health and medicine, continued

(In case you haven't picked up on it yet, I have embarked upon a long-form essay. It will continue.)

So what is “medical” attention? It is well known but seldom seen as remarkable that most societies known to history and anthropology, even small scale ones with limited hierarchy and division of labor, have cultural roles for specialists in healing people. In societies large enough to support full-time specialists, as far as I know there is always a full-time healing profession. In some times and places these people have also been more generalist priests, with additional assigned powers, and priests can always try to get you some divine intercession, but usually there is a secular healer role as well, or more than one. There are some systems in which shamans can heal or sicken, curse your enemies, make it rain, make your object of desire fall for you, or whatever. There’s certainly variety. But in Europe and its metastasis to North America, since classical antiquity, physicians and priests have been distinct, as they are now generally around the globe.

One reason I find this remarkable is that for most of history, almost everywhere in the world, these people couldn’t actually do much, if any, good, in most cases. They may have had some useful skills – to set broken bones, maybe to cut out or saw off rotting parts, perhaps out of their formulary of dozens or hundreds of concoctions a few were truly beneficial. But as we now know, most of what they did was at best useless, but often harmful, they best-known example being bloodletting. But it’s perhaps less widely recognized that, lacking any concept of pathogenesis, surgeons and obstetricians were probably the world’s leading source of infection, and thereby managed to kill innumerable patients and birthing women.

The scientific revolution that upended cosmology and physics starting in the 16th Century (Copernicus died in 1543, Newton in 1727) didn’t really get going in biology until the 19th Century, and even then it did not at first have a great deal to offer to medicine. Darwin obviously caused quite the brouhaha, but his theory was not immediately relevant to medical practice. Ignaz Semmelweis figured out the importance of hygienic practices, such as physicians washing their hands and instruments between patients, around 1850. But he didn’t have any scientific explanation for his observations, and he was generally scorned. Once Pasteur figured out about a decade later that microbes can cause disease, we were getting somewhere; surgery and childbirth became more hygienic by the end of the century, and Pasteur’s work also led to the development of vaccines in addition to the long-available cowpox inoculation against small pox. (That was based on empirical observation, with no explanatory theory.)

So, by the beginning of the 20th Century, medicine was doing less harm than before, but still couldn’t do much good. Effective treatments for the vast majority of human ills still did not exist. Just about anybody could open a medical school and confer a medical degree, and just about anybody did. Most of these schools were owned by one or two doctors, existed to make a profit, didn’t teach much science, if any, and had low requirements for entrance and degrees. There were many competing systems of thought about the nature and causes of ill health, almost all of them completely bunk, some of them unfortunately still with us, such as homeopathy.

Then a radical discontinuity occurred in 1910.





Next: The Flexner Report and the Dreams of Reason

What is health? (continued)

A synonym for the medical enterprise in the English speaking world is “healthcare,” which you will note has now become one word. (It was still two words when I was a child, and for a while I corrected my students’ papers if they made it one.) So medicine – the social institution led, at least until recently, by people possessing the credential Doctor of Medicine – is purportedly dedicated to caring for our health.

When people visit physicians, they usually do so voluntarily. Presumably, they do this because they want the physician to make them healthier, or keep them healthy. What exactly does that mean? What are they seeking?

This question appears simple. We use the word health all the time. Most people don’t reflect on its meaning any more than they reflect on the meaning of “breakfast” or “basketball.” They answer the question at the top of this post with little thought. It’s obvious, right? Health is . . . .

Actually that’s a very tough question. The preamble to the constitution of the World Health Organization, written in 1946, used this definition: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Not only that, but “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” The second quote is chiseled into the façade of the main building of the Harvard School of Public Health. That is definitely uplifting.

It is also completely nonsensical. Start with the idea of “complete . . . well-being.” Do we really want to say that we’re unhealthy if there is anything we wish for that we do not have? And even if we can come up with a more realistic definition of complete well-being, is there any point in proclaiming that every human being has a right to the highest attainable standard of whatever it is? If we do endorse such a right, it’s not just “one of the fundamental rights,” it’s the only one, because there wouldn’t be anything left over.

