The Other Side of Rising Health Care Costs

In the public sphere, we tend to hear that the increase in health care spending as a share of GDP is a bad thing which is unsustainable and represents the evil machinations of the Medical-Industrial complex. I may sound like that sometimes myself, but it isn't exactly accurate. There is a lot of waste and misallocation of resources in the medical industry, and yes, we need to do what we can to fix that.

But us health policy wonks know there's more to it. To some extent -- maybe not the actually existing extent, but some extent -- we would expect the share of GDP spent on health care to increase secularly, and that's actually a good thing. This by Hall and Jones is one analysis along those lines, but lots of people make similar arguments.

There are really two mechanisms at work here. The first is that over time, medical technology has gotten better. We can cure many cancers that we couldn't before, or at least give people years of decent quality life. The age-adjusted death rate from heart disease has plummeted. Orthopedic surgery can very effectively fix osteoarthritis, which is one of the worst things about growing older. (It did for me!) But all this costs more. Unlike electronic gadgets, the price doesn't keep going down. We need highly trained experts, million-dollar machines, and  drug and device prices that repay expensive research (since that's the model we've chosen). Yes, new technologies can occasionally be cost-saving (though much less often than you might think) and the price can come down over time (as when drugs go off-patent), but in the real world, technological advance produces a net increase in costs.

So yes, it costs more, but it's often worth it.

The second mechanism is that as people grow more affluent, once they've met their basic needs for food, clothing and shelter and whatever else they really, really want, health care is high on the list for disposing of income. We get the elective surgery; we go to the doctor and get checked out, and yes, they'll always find something. And yes, most of us pay only a small share of  our health care expenses out of pocket, but consumer and public demand that insurers cover expensive treatments is irresistible. When they try not doing it, there is an outcry. (Although weirdly, many of the same people who do the outcrying have no problem with some people having no health insurance at all.) So Medicare and private insurance will pay the $200,000 to keep someone with terminal cancer alive for three months.

But even that is not necessarily wrong, up to a point. When we have little time left, each day is more precious. And median survival conceals the exceptions who live a long time. And that also means hope --if you can hang on a bit longer, they might come up with a new treatment. This actually happens. For example, not-so-great HIV drugs kept some people alive  long enough to get better ones.

So, in principle, we could be happy to see medical expenditures increase as a percentage of the economy. That's a choice we can make and feel wise about. That's happening everywhere, including Canada and the UK with their single payer and socialized systems, respectively. But those parallel lines are much lower. They are spending more over time, and reaping benefits, but they are also spending a lot less than we are. Both can be true.  

The real problem with Medicaid expansion

As you may have heard, the Republican Governors' united front against Medicaid expansion is fracturing. They never had a really good explanation of why they would not accept free money from the federal government to cover their uninsured working poor, except that ideologically it's just wrong to spend tax money to make people's lives better and  they'd have to kick in a few percent down the road. But now Pennsylvania, Arkansas, Arizona, Wyoming and others are implementing Medicaid expansion in one form or another.

Many observers considered this inevitable in the long run because a) people can see that neighboring states are better off, not worse off, when they accept Medicaid expansion, b) hospitals and other health care providers are a powerful constituency in favor of Medicaid expansion and c) so are employers with low-wage work forces. There doesn't seem to be any way, politically, for Republican politicians to get away forever with screwing their citizens and major employers.

But now Dylan Scott, in TPM, drawing on an observation by Nelson Lichtenstein of UCSB, explains why many states still resist: they are the former Confederate States of America and the large majority of beneficiaries of Medicaid expansion would be African Americans (and Latinos in many cases, I might add). Arkansas and Kentucky are expanding Medicaid, but they have Democratic governors.

Let's face facts here folks: the reason that many low and moderate income white folks are opposed to government programs that would benefit them is that they think more of the benefit goes to people who are unworthy, and said people's unworthiness is predicated on their pigmentation. It is because racism divides our working class that we have the stingiest social welfare state among the wealthy countries, and that is why we have so many people who vote against their own self-interest and are seduced by the unalloyed bullshit of libertarianism.

