Hard questions

It's ethics week at the New England Journal of Medicine. Two questions get debated:

Is it ethical for employers to refuse to hire smokers? Pro here, and con here.

Should it be legal for physicians to assist in suicide of terminally ill people? Pro and con at the same URL.

I'm going to say that as far as disqualifying nicotine fiends from employment, I'm 100% agin' it. There are many telling arguments. First of all, where does it stop? Fat people? People who don't take their anti-hypertensives regularly? People who have more than 2 alcoholic beverages each day? People who don't eat five servings of fruits and vegetables? You get the idea. You need to somehow justify why smoking, among all unhealthy habits, is unique.

Second, it's an addiction. Many people think of addiction as a disease. That's debatable on semantic and philosophical grounds, which I won't go into here, but the point is, it's not really voluntary. Most smokers start as minors, in large part because tobacco companies snare their immature judgment with slick marketing campaigns. Then they find it very difficult to stop. (Most smokers want to quite.) Just mouthing the words "personal responsibility" is begging the question. (Yes, I used the phrase appropriately: it's assuming the consequent.)

Third, smokers are disproportionately to be lower income, lower educated, and non-white. So it just adds to the discrimination and disadvantages many people already face.

The pro arguments are basically three. Two are pretty much answerable in the same way. These are that other insurance ratepayers, particularly other employees of the company and the company itself, have to pay for their increased disease risk. Yes, but that's the whole point of insurance. See above regarding fat people etc. You could use that argument to refuse to hire people with HIV, or diabetes, or cancer. Good luck with that. The second argument, which is increased risk of absenteeism or shortened job tenure, is answerable in exactly the same way.

The third reason, mostly applicable to health care providers, is setting a good example for customers. See above, fatness. Obviously, it is 100% legitimate to forbid smoking on the premises, but that's a separate question.

What you should do is provide encouragement and assistance for smoking cessation.

As for physician-assisted suicide, I find that more difficult.

Use a condom!

Gonorrhea was basically untreatable, or in any event the treatment wasn't much good, until the 1930s, but that didn't last long because the little buggers quickly evolved resistance to sulfa drugs. Along came penicillin, which was good until the mid-1970s, then we lost that one. Then we went to antibiotics called fluoroquinolones. Alas, by 2007, resistant strains emerged so CDC recommended use of cephalosporins, most commonly Ceftriaxone.

You know what's coming, right? Celphalosporin resistant gonorrhea has appeared in Asia and Europe, and now it's here in the Greatest Country on Earth.™ It isn't very common yet but it won't be long. The real bummer is that gonorrhea is still resistant to the older antibiotics. Sometimes, when we stop using an antibiotic, the germs devolve their resistance, because the resistant strains are otherwise at a selective disadvantage in the absence of the chemical. Not so in this case. There is nothing left.

Public health programs in the U.S. have been steadily defunded in recent years, meaning that STD prevention and treatment programs have been weakened. Preventing the further spread of resistance requires identifying people with STDs as early as possible, treating them effectively, and of course preventing new infections from happening in the first place. One suggestion -- don't go to Catholic hospitals or affiliated clinics. They won't give out condoms or advise people to use them. That's because the Catholic bishops hate humanity.

Another suggestion -- don't vote for politicians who oppose comprehensive sexuality education in the schools, who oppose publicly funded research into sexual behavior and associated epidemiology, or who want to cut funding for public health programs and public health research, or who don't want to teach children the true facts about evolution. Do vote for politicians who want to increase support for public health. It's usually an easy choice because the party label will tell you.

And behave responsibly in your own life. That is all. We will be really sorry if this gets any worse.

Thinking Globally

It's an artificial occasion, but then again, most occasions are artificial. With about 1,000 days to go until the target date for the UN's Millennium Development goals, the organization is making a marketing push and they are getting some attention. Not in the United States, of course, where people generally don't give a rat's ass about the rest of the world. But BMJ, among other durn furriners, has marked the occasion with a couple of commentaries.

Charles Kenney of the Center for Global Development  considers what new set of goals should be established once the 2015 target has passed. Summarizing progress so far, we have already "halved the proportion of people living on less than $1.25 a day," we're basically on the way toward getting as many girls into school as boys (with exceptions, obviously), and lives of slum dwellers have been improved in accordance with the goal. We aren't doing so well in other areas. More than 15% of people in poor countries are still malnourished, gender equity aside 10% of children still don't get enrolled in primary school, mortality among children under 5 has fallen but remains at more than 6%, and maternal deaths have not fallen enough either. Results with HIV are mixed, with declining incidence but prevalence still rising and many people not being treated.

A lot of the progress, particularly on poverty, is actually attributable to strong economic growth in China and India. Sub-Saharan Africa in particular hasn't done so well. Supporting public health and health care through international aid can be effective, but it isn't sustainable. Rich country support has fallen, due to both economic and political conditions. But in the long run, countries that are now poor will have to develop sustainable, indigenous infrastructure. Done wrong, foreign aid is indeed a recipe for corruption, waste and dependency. (Viz Afghanistan, also one of the exceptions when it comes to gender equity in education.)

But, more profoundly, as David Legge and David Sanders remind us in the same issue, focusing on outcomes really misses the target. "As well as the health crisis (untreated AIDS, escalating tuberculosis, avoidable child and maternal deaths), humanity faces a more complex set of global crises, including global warming, financial instability, food insecurity, an unsustainable population, and environmental degradation." They credit the People's Health Movement with arguing that "the post-2015 development agenda will need to confront the underlying dynamics that are driving widening inequality, creating avoidable suffering, and accelerating global warming."

As I argued in my master's thesis too long ago to mention, the ideology of progress stands in the way of our honestly confronting our situation. We think that we are much wiser, and more powerful, and better off than our ancestors, and that with a few fits and starts, human history has been an upward trajectory. Not so: we have lost as much as we have gained. We invent technologies to solve problems and enrich ourselves in our current social and physical context, but  in doing so we inevitably create changed contexts that confront us with new problems for which the solutions, in turn, create their own harmful side effects and new challenges. We are like a patient who takes a drug , then another to combat its side effects, then another to combat the side effects of the second, and on and on, but without cure.

Powerful elites, of course, stand in the way of correct diagnosis because they have so much to lose. But so do we all, if we cannot see through to the heart of our problems.

Headlines

I read the New England Journal of Medicine every Wednesday morning when the new issue hits Your Intertubes. So today there were quite a few items worth discussing here, one of which, to my surprise, ended up in the upper-right-hand-corner place of honor on the front page of the New York Times. No need to link to the Times, which will eventually try to hit you up for money if you keep going there, since NEJM, bowing to the awesome power of Stayin' Alive which has berated it over the decades for its paywall, has made the piece available to you, the common rabble.

We have long known qualitatively that as more and more people live a long time, we're going to have a huge increase in the number of people living with dementia, and that this will cost unimaginable gobs of money as well as being a terrible personal strain on loved ones. (Believe me, I know. My father had a long, slow course of dementia which led from care at home which was very stressful to my mother, to an assisted living facility, to a nursing home, which wiped out my parents' savings, to a lingering death.) Basically the news here is that they did some fairly convincing quantitative calculations which find that right now, almost 15% of the population 70 and older is diagnosable with dementia, that it's already costing somewhere around $200 billion a year, and that it will increase 80% by 2040. This is mostly for custodial care rather than medical services. Medicare doesn't pay for that, which means you have to wipe out your savings, as my parents did, before Medicaid will pick up the tab. Since we're talking somewhere around $40,000 a year, vanishingly few old folks have the income to cover it, obviously.

That's bad news, to be sure. But in the same issue, A.J. McMichael makes the case that human civilization is not sustainable, unless we make some very radical changes in the way we all live. I guess that's not exactly news, so why should we read about it in the New York Times?  But, if there is a single point to all this, it is . . .

We're spending all our time talking about how we need to cut federal spending and balance the budget because otherwise we'll be placing a great burden on our children and grandchildren. That, my friends, is from opposite world. The catastrophe that awaits our descendants will happen because we don't spend the money now to avert it. We need a massive investment in renewable energy, energy conservation, population control (yep, Godless contraception), medical research, long-term care infrastructure, and I could go on and on but you get the idea. Rich people, who are hiding trillions of dollars from the tax collector in the British Virgin Islands and many other places, while whining about the taxes they don't manage to evade, have plenty of money to save humanity, but they don't want to. Because evidently they aren't examples.

Hey indeedy . . .

Sarah Kendzior, a newly minted Ph.D. in anthropology, discusses the recent vote by the senate to prohibit the National Science Foundation from funding political science research. This is not really a vote per se -- it was an amendment tucked inside the continuing resolution to keep the government from shutting down. But Democrats went along to avoid a fight (as always). Here's the fuller story on the Senate action.

