Too much news

You hardly know where to begin. Anyway --

Obama has decided to delay the insurance mandate in the ACA by one year. This is actually wise. In this respect, the law was horribly crafted. The first thing you learn in Public Policy 101 is not to create a "cliff," meaning in this case that there was no employer mandate at all with 49 full time employees, then it kicked in for all a company's employees when they hire the 50th. You don't need to take the course to see why that doesn't work.

The right way to do this is to impose a penalty on the 50th employee and subsequent employees only; therefore no cliff and if you need a 50th employee, the added cost is small so you'll probably go ahead and do it anyway. Once you get up to 60 or 70 or so, you'll say what the heck, might as well start offering insurance for everybody -- as most companies that size already do. Meanwhile you've paid a bit to help the subsidies for people buying individual insurance. Congress could fix that, of course, but they won't -- unless the Democrats take both chambers in 2014. The fate of humanity depends on that happening, so start working now.

Oh yeah, the fate of humanity. I'm sweltering as I write this, taking the day off from work and no AC at home. I wonder what will happen when all those folks who've fled the northern winters for the sunny paradise of the Southwest find the place uninhabitable?

Cure Schmure

No doubt you have encountered the hype about a purported cure for HIV infection. That would indeed be great news, but sadly, no. Here's an example of the selective and misleading coverage this is getting.

Two men who happened to develop some form of cancer (not specified in the public story) while also being HIV+ received the treatment called "bone marrow" transplant, continued to take antiretroviral medications throughout the procedure and recovery, and now appear to be free of HIV. They seem to have turned great misfortune into good fortune, but in reality, this is a big, fat, so what?

Here's the real deal. The procedure they underwent is more properly called an allogeneic hematopoeitic stem cell transplant (HSCT). Nowadays they don't actually transplant bone marrow, but rather the cells that reside in bone marrow which are the progenitors of blood cells. Doctors do this for a few different reasons. The most common is that the person has some form of leukemia -- abnormal proliferation of white blood cells, which is a kind of cancer. In this case, if chemotherapy doesn't work, the alternative is to destroy the person's HSCs with radiation or chemicals, and replace them with cells from a donor. Other reasons are lethal abnormalities of red blood cells -- aplastic anemia, and the procedure is increasingly being done for severe sickle cell disease.

The reason this appears to cure HIV is that the virus lives in white blood cells. Replace them all, and you eliminate it. It may also lurk in other reservoirs, but if so the new immune system gets to work on a very low presence of HIV infection, and is able to wipe it out.

That's all well and good but it does not mean that everybody living with HIV should now go and get one of these procedures. Alas, the cure risks being worse than the disease, because HIV can be controlled with drugs, but allogeneic HSCT creates a risk of what is called graft vs. host disease (GVHD). The new immune system was originally somebody else's, and it is likely to recognize the recipient as foreign, whereupon it starts destroying the person's tissues and organs. This is basically incurable and causes severe symptoms and a short life. In order to prevent it, you have to take immunosuppresive drugs which means that you have -- wait for it -- immunodeficiency. Which was your problem in the first place. In spite of this, some people get GVHD anyway. (And, I should have added originally, you might die while you're waiting for your new immune system to reconstitute. In fact you have about a 25% chance of that happening. It's a desperation move, not an ordinary treatment for anything.)

So whether a feasible cure for HIV/AIDS might somehow follow from this observation is unclear, but personally I don't see it. If there is a path from here to there, it's a long one. The bad news is that lots of people will see this overhyped story and get false hope, or believe that a cure exists which is being withheld, or offered only to the wealthy. I wish the hope were real, but not yet. Keep taking your pills.

Category Error

It seems there is a new conservative society trying to get established in graduate schools of "business, medicine and public policy," inspired by opposition to the affordable care act. They think the reason you don't read a lot about the wondrous powers of the Free Market™ to heal our health care system is because we're all socialist atheist commies.

No, actually the reason you don't read in Health Affairs all about the stuff they fervently believe in is not because academia is ruled by ideologues, it's because what they believe is not true, and the purpose of academic inquiry is to find the truth. Excerpt:

The Duke group’s guest speakers included Dr. Keith Smith, an Oklahoma City anesthesiologist whose surgical center lists the costs of its medical procedures online in a move toward price transparency. The practice only accepts private health insurance, not Medicaid or Medicare. . . .

The Benjamin Rush Society traces its roots to 2008, when Canadian activist Sally Pipes organized a Washington meeting with support from the Kansas City-based Ewing Marion Kauffman Foundation. Its credo: “the profession of medicine calls its practitioners to serve their patients rather than the government.” Conversely, they also support so-called “concierge medicine” in which those with more money pay for individualized care otherwise unavailable.

Now, personally, I have no problem with that. They can refuse to take insurance and only work for rich people if they want to. However, it does not follow that the Free Market™ therefor is the solution to our dysfunctional health care system because think about it Randroids: what happens to people who cannot afford to pay Dr. Keith Smith for an appendectomy when there isn't any Medicaid or Medicare?

Ridiculous.

Having a sad

I believe I have previously confessed to being a New England Patriots fan. Yes, I know, to you football is probably stupider than Celebrity Apprentice, but there it is. If you haven't been living under a rock you know that Patriots tight end Aaron Hernandez is in jail, charged with murder. This is bad news for the team because his if-anything-even-more-unstoppable counterpart Rob Gronkowski has had multiple surgeries and who knows if he'll play again or how good he'll be. When they were on the field together, they could not be defended. But now genius coach Bellicheck and golden boy quarterback Tom Brady will need a plan B.

You don't need me to tell you that making heroes and role models of athletes is fool's gold. There are some good and wise among them but the ranks of professional athletes are not the place to go looking for such. In fact, that's where you go to look for arrogant pricks because they've been entitled, worshiped and enjoyed impunity since high school or even earlier.

This, however, is an outlier. Hernandez had just signed a contract for $40 million and trousered a $16 million signing bonus. He has an 8 month old baby and fiancee. If you haven't followed the details, according to the prosecutor's statement in court, Hernandez summoned a couple of low-life acquaintances from his old home town of Bristol, Connecticut, and they all went and picked up this guy Odin Lloyd, who was dating the sister of said fiancee and so was a potential brother in law. They drove him to a gravel pit and shot him five times. The only motive offered by the prosecutor was that Lloyd had spoken with the wrong people in a bar. Who knows what that means.

For those of you wishing to commit similar murders, here are a few tips. If you leave your cell phone on while driving around, the police can retrace everywhere you have been. They can also read all your text messages. Also, too, there are surveillance cameras all over creation. It's not just the NSA that can see all this, the only difference being that the police need a warrant. But if you kill people, they can get one.

Another tip: if you bring in small timers on a big ticket (e.g., life without parole), they'll flip like pancakes. One of the accomplices walked into a police station in Miramar, Florida, and said "Hi, you're looking for me?" He's obviously planning to be sweetly cooperative given the right incentive, and I'm sure the DA will be happy to offer, say, 10 to 20, maybe out in 8, in return for a well performed recital.

So, a trial presumably awaits but assuming the worse for Mr. Hernandez, unfortunately, the $16 million won't be taking care of the baby. In addition to the wrongful death suit from Lloyd's family, rumors are flying about that Hernandez was responsible for a drive-by shooting in Boston last summer that killed two completely innocent, law-abiding clubgoers. It seems they had been involved in some sort of altercation earlier in a bar at which Hernandez was present. Oh yeah. A guy in Florida is already suing Hernandez for shooting him in the head after -- wait for it -- an argument in a bar.

I would advise Hernandez to stay out of bars from now on but that probably won't be necessary. The point of all this, if there is one? This guy is starting to look like a psycho Steven King could not have imagined. Also astonishingly stupid. Most folks who shoot people over nothing have nothing to lose. Maybe he's been bumped in the head too many times, I wouldn't know. But whatever the reason, as I've said before, when the cerebral cortex goes haywire it can act in totally unpredictably. Anything can happen. It's a wondrous gift, this network of neurons that distinguishes us from the beasts, and a terrible curse.

Radio Daze

On my drive back from Baltimore, I-95 was a 300 mile long demolition derby. One of my unscheduled stops found me at the exact mid-point of the Millard Tydings bridge over the Susquehanna river at the top of Chesapeake Bay, dead stop, for an hour. It was rather festive, actually. The people got out of their vehicles to take photographs of the magnificent view, smoke cigarettes (the rate of smoking among people driving on the interstate seems to be considerably higher than that of the general population), empty bottles of urine, and otherwise enjoy themselves.