Oh yeah. That's also why we have a War on Drugs. And  a whole lot else that's wrong.

What am I missing?

This seems to me very simple and obvious. It is not among the goals of police work to shoot and kill unarmed citizens. If that happens, we can conclude that the police officer did not follow a proper protocol, and the officer's conduct was not what we expect of police officers. The proof of this is the dead person.

It is preposterous to say that the officer may be justified in his actions and that this may be a "good shoot," as they say. Res ipsa loquitur. You had a live, healthy, unarmed person presenting no danger to anyone. Now you have a dead person. That is bad. The police officer did it. The police officer did a bad thing. We can go ahead and learn more about the events but we already know enough to say the above. QED.

And, if I may go on, what Americans do not seem to understand is that the purpose of guns is to kill. Guns are machines designed and manufactured for the sole purpose of killing large metazoans, including humans. That is all they are good for. That is why they exist. That anybody would think that a child should be taught that it is fun to shoot guns is just sick. If you happen to be among the few people on earth who feed themselves by hunting wild animals, then it's your job, and maybe you need to teach your children how to do it assuming they will survive by the same means. Otherwise, the purpose of guns is to kill humans. That is not fun.

Automatic rifles are for the latter purpose -- killing humans -- only. If you think that you should provide your nine year old child with the fun experience of using a machine that exists for the sole purpose of slaughtering humans, you are depraved. And depravity is, of course, a God-given right embodied in the sacred Second Amendment to the Constitution, the only one that counts.

GMO Deception: the final word

It pains me to write this, because Sheldon Krimsky is a friend and mentor, and someone I really admire. But I have to tell it like it is.

As I said last time, all new technologies are likely to have unintended consequences. Furthermore, corporate patent owners aren't in business to save humanity, they are in business to make profit. It is indubitably wise to approach new technologies, and the promises of their purveyors, with skepticism. I believe that the following are entirely respectable arguments:

1) The Roundup/Roundup Ready system is a bad deal for farmers, for consumers, for the rural economy, and for all of us as inhabitants of the biosphere. It does not increase the food supply, it just substitutes capital for labor in agriculture. And that won't last long, as glyphosate resistant weeds proliferate. By the way, one more thing, glyphosate has been killing the milkweed that normally like to grow on the edges of farm fields, devastating the monarch butterflies that depend on it. Roundup is not harmless to animal life either, as Monsanto claims, especially because of its so-called "inert" ingredients which are actually toxic surfactants. There is a good case to be made for banning this system.

That said, this is not an indictment of GMO technology, but of a single implementation. Glyphosate resistance could have been achieved by conventional breeding, in principle. That wouldn't make any difference.

2) Crops that produce Bt are less problematic because farmers would use insecticides anyway. If anything, Bt crops mean less pesticide exposure for farmers and farmhands, and as insecticides go, Bt is among the least obnoxious. Although it is possible for relatively small scale farmers to use pest control practices that seldom require use of insecticides, it is not practical to feed the world without them as of now. But there's a good chance that your local insects will become resistant to Bt and you'll have to start spraying other stuff again in due course. So it's not a long term solution to anything.

3) It is true that GMO crops with useful properties other than chemical pest control have not been taken up on a large scale. They don't seem to work very well and aren't particularly appealing to farmers. Conventional breeding can apparently do about as good a job of improving drought resistance and salt tolerance, and achieving reduced nutrient requirements, and so far there haven't been any major breakthroughs in these areas from GM.

4) You can certainly argue that new technologies could have unpredictable effects and that we need to do more research to establish safety than we have been doing. Probably the regulatory regime is inadequate and we're certainly nuts to trust the manufacturers to do the research, decide what gets published, and assure us that it's all safe. I'm not as alarmed about the safety and nutritional properties of GMO crops as the editors and contributors to The GMO Deception seem to be, but it's not crazy to take precautions.