Anyway, Kendzior's major points are ones I have made in the past, maybe not so well. The Republican war against science and reason succeeds as well as it does because academic researchers insulate themselves from the public. Research reports are hidden behind very high paywalls -- subscriptions to scholarly journals cost hundreds of dollars a year -- and they are written in obscure jargon the main purpose of which is to make it all seem mysterious and profound to outsiders.

As long as scientists depend for their career advancement and research funding solely on publication in peer reviewed journals and arcane communication within a highly specialized circle, we aren't going to have a whole lot of political support to pay for what we do. We need to serve the people, engage with the people, listen to the people, and communicate with the people. Yet writing for a general audience and engaging in public debate can actually harm scholarly careers. (It's a major reason why Paul Starr didn't get tenure at Harvard.)

The Open Access publication movement helps. When I publish in open access journals, I hear from people -- not people in academia, but people who are working in public health and clinical care. I got invited by a state health department to do a webinar on one of my open access papers for people involved in HIV care and prevention. I got an e-mail from the AIDS Action Committee of Massachusetts, and from front-line workers in the U.S. and Canada. That never happens, believe me, when I publish in subscription-only scholarly journals. There are lots of folks out there who are hungry for the latest ideas and findings that are relevant to the work they do, but most of it is unavailable to them. (I also like to give myself some credit for writing in accessible English.)

That is absurd, unethical, and counterproductive to the cause of continued public support for science. Without that support, we're out of work. So it's high time for us to change our ways.

The "sequester" isn't just dumb . . .

It's catastrophic. Unfortunately, most of the catastrophe will go unnoticed by most people, most certainly including the corporate media. Janice Hopkins Tanne in BMJ reviews the impact on public health and health research.

The Federation of American Societies for Experimental Biology, representing 100 000 members, said sequestration cuts “of this scale in a short timeframe will be calamitous. It will require arbitrary funding cuts that will prevent critical research projects from reaching completion. Other potentially lifesaving research projects will not even get off the ground. In anticipation of the possible cuts, NIH funding rates have sunk to an all time low . . . The number of research project grants funded by NIH [National Institutes of Health] has declined every year since 2004.”

The result of this is that entire programs of research are simply terminated before they come to fruition. Even before the sequester, only about 7% of research applications were being funded. This means that graduating Ph.D.s won't get fellowships, and post-docs will never get faculty jobs. The investment we have already made in their educations will be wasted. Scientific research will be set back by decades. Did you have hope for your loved one with MS, or a refractory cancer, or incipient dementia? Were you hoping that the health care system would start to deliver care that's more efficient, compassionate, and effective?

Well, the Congress has spoken. Drop dead.

You're an ignorant idiot

Well, okay, not you or me, but most people think they understand shit much better than they really do. Psychologists can't just say that, they need a fancy term for it, so they call it the Illusion of Explanatory Depth. For example, do you know how a toilet works?* Or a zipper? (How does it unzip, anyway?)**

In the linked essay, my colleague Steve Sloman and Phillip Fernbach discuss it in relation to politics and public policy.

I'll forgive the false balance since they were getting themselves published in the New York Times, but the basic idea is, if you ask people if they say, understand Obamacare and know why they hate it, they'll say definitely, they know all about it. If you ask them to justify their position they'll say something like it's sushulism, it's a government take-over of health care, it will kill people (Michelle Bachmann says that's already happening), etc.

So just ask them this: explain Obamacare. What does the legislation actually do? Much of the time, they'll stare at you bug-eyed and their jaw will go up and down and they'll say "Muh, muh, muh." They know they're supposed to hate it, but they don't know what it is. Steve finds that after that, their views tend to moderate.

I'm afraid I don't really know what the liberal equivalent is. If somebody cares to nominate a conservative policy that liberals don't like because they don't know what's actually in it, I'll listen. Meanwhile I think this is pretty much a one-way street.

* Hint: It's a siphon. Look at the back of the base, you'll see the profile of the drain pipe. Its top is above the water level in the bowl. Take it from there.

**  Hint: You have to know what's inside the slider.

Okay, I've been flacked

Got another one of those e-mails from publicists that pour into my in-box, due to the world dominating influence of Stayin' Alive. This is that one in a million that doesn't go to instant oblivion. Ken Murray, M.D. discusses the deaths of physicians in an on-line publication that purports to be the Saturday Evening Post. I don't know what this effort has to do with the original magazine that featured those famous Norman Rockwell covers, but be that as it may.

Dr. Murray's first point, which is actually quite well known but probably not by the general public, is that physicians are very unlikely to want heroic measures to extend their lives. And it's because they've seen plenty of futile and tortuous "care" administered to others. They know enough not to want it for themselves. He writes, "To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask."

But the real question he ponders is why, given that they know this, they do it anyway. In fact, they very often do it even when people have given orders that they don't want it. It has been shown in published studies that Do Not Resuscitate Orders, and other components of living wills, are quite frequently ignored. And even where families are left to make decisions, they don't often offer "do nothing, let nature take its course" as an option. He thinks that it has little to do with the chance to make money and more to do with cultural pressure and fear of legal peril. Maybe so.

As you will recall, the effort to include Medicare payment for counseling about end-of-life options in the Affordable Care Act was scuttled because of mindless fools, including a particularly vacuum-headed example from Alaska, started shrieking nonsense about death panels.  Well, please think about it anyway.

Ideology is weird

As NPR's Julie Rovner explains here, all those Republican governors who were yelling "Big gummint" and refusing to accept the Medicaid expansion just might change their minds and follow the example of Arkansas. It turns out Republicans just might go along with letting the federal government cover more of their citizens if the money is used to buy the people private insurance.

Now, I don't think anybody can come up with a good reason why that's perfectly okay, whereas having the state Medicaid program pay their bills is not. Oh yeah -- it means the private insurance company gets to take a cut of the money. But as far as Ayn Rand and Grover Norquist are concerned, it's still money stolen from the makers for the benefit of the moochers. Or rather, from the trust fund babies for the benefit of the toilet scrubbers and line cooks, as far as reality is concerned, which rather seems the other way around.

The real difference is, of course, that insurance execs will get bigger bonuses, a portion of which they will donate to Republican candidates. Ain't democracy wonderful.

Science marches on

As I believe I have mentioned before, I'm a lifelong (well, since age 13) subscriber to Scientific American. They've been trying to dumb it down a bit of late, but it's still a great way to keep up with what's going on in disciplines from my own. You can't read the actual magazine without a subscription, but the free stuff they do offer is here.

So, comes now Brian Switek in the latest issue with the most important and vexing mystery facing science. How did dinosaurs do it? And by "it," I mean what you think "it" means.

The most substantial clue is that the living birds which are closest to the base of the lineage possess a male member. (I assume I don't have to tell you that birds are in fact dinosaurs.) You may not have known that most birds do not -- they just kind of rub up together. I didn't know that in fact. Anyway, crocodilians, the lineage most closely related to the dinosaurs/slash birds, are similarly endowed. Ergo, dinosaurs had wieners.

But, as you already know, some of them were really, really big, and they had big fat tails that would be hard to get out of the way. It turns out, based on computer simulations (yes, some cheetoh-dusted Dr. Pepper swillers actually did this) that the females could have supported the weight of the males in the standard posture of four-legged mammals. (There is a business in the nearby town called Doggie Style Pet Grooming. Really.) However, there are two problems. One is the tail. This could have been a manageable problem assuming the male threw only one leg over the female and approached somewhat from the side.

However, as you probably recall from your youthful obsessions, many dinosaurs had elaborate plates and spikes along their spines which would have turned any amorous male into a eunuch. One possibility is that the female lay down on her side. It occurs to me that they might even have addressed more hominum, as Melville said of the whales.

The main reason I raise this issue is that it asks us to reflect on why we do science. I mean, who cares? What difference does it make? The answer is, we're curious. We just want to know stuff. We want to figure it out. More than that, human knowledge is a single structure. Physics, cosmology, biology, chemistry, archaeology, geology, astronomy -- all are woven together in a single tapestry of light. Everything we learn, everything we figure out, makes everything else more clear.

This is one reason why religion is so destructive. Every false belief founded on faith degrades all of understanding and assails the foundation of every other truth.

Exciting New Toy!

Until I have a chance to do a real post, please amuse yourselves with the Thomas Friedman op-ed generator. It's completely random, completely meaningless, and even better than the real thing!

Radical Discontinuity

We've certainly had our share of catastrophes lately -- think of the southeast Asian and Japanese tsunamis, Haitian earthquake, Katrina, Sandy, great floods and droughts all over, the emergence of HIV. All of these have disrupted countless lives and destroyed or radically changed communities, towns and cities. But the broad course of history flows on little affected by these events, however dramatic they are. (The Japanese tsunami has significantly weakened the Japanese nation, an important economic power, with perhaps some effect on geopolitics, but it doesn't change anything fundamental about the world order.)