We must begin by accepting the human condition. We are all of us born with an incurable, inevitably progressive disease which, beginning in our third decade, gradually degrades our physical and mental capacities and is ultimately fatal. We are, in other words, mortal, and we grow old. What is more, our initial endowments differ. If a congenital condition deprives us of complete well-being, have we suffered a violation of our fundamental human rights? Or is there perhaps a more constructive way to look at that situation?

It doesn’t take much thought to see, further, that my well-being may conflict with yours, and that determinants of my own well-being may conflict with each other. I have the privilege of living in a beautiful place in the country, and having a very desirable job in the city. But this privilege is conferred by the internal combustion engine, which spews ultrafine particles into the atmosphere that contributes to heart and lung disease; causes crashes that kill 36,000 Americans every year and seriously injure many more; and is changing the global climate threatening mass extinctions and unimaginable human misery.

I could go on about this, even write a whole book about it. But our present purposes do not demand it. People don’t go to physicians to claim their fundamental human right to the highest attainable standard of health. They go because they have a particular complaint that they think may be amenable to medical intervention, which is sufficiently disturbing to make the trouble and possible expense worth the trouble and downsides of medical attention.

More on this anon.

A simple question

In general, would you say your health is excellent, very good, good, fair or poor?

Believe it or not, how you answer that question is a good predictor of how long you will live -- whether you are a young person, or an older person with cancer. It doesn't much matter exactly how it's worded -- you can ask, "How would you rate your overall health during the past week?" or "How do you regard your health?" or anything similar. It doesn't really matter what response categories you offer either -- the excellent to poor scale I used, or a 100 point visual analogue scale, or a seven point scale. And it doesn't really matter if you ask people to compare themselves to others their own age, or just ask the question in a very general way.

The power of this question is a bit of a mystery. People are presumably using different comparators -- e.g. how they felt before they were diagnosed with Annamannapunna, or people they know, or their parents at the same age, or some imaginary ideal. Who knows?

And health obviously means different things to different people. It's actually impossible to define compellingly. "The absence of disease" seems basically circular, since the only way to define disease is as a state of less than optimal health. "Well being" might be a synonym but then what does that mean? People usually think of health as having biological, psychological and social components -- some people want to sneak in spiritual but I think that's just a psychological state. But which of those is most important? If you're happy even though you have MS are you healthy? What if you're the world decathlon champion but you're sad?

None of this seems to make any difference. The question is better correlated with the highly specific and reliable end point of longevity from time now than most physical indicators. Why do you think that is? And what does it mean to you?

Sad, Mad, or Bad?*

Until the last century, and really to any large extent not until somewhere around the middle of it, people were lucky if their physicians did them more good than harm. But then medicine achieved great triumphs and claimed immense cultural authority and prestige. This happened when biological science enabled physicians to identify specific disease processes and offer targeted, effective treatment.

The huge win was antibiotics, which became widely available and effective around the time of World War II. People can argue about whether streptococci or mycobateria are really the ultimate cause of disease, or if it isn't the strength of our immune systems or our conditions of hygiene, but there is no doubt that if you give people the right antibiotics -- at least until lately -- the symptoms caused by infection with these organisms will disappear and the people will be all better.

The magic we can work with heart disease, the various diseases in the broad category of cancer, autoimmune diseases, and others, is less wondrous. Still, doctors understand fairly well what is going on with these afflictions and often they can do a lot to extend life, relieve disability and suffering, and even in some cases cure them. Sure, there's diagnostic uncertainty and controversy about the clinical or lab findings that merit a disease label and call for treatment, but these are largely pragmatic arguments over costs and benefits, the interpretation of statistics, or the reliability of observations, rather than deeply philosophical quandaries.

In most fields of medicine, however, we encounter entities called syndromes -- collections of symptoms which are often seen together, for which the cause is not understood, but for which people have proposed names. Some current notable examples are fibromyalgia, which is usually treated by rheumatologists, and metabolic syndrome, which may end up in the purview of an endrocrinologist. People often argue over whether these are "real diseases," or perhaps coincidental co-occurrences, or two or more unrelated processes that look similar, or perhaps separate processes with common risk factors. Further investigation often resolves these questions. For example, we now know that tertiary syphilis is not the same thing as schizophrenia, and it has passed from the purview of psychiatrists to infectious disease specialists.