So yes, we ought to be having more of a public discussion about not only GMO, but agricultural practices, pesticide regulation, and the farm economy in general. There are extremely important issues, including fossil fuel inputs, nutrient runoff, the exploitation of farm labor, water shortage, hunger (which is not because there isn't enough food in the world, at least not yet), we could go on and on. Genetic engineering vs. conventional breeding is not really a meaningful category here, in my view. Every question must be considered on its own merits.

So that bring us to the book. The publicist's e-mail to me was headlined "Easily digestible look at the GMO debate." Alas, it is not easily digestible. On the one hand, the dozens of essays repeat the same information and arguments innumerable times; on the other hand, they leave perplexing gaps. As I said before, their chronological order is completely random. You'll read a set of dire predictions written in the 1980s and never learn if any of them came true. You'll read an alarmed critique of the regulatory regime in 1990 and you're on your own trying to figure out if the information is updated somewhere else in the volume. Slogging through this is nearly impossible.

At the same time, the depth of analysis and quality of evidence presented is often very thin. There is much argument by assertion, and generally a failure to seriously engage the arguments of those with opposing views. The reader does not get any sense of the debate, only an unrelenting polemic, some of which has already been debunked.

The world is crying out for a coherent, readable, intelligible and intellectually responsible discussion of these issues. Kudos to the editors for trying to bring attention and rebalance the debate, but this book isn't it.

Another GMO deception

Alas, the publishers of The GMO Deception had bad timing in one respect. One of the essays in the book, by Indrani Barpujari and Birendra Brau, alleges that suicides of farmers in India are caused by the widespread adoption of cotton that expresses the insecticide Bt. The basic idea is that the seeds are much more expensive than traditional seeds, driving the farmers into debt. (The essay was first published in 2007, and no attempt is made in the volume to bring the information up to date, a highly annoying feature of this book I mentioned in my first post about it.)

Now Michael Specter in the New Yorker gives this a massive, compelling debunking. It turns out that yeah, the seeds cost more, but the farmers save more than that on pesticides. And they also avoid exposing themselves and their families to sprayed insecticides. Although agriculture in India is economically stressed, it has nothing to do with GMO crops.

As I posted to Pharyngula:

It’s unfortunate that the discussion of GMO crops has been polluted, as it were, by tendentious hogwash on the part of opponents as well as proponents. It makes it very difficult to have a reasoned discussion of the issues because if you take a critical stance on some particular, you get lumped in with the anti-GMO crazies, whereas if you have anything nice to say about any particular application of GM you get lumped in with the rapacious capitalists.
I hope we can avoid that here. Every technology — every technology — has unintended ill effects. Take for example the automobile. It is a scientific fact that internal combustion engines work, and get you from point A to point B faster than horses. They can be made more or less safe, and more or less polluting, and there may be ways to make the other social externalities (e.g. urban sprawl and obesity and highways that slice through communities and all that stuff) less bad. But the costs and benefits of automobile-related policy and regulation are properly subject to debate, the possible costs now including the devastation of the planetary ecology and human civilization. And the automobile manufacturers obviously cannot be taken at face value when they make claims. The same goes for GMO crops and Monsanto.

Unfortunately, The GMO Deception is often tendentious and fails to contribute to the prospects for such a reasoned discussion. People just get dug in and then there's no possibility of movement.

To Be Continued.

Roundup Ready

Okay, back to the GMO thing. Although GMO proponents claim that genetic engineering can produce crops that are drought resistant, salt resistant, higher yielding, need less fertilizer, and all sorts of other wonderfulness that can benefit small farmers and help feed the world, in fact all but a tiny fraction of actually existing GMO crops are engineered for one of two properties: herbicide resistance, and natural expression of the insecticide Bt toxin.