To be sure, the cumulative effect of global climate change will have a radical global impact. The wise among us -- which does not seem to include our political leadership -- are working hard to understand what this is likely to be, and to find ways to avert the worst and cope with the inevitable. But I have been thinking of late that all of our hopes and worries about the future are quite likely to prove largely irrelevant on the scale of decades. Completely unpredictable events will almost certainly intercede. Arguments about the federal budget in 2050, with which we are presently obsessed, are preposterous.

In 1859, when Edwin Drake drilled his oil well in Pennsylvania, petroleum was essentially viewed as the source of kerosene, a replacement for whale oil and tallow candles. Nobody could have anticipated that it would be more important than that. As it turned out, it wasn't long before people no longer lit their homes with open flames of any kind, yet petroleum ended up changing the world more radically, in fewer years, than any innovation since language.

On the down side, I got to thinking about this because of the recent discovery in London of a mass grave from the Black Death. In parts of Europe, it killed one third or more of the population, maybe half. Historians will argue about the consequences, but it is entirely plausible to argue that it brought about the end of the Middle Ages and opened the way for the Renaissance and  Enlightenment. Suddenly, there was twice as much land, housing, livestock and tools per person. Labor was scarce and the peasantry suddenly in a much stronger relationship with the gentry. Land peonage could not endure, and the old ways started to fall away.

We might well have a global pandemic of some highly transmissible and deadly pathogen that we cannot quickly control. Public health authorities are continually insomniac over this possibility. Decimation of the human population would have unpredictable consequences in the long term, but immediately of course it would be horrific. Lots of other really bad stuff could also happen, but I'm not writing this to catalog them, that's not the oint.

On the up side, the possibility of a radically transformative technological innovation that saves us from our present multiple crises like a deus ex machina can't be ruled out. A breakthrough light, compact, energy storage technology; viable fusion energy; room temperature superconduction -- it could happen. And any of 1 million things I haven't thought of. In other words, the one safe prediction is that the future won't be anything like people are predicting.

Public Opinion Polling

I just saw Al Sharpton (I don't call him "Reverend" because I don't revere him) report that 53% of Americans think "The Iraq war was a mistake."

Had I been among those polled, I would not have answered that it was a mistake. Obviously, they did it on purpose. It was a crime against humanity. It was a monstrous evil perpetrated against people in Iraq and the United States, first and foremost, but everyone and every living thing on the planet to some degree. It was a world historical crime with the complicity of, among others who you might think you admire including Hillary Clinton, Christopher Hitchens, Mary McGrory and the entire editorial staff of the New York Times, Washington Post, and Boston Globe. Whatever it was, it was not a mistake.

I am really sorry to be a downer . . .

but, the new BMJ demands that I bum you out.

Britain's Chief Medical Officer -- kind of like our Surgeon General, except that she actually gets  out of bed in the morning -- issues a report on antibiotic resistance. Yes, I write about this from time to time and hear and there you will hear someone cry with alarm, and yet nobody does a damn thing about it.

It seems that after the Good Lord intelligently designed microorganisms that can kill us and make us sick, He forgot to prevent them from evolving. Yes, yes I know, he's a total doofus. Anyway, they've been doing that ever since we even more intelligently designed antibiotics that can kill them, and now they're starting to escape en masse. There have been no new classes of antibiotics developed since 1987, and nothing is in sight.

What happens if we lose antibiotics? We won't just go back to a world where a sore throat or a cut finger can kill you. As Smith and Coast point out, we'll also lose the ability to do surgery. No more joint replacements, no more cancer resection. No more health care as we know it.

And why aren't drug companies reinvesting some of those trillions in profits into developing new antimicrobials? Easy. That's not where the big bucks are. They can sell you a ten day course of an antibiotic, or get you to take statins or antidepressants for the rest of your life. They are much more interested in the latter.

And why are we still feeding antibiotics to livestock? Because our politicians want the money from the pharmaceutical industry and agribusiness, just like they want the money from the fossil fuel industry, more than they want humanity to survive into the next century. Other than that, they're public servants.

More on valuing health outcomes

Okay, so now for some of the low-hanging fruit.*

Ideally -- but not necessarily really -- the way treatments such as new drugs are evaluated is through randomized controlled trials (RCTs), conducted according to certain standards. One of the most important of these (and probably most often violated, in the past at least) is that the trial must test pre-specified outcomes. The reason for this stringent requirement has to do with the rules of inference. Whoo. Here goes some headbanging.

As I presume most readers basically know, the way you do an RCT is to divide a bunch of people at random into two groups. One of them gets the magic potion, and the other doesn't. Whatever your specified outcome may be, there's a chance that even if the stuff doesn't work, more people in the intervention arm will have the outcome, just by random variation. You can calculate what that probability is, given the observed difference between the two groups. It's called the p value. Pretty much arbitrarily, we say it has to be less than 5% (p < .05) in order to call the trial successful.

Here's where the big problem comes in. There are bound to be some differences, actually a lot of differences, between the two groups. If you go looking around for them until you find one, and then calculate its p value as if you had specified the outcome in advance, that p value is bo - o - o - gus. Basically, it's meaningless.

Here's another problem. In order to get a drug approved, companies have to show that based on the above procedure, it's better than placebo. But they don't have to show that it's better than an existing, quite likely cheaper, alternative. They also don't have to show that the benefit is of any particular magnitude, and they don't even necessarily have to show that it actually benefits people at all. They can rely on so-called "surrogate end points," that is, indicators that are thought to be predictive of better health outcomes, such as lower LDL ("bad" cholesterol), but which might not actually be better after all. More than once, a drug approved on the basis of a surrogate endpoint has ultimately been found not to produce the expected better outcome.

So . .. Long story short, there are quite a few interventions out there that really aren't better than cheaper ones, or which don't really do any good at all for most of the people who get them. There is a voluntary effort now by many of the medical societies to encourage their members not to use some of these, but no general authority that says, for example, that Medicare won't pay for them.

That's because Congress forbids Medicare from taking cost into account in deciding whether it will pay for treatments. We could start by not paying for stuff that isn't any better than cheaper stuff, or that really doesn't do any good. But as soon as somebody proposes it, we get ignorant idiots screaming about death panels.

Next I'll talk about some harder issues, since this one ought to be easy.





* George Orwell advised "never use a metaphor, simile or other figure of speech which you are used to seeing in print," in the interest of avoiding cliched writing. Sorry George, just couldn't find a better alternative.

Valuing health outcomes

Recent discussion here has raised one of the most contentious issues in health economics and health policy -- one that happens to be largely ignored in the political discourse. That is how we put a value on  people's states of health (once we have even figured out how to define them). That we must do so in order to make any sense out of arguments about the cost of health care and how we pay for it, to the extent that it comes up at all, is generally treated as a morally outrageous assertion.

For the present I won't even get into the valuation of other kinds of programs and policies, which may have a much greater impact on your health than whatever it is doctors do to you, but you can extrapolate some of this discussion yourself.

Some people have said that we shouldn't be so alarmed about the rising share of GDP represented by the medical industry. Medicine has much more to offer nowadays than it once did, while the cost of other necessities as a share of the economy has come way down. Since we no longer have to spend much of our income on food, and there are more effective, albeit expensive, medical treatments out there, of course we're spending more of our budget on them.

This is a perfectly reasonable point. Before automobiles existed, we didn't spend anything on them. Now buying them, maintaining, fueling and insuring them is a big chunk of our budget. But two issues remain.

1) As of now that share has long since stopped going up, in fact it's going down. Car ownership is not getting further and further out of reach for more and more people.

2) Consumers can do a reasonably good job of matching what they spend on owning and operating motor vehicles to the values they derive therefrom. Since all I want is to get from here to there reliably, I can figure out what relatively cheap car will do that for me. (Full disclosure: I just bought a slightly used Nissan Sentra.)  If I am afraid that a certain of my body parts is too small, and I think that owning an expensive motor vehicle will compensate, then my own judgment of how much to spend on a muscle car or a monster SUV may seem foolish to you, but it's my own choice.

Medical services -- or health care if you will, though I think the phrase is a misnomer -- don't work that way. As a consumer, I am inevitably very uncertain about the value I will derive from a given medical intervention. Let's leave aside for now the substantial additional complication that I may not have to pay for it, or at least not for most of what gets charged for it. Rather we'll take a social level view, as a taxpayer or insurance ratepayer. Is it worth it to get an imaging procedure, take a pill, have surgery? And let's also leave aside the fact, noted a few days ago, that the price may vary hugely depending on the vendor. Let's assume some identifiable average cost.

At this point, especially if life expectancy is at issue, a lot of people will just try to toss out the whole problem and say that you can't put a price on life or health. That is a feckless response because we in fact do. Your health insurance premium costs a finite amount, which some people can afford and others cannot. Medicaid doesn't cover most people who can't afford private insurance. Medicare covers almost everybody over age 65, but now a lot of people are saying we can't continue to pay as much for it as we are now, or at least not as much as we are likely to in the future under current policies. When you have needs your insurance won't pay for, either you pay for them yourself, or nobody does, in which case you suffer or die.