The bad news, other than whatever horrific injuries and/or deaths had occurred ahead of us, was the available radio frequency electromagnetic radiation. We were beyond the signal of the NPR station in Baltimore and had yet to pick up WHYY in Philadelphia. The FM featured 5 different Christian stations with various blowhards explaining the meaning of the Bible and how we were doomed to the fate of Sodom, one Christian music station, and one station playing really crappy country music.

So I checked out the AM. Get this: Rush Limbaugh was on six different stations. Really. Simultaneously. How do they compete with each other for listeners? And is the vulgar pigboy on 24 hours a day, or what? Another station featured a different right wing extremist, there was a sports talk station, and another station playing really crappy country music. And that was it.

So if the good people of Havre de Grace want to listen to the radio, these appear to be their options. Is it like this in much of the country?  

Sharing the convention center

I don't really have much value added to go with this observation, but there are two conferences going on right now in the Baltimore Convention Center: Academy Health, and the Armed Forces Communications and Electronics Association. I didn't even know what the other conference was for a couple of days, even though their registration booth is right on the path from the hotels to our half of the building, because the name of the organization does not appear anywhere, only the initials. 

Anyhow, I looked up the calendar of events on-line and figured out what it is. 

Event Name:	AFCEA International Cyber Symposium Website
Event Date:	06/25/2013 - 06/27/2013
Event Organizer:	AFCEA
Description:	National security is continuously being redefined as awareness of the cyberspace domain evolves. Cyber threats and challenges grow every day. Successfully defending our networks requires a team approach. With this in mind, the Cyber symposium will engage the key players, including the U.S. government, the international community, industry and academia, to discuss the development of robust cyberspace capabilities and partnerships.
Event Category:	Symposium
Event Theme:	Defining Full Spectrum Global Cyberspace Operations
Location:	Baltimore Convention Center Baltimore, MD

A few tips:

OPSEC Note

Events like the AFCEA International Cyber Symposium present opportunities for America's adversaries to target U.S. Government employees, academia, defense industry, and other personnel in order to collect our Critical Information. Be a hard target!  Use good OPSEC practices to protect yourself and your organization's mission.

Here are some things to think about:

• Be aware of your surroundings when discussing sensitive unclassified Critical Information during the conference and after hours, in common/public areas (e.g. social gatherings, networking mixers, etc.).
• Don't make it easy for eavesdroppers to be part of your conversations.
• Be suspicious of strangers - even though they sound like they belong at the conference, don't assume they are there for the same purpose as you.
• Use caution when sharing information with someone you don't know. Ask others to confirm a person's identity before sharing Critical Information about your organization's past, ongoing or future operations/activities/events.
• Protect your personal information, such as your room number and daily schedule.  Don't give out your business cards freely, particularly when outside the United States. Remember, phishing is still the #1 adversary threat vector into your personal and government computers/devices/networks, etc.
• If you use a laptop or other portable electronic device (personal or government-owned) use it cautiously. Disable the Bluetooth and WLAN/Wi-Fi connections when not in use, and if you use this type of connectivity understand that you may expose personal and work-related Critical Information to an adversary. Be especially cautious when using unencrypted/unsecure WLAN/Wi-Fi hotspots.

                                   

BE SMART!    BE SAFE!   PRACTICE GOOD OPSEC!

Look, I suppose this is necessary. Maybe. If we lack imagination. But I don't particularly like living in a world where I have no secrets from the government, but they have lots of secrets from me. The armed forces work for the taxpayers. We're supposed to know what they're doing, and decide if we like it or not, and our elected representatives are supposed to be responsive to our wishes in their fully informed control over what the military does. Obviously, that's not how it is.This is very wrong.

 

Why do we even bother?

I often ask myself. I'm at the Academy Health Annual Research Meeting, which as I believe I mentioned is the bit health services research shindig. What most of these people do is crunch huge so-called administrative data sets -- that's like Medicare and Medicaid billing data, for example, combined with other available data that give some idea of outcomes, be it deaths or diagnoses  -- so they can look at things like hospital admissions and readmissions, screening rates, and other outcomes associated with various policies and practices. The idea is to inform policy makers. If you ask almost anybody here, they'll tell you that what we really need is single payer national health care, but it ain't gonna happen.

Anyway, this morning we heard from my colleague Chima Ndumele, who finds that when Massachusetts and other states expanded Medicaid eligibility to include people with incomes above poverty, it did not, repeat did not, lead to reduced access for people who already were covered. This is a big objection that many people have to the Affordable Care Act, i.e. there aren't enough primary care providers so you're just going to make it harder for people who are already covered. Don't know what will happen in the Republican states, but so far the states that did it on their own haven't had major problems.

Susan Haber of RTI finds that states that offer higher Medicaid reimbursement for primary care visits also have higher rates of cervical, colorectal and breast cancer screening -- regardless of the reimbursement for those services. Makes sense. You have to get in to see the doctor in order to get referred for screening. Less colorectal cancer will also save money in the long run, given that nobody cares whether poor people get cancer.

Suk-Fong Tang finds that pediatricians are more likely to accept new Medicaid patients when, yes, they are paid more, but also when it's easier for them to get their patients referred for specialty care, including dentistry. Also makes sense, it's a big pain if they have to spend all their time tracking down somebody who will meet their patients' needs.

Yeah yeah. If we pay primary care doctors half decently (Medicaid pays a fraction of private insurance and less than Medicare), if we make more people eligible for health insurance, if we have a better integrated system, more people will get the care they need and get and stay healthier. We'll have a more productive society and it will be well worth it. But that doesn't matter. Public policy isn't built on facts and reason, it's built on ideology and the will of the powerful. You can tell all this to your congressional representatives and state legislators, but they won't care.

A scholar's life

As if I haven't baltied enough already, tomorrow I'm going to Balti more. Specifically, the Academy Health Annual Research Meeting, Academy Health being the health services research association. I'll be presenting my super duper innovative methods for breaking down and reproducibly characterizing clinical communication.

I won't bore y'all with the details, but the major idea is that you can identify specific kinds of tasks -- such as collecting information to make a diagnosis or otherwise put a name on a problem, educating a patient, making a treatment decision, or providing emotional support and building rapport -- specific subject matter of importance, such as symptoms, pharmaceutical treatment, diagnosis, health-related behaviors, psycho-social problems -- and specific speech transactions (illocutions or speech acts) such as various forms of questioning, giving concrete information, expressing feelings or desires, giving instructions, and so on. If you break down a transcript on all three dimensions, you can say a whole lot about what happened in a visit and what the relationship between the people was like.

There's no Nobel Prize for this, and it won't make the New York Times either, but if you think about it, talking with patients is 90% of medicine. It doesn't matter what the pills do if you don't take them. Whether I can really do any good with all this remains to be seen, but I'm hopeful.

Emptying the inbox

A couple of worthwhile gleanings from amongst the continual torrent of spam. . . .

The consulting firm Avalere Health, apparently in the now required hope that I'll give them some free  publicity, keeps sending me freebie information from their studies. Today they let us know that:

As plans begin to unveil their initial health plan rate filings [in accordance with the Affordable Care Act], a new Avalere Health analysis shows that in nine states the second-lowest cost “Silver” premiums appear to be lower than the Congressional Budget Office (CBO) estimate for 2016. Premiums for the second-lowest cost Silver plans for a 40-year-old nonsmoker will range from a low of $205 in one region in Oregon to a high of $413 in another region in Vermont. CBO previously projected nationwide the average monthly premium for the second-lowest cost Silver plan would be $433.

 

These second-lowest cost Silver premiums will be used to set federal premium subsidies. If premiums are lower than was projected by CBO, federal costs for per-person subsidies may be lower than expected, thus saving the federal government money.

 

“The initial data suggest that competition in exchanges is working to lower premiums, which will benefit nonsubsidized enrollees and the federal government,” says Caroline Pearson, vice president at Avalere Health.

On the whole, as implementation of the Kenyan Muslim Socialist Communist Atheistic Obamacare approaches, prospects for a reasonably smooth roll out seem to be looking better.

Yes, yes, young healthy people who are not eligible for subsidies will still pay more than they would if they were buying insurance in today's less regulated market, even given the above good news. But calm down. which most of them are not doing anyway. So their experience will not be, in most cases, a rate increase, but rather the requirement to buy insurance at all. (If you're a young person insured through employment, nothing will change.) But that's a feature, not a bug. Yes, the young and healthy will subsidize the older and sicker, which is what happens in a single payer system or really any reasonably equitable system of universal coverage. But that is precisely what creates justice and equity -- over the life course, rather than cross sectionally. Which is what you want, because, sorry to break it to you, you will get older.

