's real. I perceive a modest burst of assertiveness by scientists and the defenders of science. All of a sudden we're allowed to talk about climate change, Marco Rubio gets an actual hard time from the corporate media over the age of the earth, even Ross Douthat excoriates the Republican party for cozying up to creationism.

So I'm inspired once again to ponder why so many people are alienated from reason and reality. Now, this gets tricky. Obviously there are legitimate disagreements in this world, and the route we got from finding truth in ancient fables to figuring out that the universe is more than 13 billion years old, the earth about 4.5 billion years old, and the life we see around us and partake of results from the process of evolution by mutation and selection. If you haven't studied these matters in depth, it seems as though you're simply being asked to choose between justification from the authority of your preacher, or the authority of some snotty kid who got into Harvard whereas you never had the chance.

There isn't any magic ruler that tells us what's true. We can learn enough about a small part of science to convince ourselves, but to a considerable extent we do have to trust authority. The real heuristic we need is to choose between authorities. I can't prove to you the credibility of the standard model of particle physics or the pathogenesis of atrial fibrillation, although I can make a pretty good case for evolution.

I think there are a few different varieties of denialism. People cling to homeopathy for different reasons than they cling to creationism, or global warming denialism, or holocaust denialism, or AIDS denialism. We call these by the same term but they aren't quite the same phenomenon. I'll try to sort it out in the next post.

The Horror! The Horror!

As New Englanders grimly contemplate a month or more of Gronklessness*, an even more horrific prospect appears on the horizon: that president Obama might remove John Kerry from the Senate to the Cabinet, whereupon Scott Brown will rise from the grave, compelled yet again to devour human brains.

Massachusetts law requires a special election to fill a Senate vacancy. That's how Scott Brown became a senator in the first place. Massachusetts Democrats don't have any compelling candidates to fill a new vacancy. Just witness the ragtag band of Whotheheckareyous? who ran against Elizabeth Warren in the primary.

But wait, it gets worse. Possibly corrupt and definitely irresponsible lieutenant governor Tim Murray is making noises about running. In a well-financed campaign, he would be a gigantic human target.
Did I say well-financed? A zombie Scott Brown candidacy will be the opportunity for the wounded and enraged financiers of the Romney debacle to recover a shred of their dignity, and there will be no competition for their money. Massachusetts will be carpeted a foot deep in cash. Blimps advertising Scott Brown will hover over every city square and village green. They won't just buy every commercial slot on radio and TV. They'll buy the TV stations and run 24 hour Scott Brown infomercials. They'll buy the Boston Globe, Worcester Telegraph and Gazette, and Berkshire Eagle, and rename them respectively the Boston, Worcester and Berkshire ScottBrownforSenate.

Brown has already proved he can win a bye-election, he already has an organization and enthusiastic, experienced volunteers. The Democrats had the candidate they wanted on November 6 and pretty even finances, and Brown still outpolled Obama by something like ten points and made it close until near the end. He'll get a sympathy vote this time around as well.
Mr. President, please, in the name of all that is good and decent, don't do it! Sen. Kerry, think of the children!

*For those who don't follow the game where steroid abusers in plastic armor beat the crap out of each other, that's New England Patriots superhuman tight end Rob Gronkowski, out of action with a broken arm.

The issue you can't talk about

As a commenter who wandered over from Informed Comment to berate me on the previous post illustrates, and as David Atkins here laments, there are reasons - not exactly good ones, but reasons - why bloggers are wary of writing about the Israel-Palestine thing.

Nevertheless, I'll take a chance. First of all, just so you know, I was at one time professionally involved in Middle East related activism, as staffperson for an organization called the Lebanon Emergency Committee. This was a coalition formed in the Boston area following the invasion of Lebanon by Israel in 1982, in pursuit of the PLO. Yes, we wanted Israel out of Lebanon, among other objectives for both the Lebanese and the Palestinian people. Unfortunately neither has fared all that well since.

The fact is, the Israeli occupation of the West Bank, and the Israeli settlements there, are in violation of international law and several United Nations resolutions. There is a vast imbalance in power between Israel and Palestine, and the Palestinian people are simply being crushed, politically and economically, by a movement of settlers, mostly from Europe, who claim that God gave them the land on which the Palestinians have lived from time immemorial, and who are slowly, relentlessly, exercising this utterly absurd claim.