So, we have finite resources that we probably ought to allocate on some rational basis. But this is very difficult. Here are some of the challenges:

1) Benefits of medical interventions are usually quite uncertain. My car gets me to work and back reliably, but I'm not sure what lisinopril is doing for me. I have some vaguely quantifiable risk of heart or kidney disease without taking it, while it is far from clear how much that risk is reduced when I do take it. Exactly when I might develop symptoms, how severe they might be, and how gravely that would burden me, none can say.

2) There are almost always alternatives. I might be able to lower my blood pressure by taking great care with my diet, exercising more strenuously and regularly, and having a less stressful life. All that sounds lovely, but it may also come with costs or be simply unattainable. I could take different pills, with different side effects.

3) There might be other issues which are more urgent for me, for example if I were a tobacco addict, or severely overweight. Handing me a pill to lower my blood pressure might actually give me an excuse not to do something about all that -- but that's an imponderable.

4) It is very likely impossible for me to make any of these calculations on my own. That's why we pay physicians for advice about these matters. But do they know what is really important to us? Can they weigh, on our behalf, some highly uncertain relative probabilities of outcomes that even we ourselves can't be sure how to value?

5) The knowledge base on which any such calculations could be made is constantly changing, as is my personal situation -- my age, my comorbidities, my physical and social environment, my income.


Next, I'll try to define some of the easy problems -- the low hanging conceptual fruit that we can harvest easily and should; and the hard problems.

Situational Ethics

A town in Georgia is contemplating an ordinance requiring every household to own a firearm. I'm going to go out on a limb here and guess that the same people who agree with the local police chief that "I think y'all are showing the people that you're in full support of the Constitution, and as far as the Second Amendment goes, that you stand behind it, you stand behind people's rights," also think that it's tyranny to require them to buy health insurance.

I doubt they've even thought about that.

Another Open Door Crashed Through

But, sometimes you need a prestigious panel to lead the way. The report of the National Commission on Physician Payment Reform is here. The highfalutin' name is maybe a little pretentious -- it was convened by the Society of General Internal Medicine, not the gummint. And yes, internists -- primary care docs -- have a lot of skin in this game. But they say all the stuff that needs to be said.

I've been raving about these issues here for years, so I'll take this opportunity to hit a couple of high points that might fit on a bumper sticker, maybe a really big one.

First of all, did you know that the U.S. already spends about as much public money -- taxpayers' money -- per capita on health care as the other rich countries that have universal coverage and better results? It's true -- we spend more than Canada, Switzerland, France, the UK, Australia and many others. Then we spend an approximately equal amount of private money on top of that. As a result our total spending on health care per person is more than twice the average of the other wealthy countries, and by far the highest on earth. And yet we don't provide any health insurance at all to 48 million people. And our population's health status is worse than that of Paraguay.

In other words, if we were as smart as the cheese eating surrender monkeys, we could take the public money we are spending today on health care, and provide excellent health care to everyone, without making anybody pay a single dollar out of pocket. 

Why is that? Basically: we pay more for the same goods and services; we pay for a lot of stuff we'd be better off without; we don't pay enough for stuff we need more of. The fee-for-service payment model creates an incentive to do more, but not to get the best results. We pay much more to certain specialists who do expensive, high technology procedures than we do to primary care doctors who can figure out what we really need, do the cheap stuff early that really matters, and save us from unnecessary or even harmful and very expensive interventions. To whit: a radiologist earns, on average, $315,000 a year, while a primary care physician earns $158,000. No wonder there is a crushing shortage of primary care physicians, and no wonder we get far too many imaging procedures.

All this talk about the unsustainability of Medicare and Medicaid, and how we just have to cut benefits and raise the eligibility age, is either ignorant blather or deliberate lies. We can easily afford high quality care for everyone. But we aren't even having the right discussion.

More on the Nanny state

Our good old Swiss friend Ana brings up the subject of the U.S. not taking care of its people. Apropos of this question is Sarah Conly's book  Against Autonomy: Justifying Coercive Paternalism,
reviewed here by Cass Sunstein. 

Sunstein is reasonably convinced by Conley's basic argument against the libertarian presumption that we ought to leave people alone to make their own mistakes, e.g. not mandate motorcycle helmets or seat belts, ban gigantic cups of sugar water as Mayor Bloomberg wants to do, ban smoking in restaurants, that sort of thing. Her argument is essentially that people don't know what's good for them, and that they will often end up wishing that somebody had gotten a little bit paternalistic with them.

That's true enough, but both Sunstein and Conly seem to entirely miss another, perhaps more compelling point, which John Stuart Mill, the Godfather of the libertarian argument, also missed.  It is very rarely true that a person's bad choices harm that person, and that person only. It just is not the case that if you don't wear a motorcycle helmet and you end up with brain damage, the rest of us care only out of misplaced altruism.

It's astonishing to me that somebody as smart as Sunstein doesn't see this instantly. Let's make it as easy as possible. Suppose the mangled cyclist has dependent children. We can be as Randian as we want about this and presume that nobody should give a rat's ass just because they love him. But now somebody has to take care of his kids. Or let them starve I suppose, but who really wants to go there?

Oh yeah. The guy previously worked, paid taxes, maybe improved his property thereby enhancing the neighborhood, gave to charity, and spent his income thereby enriching his hard working neighbors. Now he's lying in a long-term care facility sucking money out of other people's pockets.

I mean, how could people not see this? And yes, it's just as bad if you decide to spend your days drinking 48 ounce cups of soda and wind up weighing 300 pounds, then get diabetes, osteoarthritis and heart disease. It isn't only your problem, it's all of our problem.

Duhhh.

I'm not really getting this scandal

That would be the horse meat thing. If you're perfectly happy to eat cattle, pigs, and sheep, why is it shocking and horrifying to eat horses? Especially since the whole premise of the story is that consumers couldn't tell the difference -- it takes DNA testing to discover it. The corporate media are covering the discovery of horse meat in some European prepared foods as if it's some sort of public health catastrophe. It also turns out that it is currently illegal in the U.S. to slaughter horses for human consumption. So we ship them to Canada or Mexico so they can meet that fate elsewhere.

I'm sorry but this is just bizarre. For the record, I personally don't eat any of the above. But I am not seeing the issue here, sorry.

On to more substantive issues. We're experiencing a major freakout here at the public health research shop. Whole research programs, Ph.D.s, post-doctoral fellowships,  and oh yeah, my job, are premised on the assumption that the federal investment in health research will be reasonably stable. It doesn't make a whole lot of sense to grant degrees, do post-doctoral training, and launch people on careers if there isn't going to be any way to sustain them next year. But that's the position in which we now find ourselves.

You may not think that an 8% cut in federal support for scientific research sounds all that catastrophic. So let me enlighten you. The National Institutes of Health commits the vast majority of its extramural funding to multi-year projects, typically 3 to 5 years. Some major longitudinal studies are considerably longer. Ergo, an 8% budget cut means essentially no new grants this year, at all. Or very close to none. Therefore, all of us who are completing funded projects and are ready to go on to the next funding cycle are going to be left high and dry. Our work will lurch to a halt. We'll be laying off staff and maybe ourselves.

This may sound like self-pleading. Sure, I want to keep my job and do the work that is important to me. But this is about you too. What we're trying to do is make health care more effective, and yep, cheaper -- more affordable to the taxpayers. We're trying to find better treatments and cures for the ills that plague us. We're trying to make the health care system meet your needs better, be more equitable, more humane, and more directed toward the outcomes that patients want. And, overwhelmingly, the public supports that. The people want us to keep doing what we do.

So what I'm not getting is, what is the constituency for this? How do Republicans think they can win elections by screwing the people? Explain it to me.

The world's most ignorant idiot

That's a little bit more specific than "Worst Person in the World," but probably too kind.

New Hampshire state representative Mark Warden.

The Republican Party must have a highly sophisticated search strategy to find these psychos.  But then people actually vote for them.

People used to wonder why people -- mostly women -- stay in abusive relationships. But now we understand that is a really stupid question. They're abusive, get it? One person is controlling another through intimidation, threats, psychological manipulation, and physical violence actual or latent. You can't just leave because the person has power to hurt you. You are not just "free to go, that's the whole point.

That is not a "love hate relationship," it's exploitation, assault, violation, oppression, and yes, the government and the law, as the embodiment of the expressed will of society, has a right and a responsibility to combat it and help abused people get free.

Mark Warden, schtick dreck.

Yes, this really is a breakthrough study

You may have seen coverage of this in the corporate media, but I'm going to give you a bit of value added. A randomized controlled trial finds that the so-called Mediterranean diet results in fewer strokes and heart attacks, not to mention fewer deaths, in people at high risk for heart disease.