The biggest sellers are Monsanto's "Roundup Ready" soy, corn, cotton and canola seeds. These are resistant to Monsanto's big-selling herbicide Roundup, which is a formulation of the plant toxin glyphosate. I happened to do some research on glyphosate back when I was getting my M.A. in environmental policy. It's a very broad spectrum herbicide, i.e. it kills everything that's green, ordinarily. Roundup contains what Monsanto calls "inert" ingredients that aren't even regulated. In fact they are powerful detergents, added to help wet the leaves, which are highly toxic to aquatic organisms. But I digress.

Roundup Ready crops actually have lower yields than their competitors. The benefit to farmers is that they reduce labor crops. You don't have to till and otherwise manually control weeds. Just spray the whole field, kill everything, then plant. You can spray again if you want to. But, you aren't allowed to save your own seeds and plant them next year. You have to buy the seeds, and the Roundup, from Monsanto every year. As you can see, this gives an economic advantage to large, capital intensive farms over small, labor intensive farms. More about that later. For now . . .

If you keep spraying a single herbicide in the same place year after year, what do you think will happen? If GMO organisms can be glyphosate resistant, well, plants can evolve that same property on their own. And they do. A distaster is now in the making. Quoth the New York Times:

Botanists call the weed palmer amaranth. But perhaps the most fitting, if less known, name is carelessweed. In barely a decade, it has devastated Southern cotton farms and is poised to wreak havoc in the Midwest — all because farmers got careless. [er no, as the article goes on to say that's not why] . . .

Palmer, as farmers nicknamed it, is the most notorious of a growing number of weeds that are immune to the gold standard of herbicides, glyphosate.. . .  After Monsanto began selling crops genetically engineered to resist glyphosate in the 1990s, the herbicide’s use soared. Farmers who once juggled an array of herbicides — what killed weeds in a cotton field might kill cornstalks in a cornfield — suddenly had a single herbicide that could be applied to almost all major crops without harming them. But constantly dousing crops in glyphosate exacted a price. Weeds with glyphosate-resisting genetic mutations appeared faster and more often — 16 types of weed so far in the United States. A 2012 survey concluded that glyphosate-resistant weeds had infested enough acreage of American farmland to cover a plot nearly as big as Oregon, and that the total infestation had grown 51 percent in one year. Glyphosate-resistant palmers first surfaced in 2005, in a field in Macon County, Ga. Nine years later, they are in at least 24 states.

So now farmer are going back to manual extirpation and rotating herbicides. But for many, it's too late. Palmer is almost impossible to eradicate. It produces thousands of seeds that can germinate throughout the growing season, has a large dense root system, and grows back after you cut it down. Some farmers have had no choice but to mow their entire crops. The Roundup/Roundup Ready system is now useless for them and it may take decades for some farmers to regain control of their fields. So you can go ahead and eat the GMO food, but you still might have a guilty conscience.

To be continued.

I wouldn't want you to miss . .

This New York Times correction.

An Op-Ed essay on Monday described bald eagles and ospreys incorrectly. They eat fish, and their poop is white; they do not eat berries and excrete purple feces. (Other birds, like American robins, Eurasian starlings and cedar waxwings, do.)

I'll get back on the GMO thing shortly. But I interrupt that series to note something deeply shameful about the United States. Kurdistan has accepted hundreds of thousands of Iraqi refugees, most of whom are neither Kurdish nor Moslem, despite that (de facto) country's limited resources. Nobody there is visibly complaining about it, and they're doing what they can. As the linked article says, the UN is finally making a major relief effort. Hundreds of thousands of Iraqis, and Syrians, are also in Jordan and Turkey, as well as Kurdistan.

A few tens of thousands of desperate, hungry and frightened children show up on our border and the locals organize demonstrations to prevent them from being sheltered, carrying racist signs, and blocking buses. We are a sick society.