On another front, the Campaign for Tobacco Free Kids is celebrating (if that's the word) the 100th birthday of Camel cigarettes. R.J. Reynolds has killed 1 million times as many people as John Marturano, the gangster who is currently testifying against Whitey Bulger. Yeah, it's appalling that Marturano only did 12 years for 20 murders, but Daan Delen, Chief Executive Officer of R.J. Reynolds, hasn't done a day.

A thought experiment

You're more likely to be seriously injured or killed by falling in your bathroom than by terrorists. (Fact!) So, do you support the federal government setting up a system of surveillance cameras in all the bathrooms in the United States? Don't worry, the Booz Allen employees promise not to look unless a sensor goes off suggesting that somebody might have fallen. Really. They promise.

And do you support spending something like $100 billion dollars a year (you don't know the exact amount, it's a secret) to save you from this fate? Yeah, the word has gotten out about the video surveillance in your bathroom but you have no idea what else they are doing. But why should you worry? It's for your own protection.

Now, in fact, I don't know about the $100 billion or the secrets or the surveillance -- I'm thinking you're probably against that, even if you're for the anti-terrorism thing. (Or whatever the real reason is they're doing it -- that's actually a secret as well.) But it would actually make sense to spend more modestly on a voluntary program where the local Visiting Nurse Association could inspect your home for fall risks, then install grab bars and hand rails, put traction material on the bottom of the tub, remove tripping hazards, and so on. That would keep people out of nursing homes and save Medicare and Medicaid a lot of dough.

Priorities, however.

The Cervantes Bullshit Translator

So Deputy National Security Adviser Ben Rhodes announces that the Syrian military has used chemical weapons, thereby crossing the "red line" established by president Obama and, accordingly, the U.S. will begin providing weapons to "moderate" opposition group, the Supreme Military Council.

Translation: President McCain has been calling us wusses and the corporate media is channeling him and this is not a good time for us to look "soft" on something that might be confused with national security. So we need to do something to look like badasses.

Here are your basic facts.

Whatever evidence the U.S. has had about this, they've had for months. They could have made this announcement at any time, but up until now they've said it was inconclusive.

Anyway, it doesn't actually matter. This whole chemical weapons thing is bogus. Yes, it's against international norms, but not for any particular reason. Blowing people up or shooting them actually works better. Nerve gas doesn't work if you're holed up indoors, and it's not much use in a high wind or rain. Soldiers can wear protective gear and go about their business. Bombs, however, work just great no matter the weather, they can blow up buildings with people inside them, and believe me, you won't care whether you were blown to pieces or poisoned.

The specific claim is that maybe 100 people have been killed by chemical weapons. That is out of about 100,000 who have been killed altogether in the conflict. So, 1/1,000 of the total. But that's just intolerable, whereas the 99,000 dead from bullets and bombs is not.

So this is nothing but a pretext. The corporate media will never deconstruct it or even appear the slightest bit skeptical, however. This proves that Bashar Assad is an evildoer and the U.S., being responsible for the punishment of evildoers everywhere, at least the ones we choose not to ignore or give billions of dollars a year in aid, has no choice but to act.

Also true fact: The Supreme Military Council is not the supreme military council. It represents almost none of the actual insurgent fighters, and it will never run Syria or any part of Syria. It's a phony construction of the west to give them somebody to relate to who does not include, in its official ideology, the expulsion of U.S. power and influence from the Islamic world. Once we give them weapons, they will have to find people to use them, and those will be the same people we won't give weapons to directly.

The outcome of all this is completely unpredictable but it is of little direct interest to the well being of the good people of Peoria, one way or the other. And no, they don't even have oil in Syria. Remember, Assad controlled all of Syria before this whole thing started, and nothing obviously bad was happening to us. The danger that he might regain control of more of it than he has now does not seem like an existential threat, or in fact a threat of any kind.

Indeed Senator Tester

The solon says that Snowden's leaks do not endanger national security. In fact, he thinks they're all to the good because now we'll have a debate about this stuff.

Exactly. So again, here's the real point: Why was all this a secret in the first place?

Sigh. I guess I need to say something . . .

about the current frou frah. There are many who urge us all to calm down, the government isn't snooping into your e-mails or phone calls. They're just saving their own database of information about every single phone call made in, to or from the United States -- who called what number and how long they talked, and maybe where they were physically if that's available -- in case they want to check any of it out later. And they can get all sorts of Internet activity by foreigners, which of course could include interactions with Americans but they try not to get the latter on purpose without a court order. So no biggie.

Okay, a few dots to connect here . . .

1) This is costing us bazillions of dollars. (We don't know exactly how many because it's a secret. The NSA has 20,000 employees, but that's just the beginning. There are something like 1 million people working for U.S. intelligence. They're creating billions of dollars of additional computer infrastructure. They're new data center in Utah draws 60 megawatts of electricity to run its computers. . . .

2) Meanwhile we supposedly can't afford food stamps . . .

3) Why was this a secret? Presumably any evildoer who has one neuron to rub against another assumes his phone calls and Facebook posts are available to the NSA already . . .

4) The whole Global War on the Existential Threat of Terrorism thing is complete bullshit. The only "terrorist plots" they've managed to thwart since 9/11, as far as we know, consist of dipshit losers who were recruited by provacateurs and given fake weapons. Mueller and Stewart, in the linked article which you aren't allowed to read, inventory all 50 of them. They're all like that. Sample:

49. Tampa, 2012. Under suspicion after he walked into a store seeking to purchase an al-Qaida flag, an Albanian-American loner in Tampa, Florida, plots with a police officer to detonate a car bomb, fire an assault rifle, wear an explosive vest, and take hostages, in addition to bombing nightclubs, a police center, a bridge, and a Starbuck's coffee shop. . .

44. Seattle. 2011. Two financially destitute men, angry over U.S. foreign policy, are arrested in Seattle after they purchase an FBI-supplied machine gun that they plan to use to attack a military recruiting center after they save up enough money to purchase bullets . . . .

And it goes on and on like that. We have a lot of problems we ought to be spending money on, but this isn't one of them. The original al Qaeda, that perpetrated the Sept. 11 attack, has never put together another action of consequence anywhere in the world and no longer exists. The brand name has been taken over by various organizations avenging local grievances in the Middle East. Even in 2001, more than ten times as many Americans died in car crashes as died from terrorism.This is essentially a minor, if not non-existent problem to begin with.

But the national security state is a gravy train for Booze Allen corporation and many other government contractors, and it's created all sorts of sinecures within government. Like the War on Drugs and the prison industry, it's now a very powerful vested interest.

And that's why it's a secret. Because if we know all about it, and we have an honest political debate about it, we'll stop doing it.

Onward to the murky swamps of the DSM

Since it turns out that Eric Holder and James Clapper already know all about my pathetic social life (and BTW, Glenn Greenwald says there is more to come), I might as well fess up here. I was bummed out a while back by a relationship that didn't work out, and I'm still kinda bummed out. I don't happen to want to talk to a professional counselor about it, but somebody else might. Do I have a disease? What if I stay sad for a really long time? Do I have a disease after six weeks, or six months? Do I have to be more than a certain amount sad? What difference does it make what you call it?

As you may recall, drug companies used to run ads claiming that depression was caused by a deficit of a specific neurotransmitter, serotonin; and that their pills fixed it by increasing the amount of serotonin in your brain. One of them even had a little cartoon showing serotonin ostensibly flowing between brain cells and their pill keeping it from being reabsorbed, whereupon the person got happy.

This was total, unmitigated bullshit. People diagnosed with depression have the same amount of serotonin in their cerebrospinal fluid as everybody else; and most people with depression don't respond to anti-depressants at all. (Absolutely true. At best 15% of people show a clinically meaningful response. The rest just get the side effects.)

The brain is not a bag of chemicals, and our moods, thoughts and feelings do not correspond to some overall level of one or any combination of chemicals. The brain generates the mind in all its states through highly complex processes -- networks of excitation flowing among millions of neurons to produce each and every phenomenon of consciousness. Once we have ruled out the gross abnormalities of structure or biology I discussed earlier, we are left with states that are only arbitrarily classifiable and which nobody understands very much about.