Now here's why this is a big deal. Most of what we know about nutrition and health comes from observational studies. It's very difficult to sort out the effects of nutrition on human health because, among other problems:

• People's diets are obviously very complex. You can't easily or convincingly sort out the effect of one dietary component or characteristic from all the other features of diet;
• People's diets tend to be correlated with all sorts of other facts about them, including socio-economic status, where they live which is associated with all sorts of other exposures, their culture, their consumption of health care and all sorts of health-related behaviors from smoking to physical activity to how often they have sex;
• There is confounding by indication. People who are overweight, or diabetic, or otherwise have been told by their doctors that they are at risk or believe they are for whatever reason may already be trying to modify their diets.
• Doing long-term, randomized controlled trials is extremely difficult because people don't stick to the diets they are assigned.

These Spanish investigators overcame these problems by, first of all, deliberately selecting people who are at high risk -- who have been diagnosed with diabetes or overweight, with a median age of 67 years. They included smokers, and people who are taking medications for hypertension and cholesterol. They randomly assigned them to a low fat diet group, and two Mediterranean diet groups, one of which got free olive oil and one of which got free nuts in addition to nutritional counseling.

Finding #1: People could not stick to the low fat diet. We already know that: diets are very hard to stick to. So this group ended up being basically a control group of people who eat whatever. BUT, people could stick to the Mediterranean diet group. They got to eat all they wanted -- there was no attempt at calorie control. They were allowed to drink alcohol (encouraged to be in the form of red wine with meals). They didn't have to stop smoking or lose weight or do anything else. This diet is satisfying to eat, and allows all kinds of great tasting food. So unlike all the other diets out there, it's actually possible: you can do it.

Finding #2: No, the people didn't lose weight, but they didn't gain weight either, even though they were actually encouraged to eat a lot of fat, consisting of nuts, olive oil, and fatty fish. What they also didn't do was have as many heart attacks or strokes. The big win was stroke, which was statistically significantly less likely to happen with the Mediterranean diet after three years than the regular diet. That probably drove all of the results, but everything else got at least slightly better or no worse, including death, particularly with the olive oil supplementation, although this didn't hit the arbitrary p<.05 level of significance. Still, who wants a stroke?

So no, we don't know exactly what pieces of this were most important, but it confirms what I've been saying all along. It's not how much fat you eat, it's what kind of fat. Olive oil and nut oils are what you want. Also lots of veggies, legumes, and fish. (Alas, fish are not generally a sustainable food. We'll have to figure something out in that department.)  Skip the red meat and go very easy on the dairy fat. (Some Mediterranean cuisines have more goat cheese than cow cheese, which probably also helps since it's lower in fat.) Tomato sauces with olive oil are jes' fine, as are birds. You can do that!

Sure, you should also quit smoking and maintain a healthy weight and all that, but the news here is, even if you don't do that, you still benefit. Really. It's not a mystery.

Too obvious to study?

Yes, but sometimes you need to prove the obvious before anybody will do anything about it. Believe it or not, some U.S. medical schools still don't have policies to stop drug companies from brainwashing their students. They do this by sponsoring talks in which a corrupt physician or company flack pitches their products, often accompanied by free lunch; and by handing out gifts, including not only tschochkes but also school supplies and devices of significant value. Since the American Medical Student Association, to its credit, is against these practices, and has started grading medical schools on their policies restricting marketing to students.

In the new BMJ, King et al look at the results. It turns out that for 2 of the 3 drugs they studies, graduates of medical schools that had policies restricting drug company marketing to their students were less likely to prescribe these drugs after they completed their residencies. The drugs were new, brand name drugs that weren't any better than older, cheaper generics. It's not clear why there wasn't an effect with the third one, desvenlaxafine, which by the way has not been approved for use in Europe and for which very weak evidence of efficacy exists. The authors say this appeared to be due to fairly high prescribing by the early cohort in the group less exposed to marketing as medical students, which suggests it may have been other marketing efforts that obscured the effect. Anyway . . .

There is no excuse whatsoever for any medical school to allow drug companies anywhere near its students, in any way. Drug company representatives and drug company sponsored talks or other events should be totally banned. 100% of the education medical students get about pharmaceuticals and prescribing should be provided by people with no financial interest of any kind in anything they will do once they enter practice.

Bring on your counterarguments, please. I will destroy them.

Cleaning out the inbox

I've gotten a couple of press releases lately, which I usually ignore because I don't like to be told what to write about, if you know what I mean, but these I do commend to your attention.

This Time Magazine article by Steven Brill has gotten some coverage in the blogosphere, but it won't hurt to link it here as well. The general idea is that hospitals and other health care provider institutions don't tell you ahead of time what prices they will charge, and a lot of those prices end up looking totally outrageous. They also vary enormously, and seemingly arbitrarily. Insurance companies, which you would think would have a lot of leverage, really don't when it comes to the prestigious hospitals, which the insurers' customers demand access to and which are usually regional monopolies. Medicare and Medicaid pay less, but their prices are set through the political process and you know how that works -- powerful interests prevail over consumers and taxpayers. Medicare isn't even allowed by law to negotiate over drug prices.

It is a fact that one of the main reasons health care costs so much more in the U.S. than in  civilized nations is simply that we pay more for the same goods and services. Single payer national health care would mean the payer has real bargaining power and can get those prices down. It does not, however, guarantee that it would happen given the political process in this country.

Meanwhile, Choosing Wisely has released a new list of procedures that usually aren't indicated but are often done anyway. This also has gotten some press coverage. They sent me the release on Monday but embargoed the info until today. Since I don't usually blog at 12:01 am, I was behind the curve on it. Anyway, that's another reason why we pay more here for health care -- we don't have an equivalent of the UK's National Institute on Clinical and Health Excellence that issues guidelines on what the National Health Service will pay for because it's worth it, and won't pay for because it isn't. Congress won't allow that either.

Here are a few examples:

   Don’t use feeding tubes in patients with advanced dementia. Studies show that percutaneous feeding tubes do not result in better outcomes for these patients. The recommendation states that assistance with oral feeding is a better, evidence-based approach. (American Academy of Hospice and Palliative Medicine; American Geriatrics Society)

Don’t perform routine annual Pap tests in women 30 – 65 years of age. In average-risk women, routine annual Pap tests (cervical cytology screenings) offer no advantage over screenings performed at three-year intervals. (American College of Obstetricians and Gynecologists)

·   Don’t automatically use CT scans to evaluate children’s minor head injuries. Approximately 50 percent of children who visit hospital emergency departments with head injuries are given a CT scan. CT scanning is associated with radiation exposure that may escalate future cancer risk. The recommendation calls for clinical observation prior to making a decision about needing a CT. (American Academy of Pediatrics)

But insurance, whether public or private, will pay for all of the above, no questions asked. (BTW CT to diagnose appendicitis is also questionable in many cases, but there's no systematic review or guidance on that as yet. Maybe some day . . .)

Here's something you definitely should not pay for. (No link!)

As with any computer, it is imperative to occasionally reboot, refresh or restart your body. Unbeknownst to most, your body has its own CTRL ALT DEL function that can be set into motion by a trained physician practicing a lesser-known form of therapy called Cranial Osteopathy. This technique is capable of literally resetting, restoring and recharging our bodies and minds, to operate at optimal levels by improving the health of the cervical spine . . . .

Cranial osteopathy encourages the release of stressors and sources of tension throughout the body – especially within the head and neck region. Osteopaths utilize their finely honed sense of touch to detect and restore the Cranial Rhythm and elicit a therapeutic response.

This is probably the most ridiculous, manifest bullshit I have ever seen. There is no such thing as "cranial rhythm" and there is no such thing as "rebooting" your body, and anybody who falls for this crap is an idiot who deserves to be relieved of his or her money. That is all.

Men are scum

A visitor asks whether it might be more appropriate to attribute the problem of gun violence in the U.S. to the male of the species, than to the weapons.

Our friend is certainly reality based when it comes to numbers. Men are about four times as likely to kill themselves as are women. (Although, of considerable interest and puzzlement, women are more likely to think about it, and to make unsuccessful attempts, or at least gestures.) Men are also about four times as likely to kill other people than are women, and women who do kill often kill an abusive partner, just as women who are murdered are likely victims of intimate partner violence.

So yep, men are more violent than women, and this is pretty much true throughout history and across cultures, as far as I know. People engage in a great deal of feckless (in my view) argumentation about the extent to which this may be an innate human trait, or subject to cultural modification. To me this is a false dichotomy -- all phenotypes result from the interaction of genetic inheritance with environments. The greater proclivity of the male of the species to violence exists in just about every culture we know of, so in that pragmatic sense it is as innate as the tendency for men to be taller, and to die sooner, than women.

On the other hand, the absolute level of violence, perpetrated by males or otherwise, varies a lot among cultures and, as Steven Pinker argues, has generally been declining in recent centuries. The greater lethality of available technology, including firearms, cuts against this trend, but I'm nevertheless fairly convinced that it is real.