In psychiatry, alas, the problem of classifying and naming diseases is ubiquitous. Suffering occurs in the brain and according to the scientific world view is the subjective manifestation of physical processes. However, psychiatrists generally have no idea of what these processes really are, and to the extent that they're starting to get an inkling, they can't point to or specifically treat any known abnormalities of the brain or its functioning. All they can do is propose clusters of complaints or behavioral observations and give them names.

In The Book of Woe, my friend Gary Greenberg tells the tale of the latest revision. I won't attempt to summarize the twists and turns -- it's a good read, goes down easy, and says most of what needs to be said, so give it a look. I will just make a couple of framing observations.

Psychiatrists not only have the difficulty of deciding whether the thing exists, they also have to decide whether it should be called a disease. Obviously we're all unhappy sometimes, but when exactly do we need our heads shrunk? It might be easy enough to say, whenever somebody shows up asking for help, they should get it, but there are many problems with this. One is that insurance companies won't pay for treatment if you don't have a disease. But labeling somebody with a psychiatric disease has all sorts of social implications. If you're homosexual, you don't want to be labeled with a disease because you don't think there's anything wrong with you. If you believe you have Asperger's syndrome, you want a label because you want to get special education services and you'd rather be known as having a disease than be called a dork. If you commit a crime, claiming that a disease made you do it might be seen as exculpatory. Alternatively, it could let the authorities lock you up indefinitely, as a risk. In fact, people may get psychiatric disease labels who aren't even suffering subjectively -- they're just making other people suffer. All this is a lot to wrestle with, and I'll demur for now, but Gary does it all.

Another problem is that if you don't have real diseases and the expertise to treat them, you aren't a real doctor. Having the power to name your pain and the purported unique scientific expertise to select the One True Treatment is essential to the prestige of the medical profession. Psychiatrists desperately want to be members of the club.

Alas, as Gary probably doesn't need to tell you, people become unhappy, or anxious, or lonely, or obnoxious to others because their unique selves, as forged by inheritance processed through their youthful environments confront shit that happens. A wise counselor might be able to help, but putting you into a box first and sticking a label on it is unlikely to help.

*I'm sure somebody has used that title before, but it's obvious and I made it up anew.

The sound of thundering hoofs in the distance

That's the implementation of the Affordable Care Act next year. The Commonwealth Fund's annual survey of health insurance coverage has just come out, and it's obviously not like former versions because it must talk about the future as well as the recent past (2012). The Affordable Care Act -- Obamacare, if you will, although it might be more accurate to call it CongressCare since the prez was notably passive during the whole sausage factory episode -- has already reduced the proportion of young adults 19 to 25 who were uninsured at some point during the year from 48% to 41%. That's 1.6 million people who have insurance who wouldn't otherwise.

Otherwise, we've been stuck in neutral, with almost half of all adults under age 65 either uninsured at some point, or underinsured, i.e. their out of pocket costs were so high that they couldn't afford them. Which, no surprise, means they are likely not to be buying needed medications:

Note that if you don't take the pills referenced in the chart, such as for hypertension or diabetes, you are likely to get sicker, and incur even higher medical costs. This is rationing. This is death panels.

Next year, the number of uninsured people will fall. Yes, it's likely that the cost of insurance will go up for more affluent people who aren't eligible for subsidies, because all of these sick people will now be in the pool. I say, tough shit. You can afford it, and it's your society too.

There are bound to be all sorts of problems, as there are with any major policy initiative. Normally, once we try it and find out what needs fixing, Congress fixes it. Unfortunately, we have a Republican majority in the House and an obstructive minority in the Senate that wants this to fail. So maybe it will.

Dog my cats and Rowrbrazzle

So apparently U.S. intelligence believes the Assad regime in Syria has used the organophosphate nerve gas sarin in its battle with insurgents and now everybody agrees that SOMETHING MUST BE DONE, notably president John McCain. Oy.

Having cut my blogging teeth explaining the bogosity of the whole Weapons of Mass Destruction™ thing in the months prior to the U.S. illegal war of aggression against Iraq, I must now apparently go back to the beginning and do it all over again.

Chemical weapons are battlefield weapons. They are no more massively destructive than guns or bombs. Does it really matter to you if you are blown up or poisoned? I don't care personally. By the way sarin evaporates rapidly and any place where it is used is safe within a few hours. That is not necessarily true of explosive ordinance. BTW, our friend the marathon bomber has been charged with using a weapon of mass destruction™, specifically a homemade bomb. This language is essentially meaningless.