That's the basic reality. Are there Palestinians who deny Israel's right to exist? Certainly. But the international consensus since at least the 1960s, to which the Fatah leadership is committed, is that there should be two states.

I personally do not believe that in the modern world, we should be promoting nation states based on religio-ethnic identity at all. However, Israel is a fact, and there's no way to go back. Justice cannot be established in the past, but only in the future. And future justice demands that Israel uproot the settlements, leave the West Bank, and let the Palestinians work out their own future. Israel possesses an absolutely overwhelming advantage of military force and economic power. The country is in no existential danger. Any claim to the contrary is nonsense.

Those are among the starting points for any sensible discussion. And by the way, my comment that so provoked our guest was to condemn Hamas for launching rockets at Israel. This post, if noticed, will attract even greater outrage, I expect, from the opposite direction. As Atkins says, you can't win.

Non-ignoramuses unite!

You have nothing to lose but Marco Rubio's brains, such as they are. The theory is that if the Republicans just nominate a Latino for president, it won't matter what their policies are or whether the rest of their candidates go around bewailing the threatened surrender of Anglo-Saxon civilization to the brown hordes, they'll finally get Latinos to vote for them.

Alas, having spent 15 years working for a Latino community based organization, I can tell you from long, intense personal observation that people whose heritage is from the predominantly Spanish speaking countries of the Americas are not typically ignorant idiots, unlike the Senator from Florida:

The senator, who has recently created buzz about a potential presidential run in 2016, said that he is not qualified to answer how old the Earth is, calling the question a "dispute among theologians."

"I'm not a scientist, man. I can tell you what recorded history says, I can tell you what the Bible says, but I think that's a dispute amongst theologians and I think it has nothing to do with the gross domestic product or economic growth of the United States," he told GQ Magazine. "I think the age of the universe has zero to do with how our economy is going to grow. I'm not a scientist. I don't think I'm qualified to answer a question like that."

Note that he is even stupider than might appear at first glance. He explicitly says that the dispute is among theologians, not between theologians and people who actually know something and have arguments to make based on evidence; and he thinks that the age of the earth and the age of the universe are the same question.

Here's a dispute for the theologians. Which is stupider, Marco Rubio or a blastocyst? Either way, they're both human infants, right?

And right on cue . . .

The first thing the Republicans do after they lose an election by appealing to white racism and patriarchy is start beating up a black woman. Real smart.

Greatest hits

I just found out that something I wrote back in 2005 went comparatively viral, but I had no idea at the time. It's still relevant, I think, although the assertion in the third paragraph about current control of government is arguably out of date.

Living on the edge, but still taking up way too much space 

Nov. 5, 2005

In my checkered youth, I was at one time a community organizer in Philadelphia. I worked in black and white neighborhoods -- and believe me, the city was completely segregated. I was an exotic sight in North Phillie, but I never felt unwelcome there. In the poor white neighborhood of Fishtown, however, I felt like an extraterrestrial.

Almost everyone in Fishtown claimed to be a conservative, and expressed scathing contempt for liberals. So what were some of their conservative ideas? This was the time of the Arab oil embargo and (gasp!) gasoline at a dollar a gallon. Many of Fishtown's rabid conservatives advocated nationalizing the oil companies. Other popular conservative ideas included government sponsored health care, a higher minimum wage, stopping the developers who were deliberately creating blight so they could buy up large tracts for upscale development, massive investments in public transportation (the Kensington Ave. trolley was a foretaste of hell), cleaning up the air pollution -- all kinds of radical right wing ideas. They were mostly Catholic and went to church, but I can't remember anybody giving a shit about abortion or keeping people on life support.

Now, actual real conservatives have an iron grip over all three branches of the federal government. In public opinion polls, many more people label themselves conservative than label themselves liberal. But a majority of people also tell pollsters that they are willing to pay more taxes to protect the environment, improve the schools, and do other good things; that they want universal health care; that they want curbs on development to protect communities and the environment; that they favor keeping Roe v. Wade (that one's not even close -- 65% to 29%). 82% of Americans opposed intervention in the Terri Schiavo case by the Congress and King George. In other words that particular maneuver was less popular than legalized wife beating. And oh yeah -- the majority favor sensible regulation of gun ownership.