So I would say our friend introduces another false dichotomy. Whatever the demographic profile of the killers of self or others, they'll succeed less often if the available means are less effective. Furthermore, a culture that glorifies or condones violence and fetishises weapons is going to have more violent deaths given a specified prevalence of effective means. In other words, the strategies are not mutually exclusive.

Seems like an easy question.

Energy Medicine

I changed my usual policy and left a spam comment on my previous post, because it links to an utterly outrageous fraud.

I don't spend a lot of time trashing quackery because there are plenty of people doing it with more time and resources, and a bigger readership, than me. (Viz., Science Based Medicine.) But I am curious about why so many people are attracted to so much hooey, and how is it that these malignant clowns manage to relieve said people of their hard earned cash.

One can discern a taxonomy of quackery. There is the herbalist/supplement group, which generally hews close to the scientific worldview but just doesn't bother with the facts. The claims are intrinsically plausible: that the nostrums do in fact contain biologically active chemicals which either fill nutritional needs or correct one or another form of bad chemistry in the body, just like pharmaceuticals. But they are purportedly better because they are "natural," "gentler," have fewer side effects, whatever. Big Pharma doesn't want you to know it because they aren't patentable and therefore don't bring in the big bucks.

You know what? This might be true. Sometimes it is true. Aspirin is a slightly modified form of a compound found in willow bark, which was known to the ancients. Statins are versions of a compound found in a fungus which was used by the Chinese to treat heart disease. Presumably you know about morphine, etc. Lots of drugs are derived from plant compounds. But you don't make willow bark tea, you buy aspirin, for a good reason -- you know exactly how much you are getting of a pure compound. And most of the junk on the shelves of the GNC doesn't do any good. It's almost all a ripoff. But that can be determined on a case by case basis -- the claims aren't inherently nonsensical. People have good reason to distrust pharmaceutical companies and it isn't that hard to see why they fall for the blandishments of the supplement industry.

Energy medicine is another matter. This encompasses Reiki, therapeutic touch, and acupuncture, along with some more obscure or localized shamanistic systems. It derives from a category of pre-scientific belief called vitalism, essentially the idea that life is a kind of energy or mystic force that imbues living things. In acupuncture, it is said to flow through specific channels in the body called meridians, which connect organs and locations in the body with others. These flows become blocked or diverted, and sticking in the needles is supposed to correct them. In Reiki, the practitioner "realigns" forces with his or her hands.

It is much more difficult for me to see why anybody falls for this nonsense. The "vital energy,"  the chi of acupuncture, do not exist. The meridians do not exist. These ideas are purely imaginary. Life is not in fact precisely definable, nor is the border between life and death sharply defined, but life processes are based on the same forms of energy found independent of living things. Chemistry and physics give a complete account of life. Of course we haven't filled in the innumerable details of every life process, but there is no missing or mysterious form of energy. Chemical bonds break and form, heat (and yes, a little bit of electricity) flows, gravity pulls down (to put it in vernacular terms, sorry Dr. Einstein), electromagnetic radiation strikes the cells and has readily describable effects. (Some life forms produce electromagnetic radiation, but as far as I know we don't. We do have a weak electrical field, but it doesn't particularly do anything.)

There is, to be sure, growing interest in using electrical stimulation for various healing purposes, from orthopedics to neurology. But that's plain old electricity, folks, not the mystic force field. You don't make it by waving your hands around or sticking in needles. The useful therapeutic inputs include chemicals, heat (or cold), light, physical manipulation (e.g. compression, immobilization, mobilization, stretching, surgery), electricity. The same old boring energy that pertains to dead stuff.

Okay, it's not boring. It's science. Why isn't that good enough for folks?

And while we're on the subject of supplements . . .

Last time, I mentioned that lots of people take calcium supplements for "bone health." Well, you might want to think again. The linked article presents very complex statistical analysis, but to make a long story short the authors have done everything they can to control for potential confounding in an epidemiological cohort study. (They took advantage of a cohort of Swedish women recruited originally for a study of the benefits [or lack thereof] of screening mammography.)

The bottom line is that the body regulates the level of calcium in the blood very closely. Unless you have a real calcium deficiency, more calcium won't make your bones stronger, it will just be excreted. Up to a point, that is. The basic conclusion of this study is that calcium supplementation at low levels -- say from a multivitamin -- is probably harmless, but doesn't do you any good either. However, once you get above a certain threshold, about 1400 mg/day, which you can get from taking a specific calcium supplement, it sharply raises your risk for heart attacks and death.

So once again, the same message. Eat a half decent diet. Skip the supplements, you're wasting your money and more likely to be harming yourself than helping yourself. If you have a specific nutritional deficiency, it may be a different story. Talk to your doctor.

On another subject, Merck has agreed to pay investors $688 million for keeping secret the results of trials showing that it's highly profitable blockbuster drug Vytorin doesn't reduce the risk of heart disease. The company previously paid out a mere $41.5 million to consumers in a class action suit, and $5.4 million to state attorneys general. You may remember the advertisements featuring people dressed up to look like various foodstuff, touting the useless snake oil.

Sounds like a big victory for the good guys, right? Not so much. It's chump change. In its heyday, Vytorin was being prescribed at the rate of 800,000 new scrips per week, bringing in $5 billion in one year (2007). They made a ton of money, and had to cough up a few percent. That's why they keep doing it.

Firearms policy on Earth 2

A couple of essays in the new JAMA on gun violence: one by Kellerman and Rivara on Republicans' successful efforts to defund public health research on the subject; the other by Mozffarian and colleagues on possible effective public health measures based on analogy with other health hazards. (And props to JAMA for making these available to y'all commoners.)

What is astonishing about both of these ruminations is that they are simultaneously the very paradigm of common sense; and so politically naive as to be risible. I expect the authors know that, but they figured, what the heck?

As K and R recount, Congress in 1996 tried to de-fund the CDC Center for Injury Prevention altogether, because they were figuring out that keeping a gun in the house makes you more, not less, vulnerable to violence and death. They ended up backing off slightly, but the amount of funding originally spent on gun violence was earmarked for other purposes, and language inserted in the appropriation that forbade funds being used  to "advocate or promote gun control." Not wishing to risk their agency's existence of their own careers, CDC employees have assiduously avoided the issue ever since. The restriction was later applied to NIH.

As always, Republican epistemology is "If evidence might show that we are wrong, make sure we don't get any evidence."  Reality has a well-known liberal bias.

So, what do Mozaffarian and the gang propose? Noting that 85 Americans are killed by guns every day, they look to public health successes in the areas of tobacco, unintentional poisoning, and motor vehicle safety. We have made major progress reducing harm from all of these sources.

So why don't we tax firearms and ammunition to incorporate their actual social cost in the price and fund gun safety programs, as we have done with tobacco? Riiiigght.

Why don't we require keyed or code locked security devices on guns, analogous to childproof safety packaging on drugs and chemicals? Ha!

Why don't we require mandatory gun safety classes and licensing, as we do with drivers? In your dreams.

Why don't we have a sustained media campaign to de-glamorize guns, as we did with cigarettes? Instead of being manly and cool, in other words, guys who have to go around armed all the time are wimps. Uh huh.

The fact is that of all the measures they discuss, only restrictions on large capacity magazines are under any sort of serious discussion, and that's not going to happen. (And in case you think we're talking about restricting rapid fire semi-automatic weapons, no we aren't. We're only talking about restricting "assault weapons," which just means rapid fire semi-automatic weapons that have a certain bad ass look about them. Tone down the bad ass look, and the president's proposal is inapplicable.)

If we did even half of the above, we could significantly cut down on the carnage. And in case you're wondering, so far the Supreme Court would have no problem with any of it. (The media campaign would have to be conducted by private organizations, presumably, although the government could fund more straightforward educational messages.) But should I be spending my bandwidth on a hopeless cause?

Not that the corporate media will notice . . .

or in any way change its conventional presentation of the "Tea Party" as a) a party of some kind and b) a grassroots movement of down home regular murkins who are fed up with big gummint because they believe in freedom, but it is of course a phony astroturf movement funded by the Koch brothers, which grew out of the phony smokers' rights movement with its associated science denialism funded by the tobacco industry.

As I have said here many times, in the United States we do not have public political discourse organized around competing value systems, or competing analyses of facts in evidence. We have competing sets facts, classifiable by people capable of evaluating evidence as true and false.

E.g.

True: The federal budget deficit is not the cause of our recent economic collapse and current sluggish recovery. Federal borrowing is not "crowding out" private investment. We have a shortage of demand, the cure for which is more, not less, government spending.

True: Rich people do not "create jobs," and they do not create more jobs if they are taxed less. Jobs are created when it is worthwhile to produce goods and services because there are people who want to spend the money to buy them. Right now, giving more people to rich people destroys jobs, because they are not inclined to spend most of their money.