GMO, continued

Okay, back to work. (I did a site visit on Friday and didn't feel like blogging over the weekend.) The GMO Deception is a collection of essays, mostly short, and mostly reprinted from the newsletter Gene Watch. They may date anywhere from the 1980s to the present, and they are in no particular chronological arrangement. This makes it quite difficult for the reader to develop a coherent understanding of the history, or even of the current state of affairs. One must pay close attention to the dates of the various contributions and then try to put things in order. It's always a chore and sometimes impossible. We'll read a passionate polemic decrying the regulatory regime of 1990 or worrying about gaps in knowledge in 1985, and then we're responsible for trying to find, somewhere else in the book, what has become of the situation.

This puts a substantial burden on the reviewer, because I'm not even sure I have everything straight and I've even had to do a bit of independent research to figure out what's going on. I also would recommend that Skyhorse hire a copy editor. There are some serious, fundamental howlers. These include Ralph's introduction which repeatedly refers to the herbicide Roundup as Roundup Ready, which is actually the brand name Monsanto's glyphosate resistant seeds. The error is reproduced in the introduction. Fig. 4 of the introduction is supposed to show the difference between GMO proponents' view of what happens when you introduce a single gene into an organism, and the reality. Unfortunately, both halves of the figure are identical, so there does not appear to be much difference. I won't go on because they didn't hire me to copy edit.

Anyway, Fig. 4 notwithstanding, the argument is sound. As even GMO proponent PZ Myers will not just admit, but enthusiastically affirm, gene effects are "pleiotropic." That means genes don't just do one thing. Some even code for more than one protein, by cutting and splicing at different places. But more generally, they interact with other genes, affect expression of other genes, and their products are typically involved in more than one developmental or biochemical process. So inserting one gene can cause a lot of changes in a plant beyond what is intended. (The process can also cause additional mutations.)

The regulatory regime for GMO foods in the U.S., as I understand it, requires only that manufacturers provide the FDA with a case that the single protein product of an inserted gene is safe to eat. This does not have to be based on any original animal or human research with the organism. In other words, you don't have to feed it to rats or monitor people who eat it, you just have to argue that Bt or whatever is harmless to humans. The editors and contributors to The GMO Deception don't think that's good enough, because the foodstuffs could differ in other ways from their non-modified precursors.

Well, maybe so, but others may find this a bit tendentious. After all, conventionally bred foods often differ in unintended ways from their ancestors. Conventionally bred tomatoes developed to be firmer and ripen more slowly for transport taste like cardboard. Mutations that alter proteins happen naturally all the time. Natural insect resistance, which is enhanced by intentional cross breeding, implies the expression of toxins. (This is a reason why many plants are toxic to humans, including the foliage of tomatoes and potatoes.)

It isn't clear, therefore, that genetic engineering presents any unique dangers to the food supply. We're already eating food that sacrifices nutrition for other properties, food allergies are already common, and completely natural foods contain carcinogens and other harmful substances as well as the good stuff. The fact is we have had 15 years of experience with most of the U.S. population consuming large amounts of GM corn and soybeans, and no sign of any harm except for the low quality diet that comes from eating a lot of processed corn products.

So, this is really the weakest part of the case. Yet it is the one that proponents focus on, as a handy straw man. The other objections are stronger, I think, but don't get as much attention in the political debate. It's easy to scare people with talk of "Frankenfoods," but that's a pretty speculative issue in my view and I find it tendentious. So I'll get to the more persuasive arguments in coming posts.

The GMO deception?

I received a review copy of The GMO Deception: What you need to know about the food corporations, and government agencies putting our families and our environment at risk, Sheldon Krimsky and Jeremy Gruber, eds. Skyhorse publishing, 2014. $24.95.

Major disclosure: Shelly Krimsky was my master's thesis adviser and I also took his course in environmental policy at Tufts. Ralph Nader, who wrote the foreword, was my employer in my now distant youth and I met him on a few occasions.

GMO means genetically modified organisms, but that's a bit of a misnomer since humans have been genetically modifying organisms since the dawn of agriculture, originally through selection and eventually through deliberate cross-breeding and selection. But GMO refers more specifically to organisms -- most public attention is on food crops -- that have been genetically engineered, that is they have had specific genes inserted into their DNA using modern laboratory techniques. These genes may come from different species or even different phyla or even kingdoms. It is possible to insert animal or bacterial genes into plants.