It would be nice to have a pill that could stop us from being sad. Actually, they used to prescribe amphetamines, which do work. You could ask Lenny Bruce but, uh, he's dead. It would also be nice if we could take pills so we wouldn't be shy, wouldn't be anxious, wouldn't get angry. Well, there are pills that have these effects to some extent, but it's usually a very bad idea to take them for very long. The reason is that our shyness and anxiety and anger are not caused by a deficiency of a chemical, and if you do pump in a lot of some chemical that changes how your brain works, the effects are going to be a whole lot more than the specific one you're looking for.

In fact, there are occasions on which it is very wise to be anxious, or shy, or angry. Evolution has equipped us with these states because they sometimes can save our lives, or benefit our kin. And people's personalities and capacities vary enormously, which is also a good thing for society and makes life more interesting.

Alas, we sometimes make unwise choices, or get locked into emotional states that are unpleasant or counterproductive. Some people behave in a self-defeating way consistently, or are frequently obnoxious to others. It can get so bad sometimes that we want to get help. Here's where psychiatrists come in. They want to be thought of as real doctors, so they need to be treating diseases, and they need to have pills to do it with. And so we get official names for mood disorders and personality disorders. But these are not real entities. They are pareidoilia, an "illusion or misperception involving a vague or obscure stimulus being perceived as something clear and distinct," like Jesus appearing on toast.

Oh yeah, about dementia

I'm going to interrupt the walk through the DSM to pick up on the extensive comment from KwC, on the previous post. It so happens that my father also suffered from fronto-temporal dementia, although fortunately, the personality changes he manifested were much easier for others to deal with. He did go through a stage where he was a bit stubborn about his obsessions, but quickly became sort of sweetly apathetic. His helplessness was certainly very frustrating to my mother and other caregivers, but at least he wasn't proactively obnoxious.

Unfortunately, KwC's experiences are not uncommon. Dementia can cause people to become argumentative, resentful of loved ones, paranoid, amoral, irresponsible, accusatory, even violent. Nursing home staff will often drug such people into a stupor, for their benefit rather than the patient's. It's presumably unethical, but physical restraint doesn't seem a much better option. There is no cognitive behavioral therapy or other counseling approach to such people, they are completely impervious to reason. That's the very nature of the disease.

I wish I had an answer for folks but what I do want us to consider here is the fundamental undermining of our notions of accountability and free will. However terrible it feels to see a loved one's personality so horribly transformed, few of us will say that we blame the person or believe they should be punished for their behavior. It's an organic disease of the brain, not their intention to be hurtful.

Uh oh. Dementia or not, the brain is always a physical organ which produces behavior. I can't find any defensible reason why we excuse people if we can find a brain tumor, or a traumatic brain injury, or some neurodegenerative process that shows up on a CT scan or an MRI; but otherwise put all the blame for evil on the evildoer. None of us created our self, our brains got to the state which generates our current behavior through the unfolding of genetic potential in whatever environment we happened to find ourselves, and so we became what we are at this moment.

The illusion of free will may be necessary, but that's all it is. At the extreme, that people can be spared the death penalty if they can convince a judge that they lacked the capacity to conform their conduct to the requirements of the law is nonsensical. If a person does not conform his or her conduct to the requirements of the law, a fortiori, he or she lacked the capacity to do so. We are what we are.

More on psychiatric diagnosis

Now that we've laid out some foundational issues, this seems a good time to go back to the DSM and finish constructing our deconstruction. Various categories of psychiatric diagnosis present quite different sets of issues. My friend Gary, in The Book of Woe, raises most of them in one way or another but he doesn't march us through them systematically -- it's not that kind of book. I'm a more boring sort of writer, however, so I'll just put the ducks in a row and knock them down.

There are indeed various things that can go wrong with our brains which have all the right stuff to be called a specific disease, and treated like one (to the extent treatment is possible). These would include Alzheimer's, Parkinson's, stroke, brain tumors, traumatic brain injuries, encephalitis of whatever cause. Here, we can find some gross abnormality in the perceptible physical appearance of the brain, and we can link these consistently and explicably to symptoms which are clearly undesirable and out of the ordinary. The bad news for the APA is that none of these are really psychiatric disorders. Neurologists, oncologists, surgeons, infectious disease specialists get the fees.

Then there's addiction, which seems to have a lot of the right stuff. A fairly well accepted theory of addiction to many commonly indicted chemicals is that they essentially hijack a specific circuitry in the brain that controls motivation, mediated by the neurotransmitter dopamine. There isn't exactly a lab test for this but the receptors involved are known. Effective chemical treatments are coming along for alcoholism and we also have designer opioids that can be titrated to satisfy craving without producing sedation or euphoria. (Other drugs which are sometimes abused or can produce dependency work in other ways, but again there is basic understanding of their mechanisms.)

The real debate here is whether the "disease" concept is the most practically useful, or perhaps morally appropriate, way to think about addiction. People who invite harm or risk by their ingestion of psychoactive chemicals have very different patterns of consumption, from a little bit all the time to occasional major binges; and as many people argue, it isn't the bad chemicals that produce addiction, it's usually other problems people have such as not having something else they want to do badly enough to motivate being sober. In this view, addiction isn't really an essential disease but rather a symptom of not having a life, as it were. More controversial, from the point of view of the neuroscience, the etiology, and the ontology, are proposed non-chemical addictions such as gambling, food, shopping and sex. If you accept that these can also be addictions, then the disease label seems even more problematic. The diagnosis is even fuzzier, especially since total abstinence from some of these activities is itself either abnormal or fatal; and the question of morality and personal responsibility becomes more vexed for many.

I don't have a right answer here. If the disease concept works for you in these instances, use it. If  you'd rather think of it another way, that's also defensible.

Then we have your so-called "major" mental "disorders," which are more or less schizophrenia and what is now becoming a penumbra of variously named psychotic conditions; bipolar disorder; and major depression. That these seem to have mutual inter-heritability suggests some (completely unknown) common etiological core, which helps make the case for disease. Schizophrenia has a classic presentation with onset in late adolescence or early adulthood; and a complex of symptoms including hallucinations, disordered speech and thinking, delusions, and deficits in social interaction.  There are drugs that can calm down the hallucinations and delusions, although they do leave people with flat affect and apathy, and can have terrible physical side effects.  (The drugs don't tell us anything about the cause of schizophrenia however. By analogy, the pain of a broken leg is not caused by morphine deficiency.)

All this argues for the ontological status of schizophrenia as a disease. It seems to be a reasonably identifiable specific thing, and you definitely don't want it. It turns out, however -- and this came as news to me -- that the diagnostic reliability of schizophrenia is not nearly what you might think. Many people don't exactly have all the symptoms. Ted Kakzcynski, for example (the Unabomber) was given a diagnosis of schizophrenia, but he does not have disordered speech -- on the contrary, he's pretty good with words -- and he doesn't hallucinate. Arguing that he is delusional gets you onto very thin ice -- he has opinions which are unconventional and subversive, but so do I. He doesn't think they're being beamed into his brain from Aldebaran. That he has the same "disease" as Jared Loughner is highly questionable.

In fact people's diagnoses can cycle among the major mental disorders and their sub-types, and diagnosticians will come up with different answers for the same person. One strongly suspects that there is some sort of common etiological core here, and in any case that some day we may have a specific physical  marker that corresponds to these presentations, or perhaps markers that can differentiate among them. The drugs we have for these entities, be they legitimate diseases or not, you would rather not take unless the alternative is even worse, which it often is. So the disease frame seems pretty defensible, but the attempt at sub-classification and naming, at the current state of knowledge, not so much. The basic problem here, then, is ignorance.

Next I'll go on to depression and other affective disorders; behavioral diagnoses; and personality disorders.

Patient Centered Outcomes

Okay then, even if we don't know exactly what a disease is, as people with bodies and minds, we know what we want, right? Whether or not my inability to grow hair on top of my head counts as a disease would seem irrelevant. Either I care a about it a lot, a little, or not at all. If I care about it a lot, I want a "cure." Ditto with all the bodily afflictions of aging or the spiritual afflictions of being a sentient social being. Who cares what you call it if you can fix it, right?

Wellll . . . it's not quite that simple either. to take the most straightforward case, there's a pill I can take that supposedly will reverse, or at least retard, baldness. But it might reduce my sex drive and there's a possibility, we aren't really sure, that it could increase the risk of developing a more virulent, clinically significant form of prostate cancer. Do I want to take it?