True: In the long run, the projected large federal deficits are not caused by big government or any form of discretionary spending. (In my opinion, most military spending is wasteful but for the sake of argument I'll stipulate that to be debatable.) In any event, projected growth in deficits is not based on growth in military or domestic discretionary spending. Nor are they caused by Social Security. They are largely a product of projected increases in spending on health care, and contingent on our having historically low rates of taxation by modern standards. But . . .

The reason we spend so much on health care is not because people have insurance, or we don't have a "free market." It's because we have too much of a free market. Countries with socialized health insurance spend half as much, and get more. Ideology can't trump that fact.

True: Human activity, principally burning fossil fuel but also cutting down trees, is causing the climate to change, increasing the frequency and severity of storms and droughts, making the seas rise, and otherwise wreaking havoc.

True: Sugary soft drinks and other heavily marketed elements of the U.S. diet cause people to have diabetes, and other diseases.

And so on. The only reason we pretend to have a "debate" over these issues is because rich psychopaths pay to create phony controversies. A truly independent, professional and competent journalistic establishment would tell that story, and only that story, to the American public.

Boring academic wankery

Our latest paper has been published on-line, and you can read the abstract here. If you really want to read the whole thing, which I doubt, send me an e-mail and I'll send you the PDF.

The abstract doesn't really do it justice. What we've done is break some outpatient visits into pieces -- all of the various issues that come up -- and keep track of how they are processed. It turns out, among other observations, that about half of them either don't require that anything be done, or there is in fact nothing that can be done. This isn't necessarily bad -- docs need to check in on stuff, people need to bring up stuff that's worrying them even if it turns out to be not a problem. It's just what it is.

Also, there are huge differences in the way the interaction looks depending on what task is being done. While we're trying to understand what's wrong or what's going on, the physicians ask a whole lot of closed questions and the patients give information in response. This actually takes up the bulk of most visits. There is also some patient education/information giving, during which patients ask more questions than do providers, no surprise, but not a lot more. When decisions are being made about treatment, doctors do most of the talking, patients seldom express their own wishes or ask questions, and doctors pretty much just say "This is what we'll do." So shared decision making or patient choice are quite scarce, at least in this data.

So that's a lot of what I do. We're pressing on with these methods now in other contexts, and I'm actually hoping to learn something. Meanwhile, when you go to the doctor, don't be afraid to speak up, and ask for an explanation of why a particular treatment is recommended -- or just given to you -- and whether there are alternatives you might want to know about. It turns out, by the way, that when that happens, people tend to end up using less drugs and getting fewer procedures. Which is probably good for you.

A Good Death

Some of my colleagues have used Medicare claims data to track the trajectories of dying people in 2000, 2005 and 2009. The article in JAMA is a dense, hard to read recitation of numbers, basically, so let me just unpack it for you.

Superficially, it looks like good news: many fewer people died in acute care hospitals in 2009 than in 2000 (24.6% vs. 32.6%). Most people say they prefer to die at home, but failing that, a good quality nursing home is usually a much better environment than an intensive care unit. If you're shuffling off anyhow, you don't want to be hooked up to machines with weird noises and flashing lights and strangers shoving tubes into you and whatnot. And more good news: the percentage of people receiving hospice services at the time of death went up from 21.6% to 42.2%.

But, you knew there was a "but," right?

The problem is that despite what happened at the very end, more people were hospitalized, more often, during the last months of life, and many of those people who got hospice services got it for only a day or two. In other words, we're still putting dying people in the hospital, in fact more so than before, it's just that they don't stay there until the moment of death as often, they tend to get shipped out a day or two ahead. That isn't really progress.

Now it's not clear how many of these hospitalizations were "appropriate." It's hard to predict who is going to die soon and some percentage of them no doubt looked they had a chance to pull through. But most of them are people who were clearly dying, perhaps in a nursing home already, who got sent to the hospital to get an IV antibiotic infusion or emergency rehydration or some such essentially pointless treatment.

I don't mind telling you that my father could well be in this data. (It's a 20% random sample of all the deaths of people on fee-for-service Medicare in those years.) He died in 2009, in a nursing home, receiving only palliative care, and he was not hospitalized even once in his last two years of life. But it wasn't easy for my mother and I to achieve that. My mother had to write a letter (with my help) to the nursing home, stating that she did not want my father, who was severely demented, to be hospitalized or tube fed. She had to sit down with the nursing director and have a lengthy conversation in which the nursing director tried to talk her out of it.

There is, believe it or not, a financial incentive for nursing homes to hospitalize people. They get paid by Medicaid to hold the bed while the person is in the hospital, during which time they don't have to take care of the person; and then they may be able to get paid by Medicare for a period after the person returns, which is better money than Medicaid.

So until we straighten out our completely batshit crazy health care financing non-system, it's going to be very hard to fix this or any other problem.

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

Why you are wasting your money

A couple of days ago I posted about the uselessness of dietary supplements for most people. Right on cue, some folks writing in JAMA Internal Medicine let us know what people think they are doing when they take the snake oil.

It turns out that 45% of all U.S. adults say they take dietary supplements -- mostly multivitamins -- "to improve overall health," while about 1/3 say they do it "to maintain health." Other prevalent reasons include "to prevent health problems" (20%), for heart health (15%) to "boost immunity" or prevent colds (14.5%), for healthy joints or to prevent arthritis, (12.4%), for enhanced energy, skin health, eye health, mental health, weight loss . . .

Reality check: it is all bullshit. Dietary supplements for the general public do none of the above. These authors are a bit coy about that conclusion. They review evidence, all of which is negative, and then call it mixed or unconvincing. It's convincing, folks. What has happened to you is that people on teevee lied to you, and you fell for it. Unless your doctor has identified a specific condition for which you require a nutritional supplement, there is no reason to take vitamin pills, or iron (which can actually be quite bad for you in excess!), or fish oil, or even calcium. (I delayed mention of the bone health motivation, which 1/4 of people, mostly women, give because some women have been told by their physicians that they should take calcium supplements. I doubt this really applies to 1/4 of all people, or 40% of women, however, and it's somewhat controversial anyway.)

There are a couple of other gray areas or open questions. Some people, those with dark skin in particular, might benefit from vitamin D, although this has been questioned. There is maybe a little bit of a fuzzy zone between some specific foods and dietary supplementation, olive oil, very high fiber foods like bran, there are other examples. Some foods are routinely supplemented -- e.g. folic acid and iron in refined wheat, vitamin D in milk -- which replaces what otherwise might be supplements that might reasonably be indicated for more people. But really folks. Talk to your physician, and unless there's something specific going on, you should probably save your money.

Guns don't kill people,

people kill themselves. With guns.

I haven't had a whole lot to say about the big gun safety debate going on right now in part because, if I'm going to be contrarian, I want to take the time to get my ground under me.

First, I actually find highly offensive the repeated calls by people who are ostensibly progressive and ought to know better that a priority should be to keep guns out of the hands of the mentally ill. As I have repeatedly discussed here, according to the American Psychiatric Association, half of the population is mentally ill at some point in their lives, and almost 1/4 of us are "mentally ill" right now. I actually think that's preposterous and largely consists of fake "diseases," but that's more or less beside the point. It does happen to be true that rampage killers are usually diagnosable with something, but that's pretty much tautological. The question is whether psychiatrists or anybody else can actually predict who will act violently and the answer to that is, the only really useful predictor of violent behavior is past violent behavior.

So no, preventing "mentally ill" people from buying guns is a) useless and b) offensively discriminatory. Keeping guns out of the hands of people who have been convicted of violent crimes is potentially useful, but that's already generally the law in most states as far as I know. Whether this is actually possible, however, given that guns already outnumber people in the U.S., is another question.

Second there is the nonsensical issue of assault weapons. An assault weapon is just a semi-automatic rifle with certain largely cosmetic features, such as a bayonet mount. There is something culturally repellent about them - the only reason people want to own them is so they can fantasize about being soldiers or committing mass mayhem. But they aren't functionally more dangerous than other semi-automatic weapons. Rifles in general are far more accurate at more than modest distance than are handguns, but handguns are actually responsible for most gun injuries and deaths in the U.S. I just don't see banning the sale of particular categories of firearms as being meaningful.

Large capacity magazines? Okay, those have no purpose other than killing large numbers of people in a short time. There's a perfectly good case for banning them, although again, it's probably too late to stop people who want them from getting them on a secondary market, given how many gazillions are already out there.

But now here's the real truth about gun violence. Congress has prevented the CDC or NIH from funding studies of gun injuries, because ignorance is patriotic, but people study the issue anyway. Most gun deaths in the U.S. are suicides, not homicides. If you have a gun in your house, I don't know exactly what the chances are that you will ever use it to defend yourself against an intruder. As we've seen lately in too many cases, the intruder you shoot is likely to turn out to be your own spouse or son, but that aside, I'm going to take an educated guess and say that the likelihood you will kill yourself with your gun is at least 4 orders of magnitude, i.e. 10,000 times as great, than the likelihood you will successfully defend yourself with it.