Now, back when I was knocking on doors in Fishtown the gay rights movement was just emerging and nobody was talking about gay marriage. I'm sure the Fishtowners would have opposed it had it come up. So score one for a position more associated with conservatism. But looking at the scoreboard, it's pretty clear that the supposedly democratically elected government is generally sharply opposed to the majority of voters on important issues of public policy.

What's going on? I confess I have left out the most important issue that the good people of Fishtown were worried about. In their own words, it was the niggers. They were all on welfare, and they were taking all the jobs. (That's right, I often got that in consecutive sentences. And by the way, I would estimate that 1/4 of the households in Fishtown consisted of single mothers on welfare, or disability pensioners.) They were going to push us into the river. They don't keep up their own communities -- why some of them moved in over in Kensington a couple of years ago and inside of a year, half the houses on the block were abandoned. (Oh yeah, that's their fault.) The nearest high school was dropping plaster on the kids heads, and there was a proposal to build a new high school in Fishtown, but the people were against it, unanimously. Why? Because black kids might have walked through the neighborhood on their way to school.

Frank Rizzo, the racist neo-Nazi mayor, was very popular in Fishtown. Now you know why.

Politics is complex. The right has cobbled together a coalition of minorities -- people who are willing to trade off issues that aren't terribly important to them for ones they really care about. Wall Street financial barons and corporate executives want low taxes on high incomes, minimal environmental and safety regulation, low wages and minimal protections for workers, and they have plenty of money to put into political campaigns. Most of them think the religious right consists of ignorant lunatics, but they're happy to scoop up the wacko vote for candidates who will favor the rich. The mass media, of course, are part of the corporate establishment and naturally favor its interests. Religious zealots may be in a minority, but they volunteer for political campaigns, give what little they have, and vote as a bloc. So that's an important part of the story.

But it is racism that makes it all possible. It is largely because of racism that we have such an underdeveloped social infrastructure compared with western Europe and Canada. Racism has divided the working class, and made the white majority mistrust social programs which they have been persuaded somehow favor the other at their expense. It is racism, and nothing else, that led to the ascendancy of the Republican Party in the states of the confederacy, once the Democrats embraced the Civil Rights Movement and resolved the contradiction between their role as the party of the Old South and the party of the urban north. It is racism, ultimately, that underlies the tendency of white Americans who hold liberal views on issues to label themselves as conservatives. Racism is still the central problem in this country. It still is. Yes it is. 

 

 

All twits considered

So I'm driving home last night and comes now Gary Loveman, operator of gambling casinos (audio link) who appears as a representative of the CEOs who met with the prez yesterday. He explains that we have to get the federal deficit under control, but if marginal tax rates are raised on the wealthy, it will destroy jobs. The mechanism is that rich people won't have as much money to gamble with, so he'll have to reduce some shifts.

Of course the interviewer doesn't challenge this. I mean, if you're the CEO of Caesar's, you're a serious person, right? I'm just a babbler on the radio, who am I to question anything you say?

At least we finally know how it is that the rich are the "job creators." They do it by gambling in Las Vegas. The Republicans had not gotten around to explaining that before.

I can tell you from personal experience . . .

. . . hospitals make money by screwing up.

I've written about this before, so first let me emphasize, no personal condolences or sympathy required, this happened many years ago and I'm fine now. Not to worry.

Without going into great detail, back when George Bush the First was bombing Iraq, I entered a Major Teaching Hospital of Harvard University through the emergency department. I had pain localized between my navel and right hip, with rebound tenderness and a fever. They told me I had acute appendicitis and they were going to take my appendix out. Eight hours after entering the operating room, I awoke severely dehydrated, in agony despite enough morphine to float William S. Burroughs for a week, and lacking my ascending colon. After opening me up they had seen, not appendicitis but rather a lesion that they decided was cancer but was actually diverticulitis. Eleven days and many travails and grievous errors and misjudgments later, I finally left the hospital.

I had insurance. However, they weren't happy with the amount the insurance company paid them. A couple of weeks later I received bills totaling more than $25,000 -- it would easily be twice as much in nominal dollars today. I told them to go pound sand and eventually they did but . . .

Hospitals get paid for doing stuff. The more stuff they do, the more money they make. Suppose you hired a roofer, who set up scaffolding incorrectly which caused a staging plank to crash through your living room window and smash thousands of dollars worth of antique glass. Would the roofer then bill you to repair the window and replace the artifacts? I think not. However, that's what hospitals do when the doctors make mistakes.