Ever since the Thalidomide disaster, we've required that drug manufacturers show evidence of safety and effectiveness before they are allowed to market their potions. Leaving aside, for now, the important question of the strength and credibility of the evidence they are required to submit, before you can define effectiveness you need to define what they are being effective against (or for, however you want to look at it). And that means you need to (drum roll please) name a disease and specify measurable indicators of its presence, severity, or symptomatology. And then you need a nosology of adverse effects. And you need statistical methods to relate use of the purported remedy to these outcomes, good or bad.

So we can't get away from it. We need to classify and name and measure. But who does this? And why should we agree with them?

Is a science of medicine possible that avoids questions of personal values and philosophy of the good? Why no, it isn't. A science of human biology might be possible without a moral dimension,* but medicine, no, because that is the fundamental difference between medicine and biology. So if your doctor claims to have the one true scientific answer to some question about your health or well being, no, she's mistaken.

* Though I doubt humans would be capable of practicing such a science. We can do it with fruit flies, but not ourselves.

A major semantic problem

I think at some point in the winding trail of bread crumbs I've been leaving here lately I've mentioned that we need to talk about the concept of "disease." Here's your basic dictionary definition:

a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sickness; ailment.

 It goes on to give some more metaphorical meanings, which is interesting BTW since "depravity" is among them. Anyhow . . .

You may already have concluded that this definition isn't very, well, definitive. The list of causes isn't helpful since, between genetic or developmental errors and unfavorable environmental factors we have exactly everything that can possibly happen to us. And "disordered or incorrectly functioning" just begs the question. What is order or correct functioning? There is actually another problem with this definition. As weakly as it seems to rule in or out, it actually fails to include many diseases that we do recognize, because when we name something a disease, we can't necessarily point to a specific organ, part, structure or system which is disordered or incorrectly functioning in some way that we understand. So it's not just useless, it's wrong.

For what it's worth, here's what I think we mean when talk about disease, in a medical sense.

The first category is fairly clear cut. These are situations that fulfill the definition, in which we can pretty much agree intuitively that one of our parts or processes is not functioning correctly. We don't like it when we have constant pain, or can't do something that most people can do, or die otherwise than in our sleep at age 85. If we can confidently attribute the cause to a known physical property of our body and its functioning, we can name a disease and not get much of an argument. For example, if a bacterium is eating our lungs, we can name that, and hopefully if we take the right antibiotic we can end up being cured. We had pneumonia, or TB, now we don't. Easy.

But we start to have a problem with that comparator what "most people can do." Three problems actually. The first is the threshold of "most." How uncommon or far from the norm do you have to be before you merit a disease label? For example, what used to be called mental retardation, now more politely called cognitive disability or limitation, is defined completely arbitrarily, by a measured IQ of 70 or less. Give the same person an IQ test tomorrow, it might be 75. And what's the difference between 69 and 71? There's a difference alright: if it's 69, they can't execute you, but you can get special ed.

The second is what abilities really matter. I can't grow hair on the top of my head. Is that a disease?

The third is that we are all, every one of us, born with a hereditary, incurable, inevitably fatal condition that over time robs us of our physical and mental capacities. After age 45 or so, you will need reading glasses.  Your ability to hear high frequencies will decline. Your joints will start to ache. You will lose lean muscle mass.  I don't want to continue with all this depressing stuff, you can add to this list as you like, but the point is, where do you draw the line between having diseases and the human condition of mortality? In every one of these cases, we know quite well what physical processes are responsible, but are they "incorrect" or "disordered"? I'm not sure, but doctors certainly will treat all of these conditions.

Then we have situations in which we aren't presently experiencing any misery whatsoever but doctors say we have a disease because something about us puts us at risk of misery in the future: type 2 diabetes, hypertension, hypercholesterolemia, that sort of thing. Again, these are usually defined with some arbitrary threshold on a test of some sort.

And of course as I've discussed earlier we have diseases which are labels for clusters of symptoms, often largely consisting of self-reported experiences, for which no specifically disordered or incorrectly functioning organ, system or process is known. This is particularly characteristic of psychiatric "disorders" but there are some in other fields of medicine. For most of these we also have the earlier problems of locating the threshold of diagnosable abnormality and distinguishing the inevitable pain of existence from something that needs to be cut out of us by professional intervention. To the problem of psychiatric diagnosis we also have to add that some of them are labels for the way other people feel about the patient, and are not in fact distressing to the patient, e.g. narcissistic personality disorder.

So, before we can even do these clinical trials, we need to have definitions and labels for diseases, and for the amelioration thereof. But to what extent is that a scientific question, and to what extent a moral or cultural quandary? Doctor-think is pretty much exclusively done in disease categories. It may be helpful, even necessary, but it can also be limiting, and it can be used to sell us pills and other stuff we might be better off without.  


PS: in case our friend Ana is reading, I'll be in Basel August 19-22 for the international environmental health conference. Let me know if you can do lunch.

The triumph of public health

As a commenter notes, one hypothesis for the decline in violent crime in the past two decades is the removal of lead from gasoline. This was done because of evidence linking lead exposure in infancy and early childhood to reduced IQ and poor school performance. That lead exposure could lower impulse control and social integration was not so widely recognized, but the idea that this was an additional unanticipated benefit is plausible. In fact, Herbert Needleman, the researcher credited with discovering the connection between lead and reduced IQ in the 1970s, in 2002 found an association between adjudicated delinquency and lead exposure. 

Another important fact about Needleman is that he was subjected to an intense assault on his competence, motives and integrity by the lead industry, which recruited mercenary scientists to criticize his work and launched a massive public relations and lobbying campaign to block restrictions on the use of lead. Heard anything like that before? Oh yeah, tobacco, automobile safety, climate change, pesticides . . . This is what capitalists do when science says their products harm people. They spend whatever money it takes to lie to us so they can keep on profiting from murder for as long as possible.

But, in many of these cases, they have ultimately lost. Not only have we greatly reduced childhood lead poisoning, thanks to Ralph Nader and other activists, motor vehicle travel is much safer; everyone now accepts the harmful effects of tobacco and rates of smoking are down considerably; consumer products in general are safer than before -- children's clothing is less flammable, baby cribs and toys are safer, pharmaceutical regulation is far from perfect but it's much better than we had before Thalidomide. I could go on and on -- the bottom line is we're safer and we're living longer and staying healthier because of effective public health approaches to many dangers.

But few people, and almost no politicians, are talking about a similar approach to firearms. The approaches that are talked about -- banning certain styles of rifles and universal background checks on gun purchasers -- are as feckless as they are unlikely to happen. Most gun accidents, suicides and assaults are not done with so-called assault weapons, but with handguns. In any case, banning "assault weapons" is impossible. The AR-15 is not a particular weapon, it's a kind of kit. Various components essentially snap on to a central unit, called the lower receiver. Once you have one of those you can buy whatever pieces you want, which are not in themselves firearms and can be freely manufactured, bought and sold, and make your own dream rifle. What's more, you can buy a nearly finished lowfer receiver that just needs a few holes drilled in it, and the unfinished piece is also not considered a firearm and not regulated.

The country is saturated with firearms and it's pointless to even think about somehow reversing that situation. There is no particular reason not to have universal background checks but it won't do much good either. It won't stop the daily displays of idiocy by gun owners, the suicides, or even much crime -- many guns used by criminals are stolen. But, a public health approach to gun safety could work.

First of all, we can do what we do with motor vehicles: register guns and license their operators. Every motor vehicle has a unique identification code, in several places, which is difficult to remove. It corresponds to a record of the registered owner of the vehicle. If a car is stolen, it's very difficult to sell, and if the police find it, they can trace it. One would think gun owners would be in favor of that, which would protect their property. In order to operate a motor vehicle, you need to go through training and pass a competency test. Your license is revocable for cause.

Nobody thinks this is oppressive, or that the government ultimately wants to confiscate all of our cars. On the contrary, it enhances our liberty. I would not feel free to drive on the public roads if I didn't know that it was reasonably safe to do so because unsafe vehicles and irresponsible or incompetent drivers are, to the extent possible, barred. My liberty to go to the grocery store or the movie theater, or just to sit unmolested in my own home, similarly depends on knowing that idiotic, irresponsible or antisocial people aren't going to shoot me.