Most people who haven't studied the issue assume that people who commit suicide are determined and will spend time and effort to find a way. Mostly, that just isn't so. It's an impulsive act. It's also usually unsuccessful -- unless you use a gun. The reason is pretty obvious. The purpose of guns is to kill people. They work very well. And they work quickly. Grab the gun, point at your temple or put it in your mouth, and shoot. Badabing badaboom. You haven't been convicted of a felony, you haven't been committed to a secure mental institution as a danger to yourself and others, and the gun you're using is perfectly legal, probably a handgun with six rounds. You only need one. If you had been forced to take time to plan a way, or tried a less effective method, you would probably be alive.

That's the real truth about gun violence. The best way to keep yourself safe is not to have one; or failing that, keep it locked in a safe and unloaded in between bouts of shooting cans off the top of the fence. Really. Other than that, I can't see banning any particular products as making much of a difference.

Vitamin pills: Nothing will come of nothing

This meta-analysis in the new BMJ is the most zero finding ever. I mean to tell you, the bottom line is zip, zilch, nada, bupkis, totally nothing: taking vitamin supplements, be they specifically anti-oxidant vitamins or multi-vitamins or whatever you want absolutely, positively, does not prevent heart disease or the bad consequences thereof based on a huge amount of unusually consistent evidence.

Other reviews have found that vitamin supplements don't prevent cancer -- in fact certain vitamin supplements actually increase the risk of cancer in smokers. Taking vitamin supplements doesn't make you live longer, doesn't stop your hair from falling out, doesn't do a damn thing for you as long as you eat a half decent diet and don't have a specific disease (such as pernicious anemia) that requires supplementation.

These products are heavily marketed, you see them on teevee all the time. Ignore the advertisements. Save your money. Eat your veggies.

That is all.

Surrealism in DC

This little post on Josh Marshall's site really made me take notice. The confirmation hearings for Chuck Hagel have been all about how he's a traitor for opposing the ultimately futile and failed "surge" in Iraq, which allowed the U.S. to get the hell out under a fragile fiction of stability so that all hell could break lose last year -- not that anybody in the U.S. has been paying attention. Trust me, Iraq is now coming apart at the seams. Also too how he is an insufficiently mad dog Zionist.

So far nobody has asked about, say, Syria, but the key point of the linked piece, and what has me quaking in my boots, is that nobody has asked him about the sequester, which it increasingly appears is going to happen because Paul Ryan evidently wants it. Or so he says. I personally don't think an 8% cut in the military budget would be a national security disaster, in fact I think it would be good for both national and global security; but I'm worried about everything else that will get trashed, including funding for my own research of course, but more than that, Great Depression II which will very likely ensue.

Of course nobody who brought this disaster on us will ever be held accountable.

Or as RL Borosage puts it  (more or less as I put it myself a few days ago:

We need a return to sensible governance. Repeal the sequester -- sudden and deep across the board cuts are idiotic. Promise to pay the debts already incurred and stop threatening a default that would shake global finances. Fund the government while working on a budget reflecting new priorities.
Commit to growing our way out of the hole we are in. Invest in areas vital to our economy and to our people. Pay for those commitments in ways that makes sense. Put people back to work and watch the deficits and debt burden come down.
That means launching a major five-year initiative to Rebuild America -- modernizing our decrepit infrastructure to make it a competitive advantage while creating jobs. Make the investments needed to provide every child with a world-class education -- from universal pre-school to skilled teachers to affordable college. Invest in research and development and sustain America as the global hotbed of innovation.
Pay for these and other vital priorities by ending the war in Afghanistan and reducing our empire of bases. Crack down on overseas tax dodges. Raise taxes on millionaires and tax the income of investors at the same rate as that of workers. End the obscene subsidies to big oil, big Pharma and big Agra.
This isn't rocket science. It is common sense. Yet, at this point, it can't be heard in the bedlam of a Washington afflicted with deficit delusions and austerity hysteria.

Why bother to offer any specifics?

What with the Republicans in Congress demanding drastic cuts in federal spending and "entitlement reform," but refusing to say what exactly the heck they are talking about, and president Obama saying that Medicare can save money without hurting beneficiaries but not bothering to say exactly how, it's obvious that all you have to do to be a successful politicians is spout empty rhetoric.

Here, the Center for American Progress proposes what it says are $385 billion in Medicare savings over 10 years without taking one single benefit away from seniors. I can't vouch for the arithmetic, but it's true that most of these reforms would definitely save some money. However . . .

They mostly save money by making suppliers -- drug companies, medical device manufacturers, hospitals, specialist physicians -- compete for their business or outright cutting payments. There is some other waste they want to wring out of the system but that's also somebody's income. That's our problem -- it isn't really Medicare beneficiaries who politicians are worried about, they don't have any money, don't contribute billions to political campaigns or superPACs or for that matter work for the news media. It's all those people who are profiting from Medicare spending. CAP can say "Hey, let's shut off the gravy train and take care of people cost-effectively," but where is the organized, financed, effective constituency for that?

Evidence based medicine

Sounds like a good idea, it's the right way to go but, it ain't easy.

Here's a problem I've been working on. Suppose you wanted to search all the relevant scientific literature and do a systematic review and metanalysis to figure out the best way to diagnose acute appendicitis. (I'll leave the definitions of unfamiliar terms in the preceding sentence for later; suffice it to say we'll be applying the best available methods for combing information from all of the good quality studies that have been done on the subject.) Then you can write a report and tell doctors how to do this. Fewer people get sent home only to have their appendix rupture; fewer people get surgery unnecessarily. Yeah!

Oh my gosh is it not nearly that easy. First of all, why are we trying to diagnose acute appendicitis in the first place? There are a lot of different tests you can use, but before you use any of them, you have to decide who to use them on. The facile answer is, people who show up at the ER with pain in the lower right quadrant of the abdomen. Then there are various other more specific clinical indicators that will raise or lower your suspicion that this really is acute appendicitis. But are we trying to diagnose appendicitis, or figure out whatever the reason might be that they have this symptom? If we go straight to question 1, maybe we're missing something else we ought to be thinking about.

And is this person a child, a woman (or for that matter a 14 year old girl) of reproductive age not known to be pregnant, a woman known to be pregnant, an adult male of [insert age category], or a very old person? How long have they had the pain? Every one of these variables means you're looking at a whole different kettle of fish.

Does the person have insurance that will pay for a CT scan or will they have to pay out of pocket -- or maybe the hospital will have to eat the cost. This is a medical emergency, potentially, so they have to treat you whether or not you can pay, but what does "treating" you mean? If you do have appendicitis, the cheapest thing to do (in hindsight), and the best from your point of view as well, is to go straight to surgery. On the other hand the totally cheapest thing to do, and the best from your point of view if you don't have appendicitis, is to send you home with advice to come back if it doesn't get better. But in either case, the wrong decision is likely to cost more and result in a much worse outcome.

You can always diagnose appendicitis, with almost perfect sensitivity and specificity, by opening up the abdomen and removing the appendix and having a pathologist look at it. But that's not really the question after all, is it? The question is, should I open the abdomen of this person with lower right quadrant pain. Maybe I'll find out they don't have appendicitis but there is some very good reason why I should have opened their abdomen. On the other hand, maybe they have an ectopic pregnancy or an ovarian tumor or colon cancer, and the wrong kind of surgeon is looking at it, who doesn't know what to do.

You can start with ultrasound, which has essentially no risk, but it's often equivocal. Then you can go to a CT scan, which does irradiate you with potentially some small long term risk, unless you're in early pregnancy in which case there may be greater risk to the fetus; you might also be less inclined to do a CT scan on a young child. If your hospital has an MRI scanner, there's no ionizing radiation but it's more expensive. And the hospital might not have one.

I could go on but you get the idea. You might be particularly averse to post-surgical pain, or you might not care so much. You might have known someone who died of a ruptured appendix so you're really anxious about it, or you might be happier to go home and wait. Whatever.

So . . . Doctors don't generally "know" what they're doing. They're just muddling through, hopefully for the best. As are we all.

Plugola

Not really, they didn't have to pay me. The Laborer's Union wants you to sign a petition asking the White House to end the delay in promulgating standards to protect workers from silica dust. Silicosis is a serious, often fatal lung disease caused by this exposure. Here's the background:

OSHA began working on new silica rules in 1997. A proposal was drafted and sent to the Office of Management and Budget (OMB) for review in February 2011. Normally, OMB has 90 days to review proposals before they are made public. However, publication has been delayed for nearly two years. Releasing the proposal for publication is just the first step in a lengthy review process. OSHA rulemaking requires public hearings and extensive opportunities for public input.

I've known about this for several years because some of my former colleagues at Tufts studied the problem. This has been crippling and killing American workers literally for centuries. There's no excuse for it to continue.