Our problem is that the propaganda used to justify the War on Terra has now trapped us. We had to invade Iraq because Saddam Hussein might possess such weapons -- even though we have always known that Syria does. (Israel, by the way, possesses nuclear weapons, but we haven't invaded them yet.) If Assad has crossed this arbitrary line, some sort of military response by the United States -- why the U.S. and not, say, Uruguay or Lichtenstein? -- is obligatory. This is all so obviously silly.

The Syrian civil war is very ugly and it's causing a whole lot of death and misery. It would be highly desirable for it to stop. But you know, it's complicated. The insurgency consists of many different groups with varying ideologies and objectives, some of which I or president McCain might like and some of which we don't like -- not necessarily entirely the same set between us. The consequences of whacking the Assad regime in some way are completely unpredictable with respect to who ends up running what parts of Syria and how. Regardless of whether the Syrian army continues to use sarin gas, it will certainly continue to fire rockets and missiles, drop bombs, and shoot guns at people, thereby killing and injuring them. And various factions will shoot at the Syrian army. Many people, including many non-combatants, will be injured, killed and displaced. Gas or no gas. Doesn't matter one whit.

Dzhokhar Tsarnaev

There, now that I've gotten the search traffic . . .

Am I the only sane person in the universe? It turns out that of the three categories I originally proposed, the Boston Marathon bombing was most like option A, the perpetrators were acting on instructions beamed directly into their brains from Alpha Centauri. While it is apparently true that they are/were Muslims and in their own minds thought that what they were doing has something to do with some form of radical Islamism, it did not in any coherent or meaningful way. They could just as easily have attached their folie a deux to Rosicrucianism or the Reptiloids for all the sense it makes. They were unconnected to any movement, conspirators or ideology outside of whatever the hell was going on inside their heads.

So why is this particular bizarre evildoing supposed to change the U.S. relationship with Russia, derail immigration reform, break out the waterboards, repeal the Fourth and Fifth Amendments, or put a surveillance camera on every corner? Because we are plainly incapable of rational thought.

It is indeed extremely disconcerting that two room temperature IQ nobodies, spending a couple of hundred dollars, can create such havoc. Every deranged doofus with a TV set now knows exactly how to replicate the feat. Channel 4 in Boston sent a reporter to the New Hampshire fireworks store where Tamerlan got the explosives. The helpful clerk explained exactly what products he bought and displayed them for the cameras. You get the pressure cooker at Walmart and the battery at Hobby Lobby. A quick Googling and you've got the complete instructions. Now you can go to the throng outside the ballpark, the free outdoor concert, or the Amtrak station and be the most famous person on earth for 4 1/2 days. That's just wonderful.

So what should we do about it? First, get a grip. This has been true, more or less, since the invention of gunpowder. Right now, mass murders, defined as 4 or more people killed in one incident in addition to the perpetrator, happen about twice a month in the U.S. It's certainly unusual for so many people to be injured at once, but here's a list of rampage killings in the Americas since 1900 which includes plenty with injuries in the two dozen range. 

Second, as far as I can see, since we're committed to continuing to allow the essentially unregulated sale of firearms and explosives, the only meaningful public policy responses have to do with making life better for people. What do I mean by that? People -- mostly young men -- get alienated and angry because they don't have opportunities for meaningful and remunerative employment, because they fail in school, because they have social difficulties and nobody offers any help. I don't know whether anybody could have detected the BoomBoom Brothers or Adam Lanza ahead of time, but but in both cases one can imagine that a better educational, social and mental health safety net could conceivably have prevented disaster.

Trashing our constitution and our liberal traditions, however, would not.

Hey Sugar

That's not a compliment, I'm afraid. I've been riding this hobbyhorse for a while. I'm happy to say the world is coming around to the point of view with which I have been allied -- sugar is among the greatest curses of civilization. Gary Taubes of the Nutrition Science Initiative discusses the history of obesity research in the new BMJ.

Here's the basic setup. Yes, we know that given the basic laws of physics, you can only gain weight if you consume more calories than you burn (and excrete, although that's presumed to be a minor issue in caloric balance). So, the prescription to prevent or treat obesity has long been simply eat less, exercise more.