Licensing means knowing that just because the magazine is detached doesn't mean there isn't a round in the chamber. It means having a gun safe and storing weapons where four-year-olds won't start playing with them. No, the cops won't go into your house to check but if something bad does happen because you were irresponsible, you will lose your license. What's wrong with that? Registration means weapons have to be equipped with safeties. It's even possible to make a weapon that won't fire unless the bearer is carrying a RFID device, in other words only you can fire your own gun unless you give permission. There are lots of possible approaches to gun safety, that won't limit anybody's liberty or ability to use guns as they wish in legal and safe ways, but we aren't allowed to talk about them.


*I was at one time very involved in lead poisoning control, which by that time was largely limited to the problem of paint in older housing. We haven't eliminated childhood lead poisoning yet, but we have greatly reduced it.

Some good news?

Actually there's quite a bit, if you step back from the media circus. By a circuitous route, I came across this, for example. Rape is notoriously under-reported to the police, but the Bureau of Justice Statistics does an annual survey of 40,000 households and 75,000 people called the National Crime Victimization Survey. (Yes, I know, that's social science and therefore un-Christian and a threat to our freedoms. No doubt the Republicans will put a stop to it soon.) It turns out that the "of completed or attempted rape or sexual assault against females from 1995 to 2010" fell by a lot -- from 5/1,000 females 12 and over to 2.1/1,000.

I don't know why -- people have various hypotheses about this. But violent crime in the U.S. in general has fallen a lot in the past couple of decades. Think about it.

A strange, sad story

This happened in my old neighborhood in Boston. This guy, a former Massachusetts state representative who graduated from UMass Amherst and went on to study at the London School of Economics (no word in the story on a degree), was busted after having 480 grams of crystal meth mailed to him at the middle school where he was working as a tutor. He's about my age.

How or why you go on from being Chair of the House Committee on Ethics, Chair of the Education Committee, and Chair of the Taxation Committee, to becoming a meth dealer in your 50s, I don't know. But it gives me occasion to think on the trajectory of people's lives. I've been very fortunate -- my career has continued to be nothing but up, in the terms that matter to me, even as I come almost within sniffing distance of the age when many people retire. (I have no such intention.) But what's happening right now to a whole lot of folks is just the opposite.

This editorial in Bloomberg News should shock us all. More than 4 million Americans who are still looking for work have been out of work more 6 months or more. Many more people -- it's hard to find out how many -- aren't counted because they have simply given up looking for work. And once you lose your grip on the job market, it's very hard to get back in -- employers actually discriminate against long-term unemployed people in hiring.

We hear countless stories about people who have worked all their lives, managed to carve out a decent middle class standard of living, and then just fell right off the rails. They're in their 50s, they can't get a job in their field, and it's just too late to start over. People have lost their homes, sucked out their retirement savings, and now they're looking at a bleak old age. There are millions of these people.

The political leadership doesn't seem to care. The only way to tighten up the job market and give these folks a chance is for the federal government to adopt a stimulative fiscal policy. In other words, spend money to rebuild the national physical and human infrastructure and put people back to work. We know damn well this is what we need to do, and that in fact it would reduce the federal budget deficit in the long term because we a healthy and growing economy will mean more tax revenues and less expenditures on the social safety net. But as Eduardo Porter laments at the linked essay, we're doing the exact opposite because we've been taken over by ideologues who have no connection to economic reality. (Porter goes off the rails himself by saying we need a grand bargain to fix the crisis in Social Security and Medicare by raising the retirement age and restricting benefits. Bullshit. All we need to do about Social Security is eliminate the cap on income subject to the SS tax. Problem solved. As for Medicare, reforming how we pay for services and rationalizing our health care system will do the job, but nobody is talking seriously about that. But I digress.)

The cruelty and fundamental irresponsibility of our political leadership is appalling. I'm not saying y'all should go out and start dealing meth, and in fact I don't know what happened to Doran. But his story did get me to thinking . . .

Cross of Gold

That would be the Randomized Controlled Trial (RCT), the "gold standard" of evidence for the effectiveness of medical interventions. ("Intervention" is the general term for anything doctors do, be it pills, surgery, recommendations to exercise, shaking a rattle and chanting the name of a benevolent spirit, you name it.)

Ideally, it works like this.

You must specify several conditions ahead of time:

a) Who is eligible to be a subject of the trial. If the intervention is intended to be curative, presumably they must meet certain diagnostic criteria for actually having disease X. You might want to restrict the trial to people in a certain age range. For example you might exclude children for such reasons as their inability to give informed consent and their differential biology from adults, or you might exclude very old people or people with significant co-morbidities because they are unlikely to respond as well and would attenuate any signal you might get. Often you exclude people who don't speak English because you only speak English. And so on.

b) Exactly what will happen to the people in each arm of the trial. This includes not only precisely what intervention, or sham intervention, they will get, but what they will be told, what kind of efforts will be made to insure they will adhere to the protocol (e.g., actually take the pills on schedule), how often they will come in to be studied, whether any effort will be made to restrict anything that might happen to them that could mess up the results (e.g. they get some other intervention outside of the study), you name it.

c) How people will be recruited and enrolled, how they will be tracked, what efforts will be made to retain them in the study.

d) The end points you are hypothesizing. For example, significantly more people in the active intervention arm will meet some criteria for not having the disease 6 months after initiating the treatment; or symptoms will be reduced by some amount according to a carefully specified measure. If you think there will be a difference in response between males and females, old folks and young, people with and without any other characteristic, you must specify in advance. You must also specify what possible adverse events you will test for or assess.

e) The number you will enroll in each arm of the study, how they will be assigned, and how both the subjects and the people involved in the investigation will be blinded as to what treatment each person is getting.

f) The "statistical power" of your study. This means that if there is a real effect of a given size -- something hypothesized to be realistic --  what percentage of the time will a study "detect' the effect with a p value < .05. This is really important and I'm pretty sure most people don't get it.

.So let me try to explain. Almost always, there is a certain amount of random variation in response. Some people just get better on their own. Some people are less responsive to a treatment than are others. Some people, in spite of meeting the diagnostic criteria, didn't actually have the thing in the first place. Whatever. The whole point of randomizing the subjects is that you hope these unmeasured factors will be evenly distributed between the two groups, but in case they aren't, you can use probabilistic reasoning to figure out the probability than an observed effect was just do to chance, versus being real. You need that randomness to compute a p value.

So, we set an arbitrary standard of 5%. If the observed effect would happen fewer than 1 time out of 20 even if there really is no difference between the groups -- the treatment is ineffective -- we call the effect significant. But an effect that is not statistically significant is not the same thing as no effect. A p value of .06 means the thing probably does too work, but you aren't allowed to make that claim. Why? No particular reason.That's just how we do it.

So what can go wrong? Plenty as you might imagine. More anon.

Remember Iraq?

Hardly anyone in the U.S. seems to remember that we blew a trillion dollars to eliminate the existential threat of Saddam's Weapons of Mass Destruction™, and bring the blessings of freedom and democracy to the Iraqi people, which would then miraculously metastasize throughout the Greater Middle East™ and bring about everlasting peace.

I spent much of the time whilst we were blowing that dough along with more than 4,000 American lives and, oh yeah, a few hundred thousand or a million Iraqis but who's counting, following events there very closely, as a contributor to Today in Iraq. (Now Today in Afghanistan, see the sidebar.) Actually, Americans pretty much forgot all about Iraq around 2007 or so, even though the last (officially acknowledged) U.S. troops didn't leave till 2011. So let's remember for at least a few seconds, okay?

I don't need to remind you that the Weapons of Mass Destruction™ didn't exist. Perhaps you do need to be reminded that even if they had existed, they would not actually have been nearly as massively destructive as the weapons the U.S. used in Iraq; chemical weapons and anthrax are highly overrated. But I digress. How's that democracy thing coming?

You probably won't have any idea if you rely on the U.S. corporate media for your information, but al Jazeera is reporting that the country is on the brink of renewed civil war; the alternative being that it break apart before that happens. At least 77 people are so far reported dead in sectarian violence today, and 200 injured. If you want some background on this you can read the Irish Times, where David Hirst explains the pretty basic history. The U.S. invasion ended up replacing a Sunni Arab minority regime with a Shiite Arab majority regime. (Kurdistan actually was already quasi-independent, and remains so.) Sunni Arabs have no political influence or rights, they don't get basic government services, and their leaders are being persecuted. So they are rebelling.