The linked article in Health Affairs reveals a major problem in efforts to control health care spending. If hospitals undertake quality improvement programs to reduce the rate of surgical errors and complications, they lose money. Not only do they have no incentive to do it, some small community hospitals might actually go broke if they didn't screw up so much.

In civilized countries such as the totalitarian dungeon to our north, hospitals are given a global budget to care for the needs of a community. It's in their interest to be competent, and efficient. So here's what we need:

We need universal, comprehensive, single payer national health care. Shout it from the rooftops.

Reality Eventuates

The Affordable Care Act, it now appears, will continue its painfully slow march toward full implementation in 2014. This has always been the essential problem: most of the good stuff that's going to happen to people won't happen until then, and that's why the opponents of the ACA have been able to rant about socialism and government takeover of health care and death panels. Once people see for themselves that nothing bad happens, game over.

However, as Timothy Jost discusses, it's going to take at least a few tweaks and also a few bucks for the ACA to really work out well. The right wing governors will have to accept the Medicaid expansion after all. Specific insurance regulations need to be promulgated (Stat!). The federal exchange needs to be set up because it appears several of the states are not going to establish exchanges out of pique. (Ideologically inconsistent, I know, to prefer federal control, but they aren't making sense about any of this to begin with.) The House Republicans will no doubt try to use extortion over the debt limit, the fiscal cliff, and federal appropriations in general to mess up the thing, whereas it actually needs some technical corrections and constructive changes.

Whether the Republicans can get away with, or think they can get away with, continuing their strategy of trying to wreck the society and the economy in the hope that the opposition will get the blame for their own vandalism, I don't know for sure. But it's looking right now like they think they can get away with it. A well-informed, honest journalistic estate dedicated to the public interest would probably stop them, but we don't have that. Look forward to the continuing hail of BS, and wish us all luck.

What frosts my pumpkin

And probably yours too. Yesterday, I had to take the day off from work to drive my mother to an appointment with a specialist physician. (Everything turned out okay.) They told her that her appointment with the doctor was at 3:00, but she should arrive at 2:30 to do all the paperwork. (So why can't they just say, "Your appointment is at 2:30"?)

So we got there at 2:30, she filled out the questionnaires, and at 3:00, they called her in to the examining suite. I then waited for 2 1/2 hours, until she finally emerged at 5:30. What the heck was going on? Answer: They did some tests, then she waited for the doctor for an hour and 40 minutes.

Now, this is a specialist. He comes to this clinic once a week, and sees only scheduled patients. He deals with no emergencies. When they book the day, they know every patient who is coming, why that person is coming, and what they are likely to have to do with that person. There is no good reason why they cannot see a person at 3:00 who is scheduled to be seen at 3:00.

The reason this happens is because of arrogance and a total lack of respect and consideration for patients. No other service industry could possibly get away with this.

We're going to fix it.

Yes, I am actually a bit less cynical today

The corporate media are, no surprise, only grudgingly conceding a Democratic victory, and pretty much universally describing the outcome of yesterday's election as essentially maintaining the status quo. It isn't.

1. The right has lost the culture wars: Gay marriage, contraception and abortion are losing issues for them now. They've lost that wedge almost everywhere. This is good news in itself, of course, but it's also an enormous clearing of the terrain for the liberal coalition.

2. Sheldon Adelson and the Koch brothers' billions couldn't buy the election because the fundamental premises behind their propaganda barrage were rejected by the voters. Yes Virginia, there is a role for government in creating a strong economy, boosting employment, and providing a safety net for the unfortunate. Rich people should pay more to help make those things happen. The basic social infrastructure of the New Deal and the Great Society is built into the bedrock of the political culture; it is unassailable, at least in 2012.

3. The right has lost the race war: It will never be possible to win an election by marshaling white racism and resentment. The changing demographics of the country rule that out forever.

4. The right has lost  the generational battle: Their electoral base is dying and the 16-year-olds who will vote in 2014 will be overwhelmingly against them.

They only held onto the House because the 2010 wave election gave them control of legislative redistricting. That advantage will gradually fade between now and 2020 as congressional districts naturally change. The Senate is considerably more liberal. Finally, the corporate media may have finally found the right-wing lies just a little too much to include in the phony balancing act, and Fox News is no longer taken seriously. Oh yeah, the religious right's influence is also clearly withering.

This is really pretty good news. The republic may endure. Now if we can really start to do something about carbon emissions . . .