But that doesn't say anything about the question of why people eat more than they need and store fat. We've heard a lot of talk lately about the "obesogenic" environment -- more sedentary jobs, sitting around in front of computer screens instead of going out and playing ball, and the availability of cheap, high calorie food. Fair enough but . . .

There has long been a hypothesis, prominent in continental Europe prior to WWII but largely forgotten since, that consuming a lot of carbohydrate, and particularly glucose and fructose, directly affects metabolism such that the body stores calories as fat without signalling satiety of hunger. In a nutshell, it's not just that sugary drinks are added, empty calories: they also go straight to the midsection while leaving you hungry. There is an ancillary hypothesis that once you have excess adiposity, the fat cells themselves stimulate storage of additional fat.

Taubes argues that we have largely forgotten this because after WWII the language of science became English, and the largely German language literature based on these ideas was no longer widely read. Maybe so but we sorta kinda have known it, we just haven't connected the dots. I have written before about the  glycemic index. Eating sugar in the absence of dietary fiber and protein causes a spike in blood sugar, followed by a spike in insulin, followed by an overcorrection and a drop in blood sugar, then you're hungry again . . .  This is the proximal cause of Type 2 diabetes, but maybe also a proximal cause of obesity. Starches also have this effect, but to a lesser degree, and they are typically consumed as part of a complete meal which moderates the glycemic spike.

I won't go further into the complexities of this. It is known that prescribing a carbohydrate restricted diet, rather than just telling people to eat less, works better at promoting weight loss in the short run, which supports the hypothesis. The trouble is that people don't often stick to carbohydrate restricted diets for the long term. But, getting sugar water out of the food supply would make it a lot easier.

Why haven't we done the research to prove this and take advantage of it to fight the obesity and diabetes epidemics? Because the "food" industry pays for disinformation, just as the tobacco industry and fossil fuel industries have done and still do. They are evil.

Coca Cola is poison, just like methamphetamine. Stay away.

Sigh . . .

I haven't said commented on Monday's terrible event because I wasn't sure I had anything original to say about it, but I feel I should add my endorsement of a few points others have made.

I lived in Boston for more than 20 years, and I worked in the Back Bay neighborhood for 15. I have walked the sidewalk where the bomb exploded hundreds of times. I have eaten in restaurants that had their windows blown out, shopped in the stores, gotten my dental work there. I've watched the marathon from across the street from where the second bomb went off. If I hadn't moved away a little more than a year ago, I likely would have been there. That is the very heart of the city -- the public library, the street where the victory parades and the First Night celebration happen, a big plaza where there are public concerts and the office workers eat lunch on sunny days, some of the city's best restaurants and most famous hotels. It's a big city but it's also a small town. You can easily walk from there to Fenway Park, City Hall and the waterfront, the South End -- Boston's answer to Greenwich Village -- nightlife, the Boston Center for the Arts, the ballet, it's all right there.

Patriots Day is the city's defining festival day. It's a holiday in just one place on earth, Boston, Massachusetts. It's the day the whole city invites the planet for a party that is uniquely Boston, recalling the deepest U.S. history and celebrating the cosmopolitan present of a world city. Whoever did this was out to do a whole lot more than kill and main people. He was out to main Boston.

Well you can forget about that. It's not going to happen. Boston will just get stronger. That said, let me get curmudgeonly about a few things.

First, the corporate media managed to prove, for the millionth time and more powerfully than ever, their utter, profound inanity. CNN ran a banner under Wolf Blitzer all evening proclaiming that the president had not used the word "terror" in his brief remarks, the point being I suppose that they were pre-promoting the expected phony Republican outrage based on the equally phony nothingburger faux "scandal" about the Benghazi incident. Then and still, we do not know whether the perpetrator was following instructions beamed directly into his brain from Alpha Centauri; was carrying out the specific orders of Ayman Al-Zawahiri to avenge the death of Osama bin Laden; or was a Christian Patriot out to punish Boston for being atheist communist Sodom. In the meantime, spending 24 hours a day interviewing yammering pseudo-experts offering data-free opinions on which of the above pertained was a complete waste of electrons.