This was basically inevitable. The U.S. political leadership and corporate media had no understanding of Iraq when they launched the war, and couldn't be bothered listening to anybody who did. Democracy does not ride into town on the barrel of tank or a one-ton bomb. We would do well to remember this as president McCain and the Sunday yammerers try to taunt the administration into blundering into the Syrian conflict. The situation in Iraq, and Syria, is very bad already and in grave peril of getting worse and spreading further. That is true. It does not follow that "we" must fix it. We can't, and if we tried it would be for all the wrong reasons, i.e. to try to install a regime that would be friendly to our perceived interests, mostly having to do with insuring that Israel remains completely unaccountable to international law and the basic norms of civilized behavior. That absolutely will not happen.

We can join the international community in trying to ameliorate the worst of the consequences of the conflict, but you know darn well the U.S. isn't going to spend serious money taking care of Arab refugees or getting humanitarian aid into a combat zone. Not when we aren't even willing to feed our own people. So it's very tragic and sad. But the people involved are going to have to work it out, and president McCain needs to shut the hell up. For once.

I'll retire to Bedlam . . .

As I have mentioned now and again, I am afflicted with a lengthy commute, during which I tend to OD on National Pubic Radio. (Did I commit a typo?) Lately it's been absolutely unendurable -- nothing but an endless stream of ridiculous bullshit about how ordinary imperfect operations of government are the worst thing since Hitler or something. Meanwhile, stuff is happening in the world that you know, actually matters, but we obviously don't need to know about it.

Sure, as Ezra Klein lays out very clearly, perhaps with a bit too much restraint, it's all about nothing, so he expects it just to go away. Unfortunately, it is completely irrelevant whether any of this crap is meaningful, has anything to do with president Obama, or is even wrong. If the Republicans keep talking about it, and the corporate media keeps channeling everything they say and Cokie and Mara keep yammering on about how the Obama presidency has now officially failed, well then -- that will be the reality.

There's nothing we can do about it.

Science and Evidence

This may not be the most entertaining post ever, but it's necessary in order to get on with our story. Clumsy exposition, if you will.

Many people make a distinction between science based medicine, and evidence based medicine. They're closely related, to be sure, but not quite the same.

Science depends on evidence, and respects evidence. But it does consist only of evidence. It includes deductions from evidence; hypotheses -- conjectures to be tested; and theories, which are explanations about the causal relationships among phenomena and the unobserved structures that underlie observations.

I'm sure most readers already know that the word "theory" is widely misunderstood, as being synonymous with "hypothesis." It is sometimes casually used in that way, by people who should know better, but I have been trying to discipline myself not to do that. Theories can be conjectural -- some of them also have the status of hypothesis -- but they aren't necessarily. Some of them are very well tested and as certainly true as anything can be, subject to refinement. Often a broader, more embracing theory will swallow up an old one, without exactly falsifying it. For example, Newtonian gravity still works well enough for many applications, but it does break down where conditions are extreme or we need extraordinary precision.

Anyway . . .

There are empirical remedies, that seem to work even though we don't know why. Often, alas, they don't work very well, or they don't work with everybody who seems to have the indication, or the balance of good and bad effects is not what we would like it to be. Psychiatric medications are, at best, in this category. People with disabling psychoses generally calm down and have reduced delusions and hallucinations if they take anti-psychotics, but nobody knows why. Randomized controlled trials provide evidence for effectiveness -- along with a lot of terrible side effects -- but there isn't any real scientific understanding of psychosis.

On the other hand, we now have a good understanding of how, say aspirin works. For millennia willow bark was an empirical remedy, then acetylsalycilic acid was isolated in the 19th Century, then we figured out -- or rather John Robert Vane did, in 1972 -- that it inhibits the synthesis of cell-signaling molecules called prostaglandins and thromboxanes. The former accounts for the anti-inflammatory and analgesic effects, the latter for the anticoagulation effect. (I think -- I'm not a real doctor.) Anyway, knowing that we can figure out a whole lot more about aspirin's good and bad effects, and try to find drugs that have more of the good ones and less of the bad ones. (We've made some serious mistakes along the way with that, but that's another story.)

Philosophically, this distinction is very important because the strength of new evidence depends not only on the inherent properties of an observation, such as the design of the experiment that produced it, but also on its prior plausibility. The famous p value is almost universally misunderstood. If we do an experiment and get a p value below .05 for a result which is a priori highly implausible, we cannot conclude that the chance the observation is true is 95%. It just isn't. It's likely just a fluke. On the other hand if we do a trial and get a p value of .2 or .3 for a highly plausible result, the hypothesis is very likely still true - in fact, we should be more confident that it is true than we were before, even though our observation is officially called "statistically insignificant." This misleads many people into thinking that the study undermined the hypothesis, when it did no such thing.

A very good example is the Oregon Medicaid experiment. In fact, enrolling in Medicaid almost certainly does ultimately have beneficial biological outcomes for people with diabetes and high blood pressure. Contrary to general interpretations, and in fact to its own authors' stated conclusions, the study did not provide evidence to the contrary.

I'll try to explain further as I go on to discuss evidence.

Science is Hard

Yes it is. Or it certainly can be. Back in Flexner's time and right through mid-Century, obviously, even though we didn't have any high quality randomized trials going on, doctors were doing stuff. Some of it was probably helpful much of the time. For example, they knew to amputate severely injured limbs, especially if there were signs of putrescence. If there's an accessible tumor, cutting it out can be helpful. It it isn't malignant, it's curative. Digitalis was used for heart disease since the 18th Century, and it is indeed helpful. There were other so-called empirical remedies back then as well, by which we mean remedies that appear to work but we don't know why.

Digitalis has survived as a useful treatment, but a lot of what doctors have done routinely for many years has not. In the 1946 National Formulary of the American Pharmaceutical Association, pills containing mercurous chloride were listed as treatment for "biliousness," a condition thought to be caused by insufficient flow of bile and characterized by constipation, headache, and general malaise. Mercury was thought to stimulate the liver; it did definitely counteract constipation, to put it mildly. Of course it is actually poisonous and long-term use of this compound was deleterious indeed.

So why did doctors believe in ineffective or even dangerous remedies? (It wasn't long before this time that they had given up bloodletting.) There are a few reasons.

The most basic is that most conditions that cause discomfort or suffering either get better on their own in a while, or fluctuate in severity. People are most likely to consult doctors when they have symptoms. Whatever nostrums or mumbo jumbo the doctor provides will then likely get credit for the patient shortly feeling better. This is how superstitions generally get started.

Furthermore, similar symptoms may have multiple causes. Even if half the people don't get better after consuming mercury, the treatment will end up getting credit for those who do. It might even really help some people, but harm twice as many. Nevertheless, thanks to confirmation bias, those who believe in it will continue to use it and be persuaded by their observations that it is sometimes effective. (Those it helps + those who get better regardless all redound to its credit; it is presumed unconnected to the harms it causes, because we have no such expectation.)

Another reason is that people just tend to like it when doctors do something, anything. The so-called placebo effect is greatly misunderstood and over-hyped, so I'll steer clear of the term for now. Let's just say that confirmation bias, and perhaps other psychological mechanisms,  mean that if people expect to feel better, they will say they feel better and perhaps, in some sense, will feel better. "Feeling better" is, after all , a purely subjective state. I could have exactly the same physical symptoms but be less troubled by them. And our experience of pain is very much affected by how much attention we pay to it. Whatever signals are coming from the peripheral nerves, we may have very different degrees of caring about them. A doctor's kindly ministrations and our presumption that we're going to feel better could be all it takes to make it so, for a while -- even if the cancer is still spreading.

All of the above, in addition to inflicting the practice of licensed, scientifically trained physicians, is of course the foundation of all forms of quackery.

In extreme cases, what we call anecdotal evidence can be quite valid. As a classic example, no-one says we need a randomized controlled trial of parachutes. Everybody knows what will happen, pretty much inevitably, if a person falls from a height of 2 miles. That people usually do it safely using a parachute is all we need to know. The curative power of insulin for people with Type 1 diabetes falls in this category, as does lemon juice for scurvy. Dr. Lind would not actually have needed his various active controls to prove the point. But these cases are rare.

Next time, a bit on the difference between the concepts of science-based medicine and evidence-based medicine.

The Fog of Science

As you may recall, in our last episode, Abraham Flexner has persuaded the world -- or at least the space between the North Atlantic and the North Pacific -- to put medicine on a scientific basis. But, it turns out that is very easy to say and very hard to do.