Second, even though you wouldn't know it from watching your teevee, worse things happen just about every day in various places around the world including two -- Iraq and Afghanistan -- where the U.S.A. bears major responsibility and additional places -- Pakistan and Yemen -- where the U.S. perpetrates much of the violence. In fact, your heroic military murdered 17 Afghan civilians, including 12 children, just last week, meriting a brief note on page 8 of the New York Times. Rachel Maddow doesn't even mention these little incidents. Oh yeah, we didn't mean to blow up a village or a wedding party, it was just a little mistake, sorry, we meant to kill somebody we were pretty sure was a bad guy, because who needs a trial anyway? Just sayin'. But if it happens to us, it's a big deal.

Third, more people are killed and maimed in car crashes in the U.S. every day than on Boylston Street on Monday. And many more people are murdered, all around the country. The impact of this is symbolic; this is the social amplification of an event which is actually not all that important in the overall scheme of things. If you're worried about your safety, stay out of automobiles before you think about avoiding crowds or arresting terrorists. And therefore, obviously, the way to deprive this wacko of any victory is to get on with your life and not to give up any of your freedom in the feckless pursuit of security. The world is somewhat dangerous. Carry on.

The fate of a shark

It is said -- don't know if it's true -- that sharks can never rest; they must keep swimming to drive water over their gills, or they will suffocate. George Monbiot reminds us that we are in a similar predicament.

His point is that the greenhouse gas emissions and other environmental impacts of Britons and Americans is not measured by what we spew from our own territory. It is measured by the global impact of our consumption. Much of the pollution we blame on China is actually generated to fill our own closets.

When I was a youth, working for Ralph Nader, I helped produce a conference on environmentalism, focusing specifically on energy. Yes, even then we were talking about renewable energy. Dr. Benjamin Spock came to talk about his own solar heated house -- in 1978. Hazel Henderson spoke about the fundamental error of confusing gross national product with human well being.I was the projectionist for a very nice little film called A Place to Live, about the Shelter Institute in Maine. I'm not sure they have the right idea after all -- country living, even if it's relatively energy efficient, can't be the option for most people. But the point is, even before a lot of people were thinking about climate change, we knew damn well that the fossil-fuel powered industrial economy could not just keep on growing forever.

Well, we also had a speaker from -- I think it was the NAACP, might have been another civil rights organization -- whose sole agenda was to let us know that calling for a "no growth" economy was a luxury for wealthy people. Economic growth was the only way to lift people out of poverty, and it had to be accelerated, not restrained.

As Monbiot writes:

Unsurprisingly, hardly anyone wants to talk about this, as the only meaningful response is a reduction in the volume of stuff we consume. And this is where even the most progressive governments’ climate policies collide with everything else they represent. As Mustapha Mond points out in Brave New World, “industrial civilization is only possible when there’s no self-denial. Self-indulgence up to the very limits imposed by hygiene and economics. Otherwise the wheels stop turning”.

The wheels of the current economic system – which depends on perpetual growth for its survival – certainly. The impossibility of sustaining this system of endless, pointless consumption without the continued erosion of the living planet and the future prospects of humankind, is the conversation we will not have.

 We have seen a reduction in the amount of fossil fuel consumed per unit of total output, but it has been overwhelmed by overall growth. The fact is that humanity as a whole is far wealthier than ever, but that wealth is more concentrated in few hands than ever before. We don't need more growth to lift people out of poverty, we need more justice. But we haven't a clue how to get there, and nobody is even talking about it. No, we can't keep on growing forever. It is a mathematical impossibility. Continued exponential growth, even at what we would now consider a fairly low rate, means that humanity will devour the solar system in a couple of hundred years. Since that won't happen, what will?

Sunday Sermonette

I find all of the arguments in favor of religion transparently wrong. Among these is the claim that religion offers consolation -- that the inevitable pain of our travels through this universe would be unendurable if we thought the universe indifferent to it. Isn't it essential comfort, say the apologists for religion, that people in distress be told that it is all part of God's plan?

This argument is coming from opposite world. I would rather make my own plans, thank you very much. And if it is God's plan for me to suffer, that will hardly make me feel better than the far more likely hypothesis that I just had some bad luck. The Almighty Lord of the Universe didn't do it to me on purpose after all. Thank God for that. Now I can just try to get on with my life and do what I can to make tomorrow better.

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.