Back in 1910, people knew more about human biology than they did in 1850 or 500 BC, to be sure. But the usefulness of that knowledge for making or keeping people healthy -- whatever that means, and remember we still haven't figured that out -- was very limited. To take stock briefly of our relevant knowledge at the time, we knew something about pathogenic microbes and the importance of sterilizing surgical instruments and wounds. We didn't have any antibiotics, however. There were some empirical remedies, such as opioid analgesics, and, well, that's about it. We didn't know anything abut endocrinology, genetics, the immune system, neurology, oncology, you name it. You could be doing laboratory research and dissecting cadavers and peering at cells under a microscope but none of it was doing your patients any good.

It so happens that in 1747, a British ship's surgeon named James Lind decided, more or less at random, to feed various stuff to soldiers suffering from scurvy. Two of them got a quart of cider every day, two others got vinegar, two got "elixir of vitriol," which is sulfuric acid; two got sea water; and two got oranges and lemons. You know what happened. However, Lind did not want to recommend that the Royal Navy give sailors oranges and lemons because they were too expensive. It took 50 years before the navy got around to it.

Anyway, as impressive as that was, it wasn't until 1943, nearly 200 years later, that anybody got around to doing another randomized controlled trial. It was a pretty good one, even by modern standards: double blind, although not truly randomized. It was done in the UK, to test the effectiveness of penicillin for the common cold. And it was negative, i.e. it didn't work. Here's the even worse news: to this day, prescriptions for antibiotics continue to be written for people with common upper respiratory tract viral infections.

From then on we continued to see more and more clinical trials, of varying quality; and we came up with more and more categories of effective treatment for problems other than infections susceptible to antibiotics. However, the intrusion of knowledge and evidence into medical practice was gradual and almost as often counterproductive as it was beneficial. There are many reasons for this which continue to vex all of us who work in medicine and related fields, and which incite volcanoes of debate and recrimination. I'll tackle the issues in upcoming posts.

Wingnuttery kills

Among the sexually transmitted infections, Human Papilloma Virus (HPV, to its friends) is among the least glamorous. Everyone knows syphilis and gonorrhea, but for some reason HPV doesn't share their celebrity. It should, because some strains of it cause a very common and highly unpleasant problem, genital warts -- or warts wherever people's parts happen to interact, and you can use your imagination. Other strains cause cancer -- cervical, genital, anal, oral and pharyngeal. In fact, HPV is basically the cause of cervical cancer.

So it doesn't take a sodomite to see that a vaccine which is highly effective in preventing transmission of HPV would be a good thing for humanity. Or so one might think. Texas Governor Rick Perry found out the hard way that this isn't so by doing the right thing for what may well be the one and only time in his term in office, and mandating that adolescent girls get the vaccine. All the lovers of Jesus  in Texas immediately raised a massive outcry because they knew that the only reason their daughters weren't having sex with the entire football team was fear of genital warts. Michelle Bachmann figured she had a knockout punch in a Republican primary debate in 2011 when she raised the issue, and said after the debate "There’s a woman who came up crying to me tonight after the debate. She said her daughter was given that vaccine. She told me her daughter suffered mental retardation as a result. There are very dangerous consequences." Sarah Palin weighed in with some cheer leading.

Hoo boy. It turns out that in Australia, the people are not insane. They've been vaccinating girls since 2007, and guess what? The diagnosis of genital warts in women and girls under 21 went down from 11.5% to .85%. It's too soon to say what will happen to cancer, but presumably in a decade or two we'll see that going way down as well. We have not, however, heard of an epidemic of sexual promiscuity in the land of the  wallaby and the billabong.

So let's be clear. Religion is bad for your brain, and your body, at least if you make it a guide to any sort of decision.  We've eradicated smallpox and we've almost done with the guinea worm and polio -- but religion has turned out to be the main obstacle to finishing the job with polio, in this case Islamic leaders claiming the polio vaccine is a Christian plot to sterilize muslims. HPV is potentially eradicable as well. But first we have to eradicate the ravings of idiots.

Okay, back at it . . .

Pardon the interruption. The radical discontinuity in 1910 was the famous Flexner report. Abraham Flexner, who worked for the Carnegie Foundation for the Advancement of Teaching, was commissioned to study medical education in the U.S. and Canada. Back then there were 155 medical schools in the former British possessions, all of which he visited. (He is often said to have studied medical education in North America, but, err, Mexico. I digress.)

It turned out that most of them were not affiliated with universities, but were owned by one or a few physicians. They had what Flexner considered insufficient curricula and clinical training. States generally did not regulate the practice of medicine or have licensing requirements for physicians. Most important, in Flexner's view, medical training and practice was not uniformly based on science. His ideals were the few university-affiliated medical schools of the time, and particularly Johns Hopkins. Flexner's recommendations led to the current model of medical education based at universities, followed by clinical apprenticeship and university-affiliated hospitals,  taught by clinicians who were also research scientists, based on claims for effectiveness based on scientific knowledge and reasoning. Less directly, his work led to the imposition of standards for medical licensing and practice. These were imposed by the states piecemeal, and I have not come across a comprehensive history, but by now we take it for granted that every state does this.

Following this revolution, the number of medical schools in the U.S. at first shrank dramatically, and as it rebounded, all of the new ones adhered to the new standards and philosophy. For better or for worse, medical school faculty came to be evaluated based on their research activities, rather than their teaching. Various heterodox "schools" of medicine, such as homeopathy and chiropractic, lost their claim to legitimacy within the new structure of scientific medicine, because their claims are biologically implausible and not supported by rigorous experiments. (Although, inexplicably, at this late date, they seem to be worming their way back in. But that's for another day.)

Medicine's claims of scientific authority were certainly vindicated by many important developments throughout the 20th Century, notably effective antibiotics, insulin for Type 1 diabetes, incremental advances in surgery and trauma care that ultimately added up to huge benefits, effective immunization against more and more pathogens. As recently as 20 years ago, when I first got into this racket, there was a legitimate argument about whether the contribution of scientific medicine to health and longevity at the population level was very important, or even provably positive; but that is no longer true.

But, history has not ended. Medical practice, and the physician and patient roles and their relationships, remain deeply problematic.

To be continued.

Bloggers are human too

I'm afraid I can't say anything intelligent today because I'm feeling like the lowest piece of crap in the Delta quadrant of the galaxy. At least this gives me a chance to comment on the whole disease ontology thing. I can't claim to be enjoying the highest attainable state of social and psychological well-being right now, and I'm sure a psychiatrist would find something to diagnose me with, but no, i don't have a disease. I suffer from the human condition.

I don't think a robot could console me right now, and I'm not one who benefits from comfort food or shopping sprees. I'll just have to carry on. So shall you.

Yo, Robot!

We interrupt this long-form essay to report on my afternoon at our Second Annual Symposium on Human-Robot Interaction. Really. I was there because I study human-human interaction and I've been roped in -- well alright, I didn't really mind, it's kind of interesting -- to letting computer scientists play with my concepts, and they might be useful for getting machines to communicate with us more usefully.

I won't go into that in a lot of depth here, but what I do want to talk about is where the nerds think this whole thing is headed. You may or may not like it. One of the potential applications for interacting robots is to be companions and caregivers for elderly people. This actually gets talked about a lot. The social problem is that more and more people are living to be old and frail and widowed and socially isolated. It's too expensive to give them homemakers and home health aids plus they're lonely. So maybe we can give them a robot.

I don't know about you but I find that fairly icky. Of course, if you could make such a robot, it could also be a house servant for able-bodied families, a janitor, a waiter -- lots of jobs. Even, yes, a nanny, and they were talking about robots being essentially Head Start teachers as well. Is this good?

Where I come in technically is that basically, Siri works, kinda, because all you do is ask her -- excuse me it -- questions and maybe give some basic instructions in a limited domain, such as calling a number. But your robot companion has to accurately interpret much more complex domains of speech, what we call the full range of illocutionary acts -- such as all the various kinds of questions, promises, and expressions of feeling, even jokes; figure out your intentions, desires, and state of mind; and respond appropriately. Note that I didn't say the robot has to understand anything -- that's different. In fact, what we've learned from decades of failure at artificial intelligence is that we have much more success getting computers to respond appropriately to language inputs if we forget about understanding and just automate the responses based on statistical correlations of language content with illocutions.

Fortunately, we are so far from this that I'm not worried about it happening any time soon. I think. But if we do give robots more and more autonomy and behavioral flexibility, then we have to start worrying about robot ethics. Also, does tossing people a robot as a substitute for human companionship or nurture mean we are meeting a social need, or consigning people to a kind of hell?