GMO foods are banned completely in Europe, but are pervasive in the U.S. food supply. Any product in the supermarket that contains corn or soy that isn't labeled "organic" will likely contain GMO products. As you probably know, there is currently controversy about whether manufacturers should even be required to label foods with GMO content. Right now, they are not. The conventional wisdom in the United States, including scientists who you likely respect such as PZ Myers and Neil DeGrasse Tyson, is that any objection to GMO crops is anti-scientific nonsense equivalent to climate change denial or creationism.

Krimsky and Gruber and the dozens of contributors to The GMO Deception beg to differ. The objections fall into three major categories.

1. Has it really been adequately established that GMO organisms are safe to eat, or at least as nutritious and healthful as conventionally bred organisms, and are regulations to insure this adequate?
2. Are there possible harmful environmental impacts of GMO crops and again, is research and regulation adequate to prevent them?
3. GMO crop systems are ultimately harmful to the agricultural economy in that they displace farm labor, promote capital intensity and larger scale thereby driving smaller farms out of business, and make farmers dependent on seed and pesticide purveyors at cost to their incomes and independence.

Each of these issues is complicated, and I'm afraid I do agree that they are far more complicated than Dr. Tyson believes. He is an astrophysicist so he has no more expertise about this than I do. The book has some serious shortcomings, which I will address. But first, in the coming days, I will take up the three areas of controversy in turn. There are some additional controversies involving GMO animals, which have a distinct ethical dimension. These are mentioned much less prominently in the book, but I may have a few words to say about this subject as well. In the meantime, if you have any thoughts or opinions about these controversies before we begin, please comment.

Political Malpractice

No, you probably didn't read it here first, but the RW Johnson Foundation has a new analysis of the fate of people in those states that refused to accept the Medicaid expansion. Since I never know for sure how much readers may already know, I feel compelled to maybe bore and talk down to you about exactly what the Medicaid expansion is.

Prior to the Affordable Care Act, in order to be eligible for Medicaid you had to be a minor child, an adult caring for minor children or a pregnant woman, and you had to be disabled. That's called "categorical eligibility." Also, generally speaking, you had to be below the official poverty level. States set varying income eligibility limits and other requirements, but every state provided Medicaid to people with no income --which means that it was the working poor who were left out in the less generous states, even if they were categorically eligible. States are reimbursed anywhere from 50% to 80% of the cost of providing Medicaid for those people, depending on the economic circumstances of the state. That is still true, it hasn't changed. That was a good enough deal that every state took it, and kept taking, no matter how conservative their government.

The Medicaid expansion eliminates categorical eligibility, which means that non-disabled adults without kids can get it. It also raises the income eligibility threshold to 138% of poverty. And it reimburses the states 100% for these newly eligible people initially, falling to 90% by 2020.

In the ACA as passed by congress and signed by the president -- AKA tyranically imposed by the socialist usurper -- states had to accept the Medicaid expansion in order to continue participating in classic Medicaid. But John Roberts, a jurist who only calls balls and strikes and would never legislate from the bench, rewrote the statute such that states can keep classic Medicaid without accepting the expansion.

As a result, 24 governors decided not to allow the federal government to provide health care to their poor and low-income citizens. Also, those people are not eligible for subsidies to buy insurance on their own because the ACA assumed they would have Medicaid. Not that they could afford it even with the subsidies. So they're out of luck. Also out of luck are the hospitals and health care workers who would get paid to take care of them.

As the RWJ Foundation tell us, by the time the dust settles in 2016, 6.7 million people in those states who would otherwise have been insured will not be. The states will forego $43 billion in reimbursement by that year, for which they would have had to spend $291 million in their own money. The main argument the Republican governors make against accepting the expansion is that cost, but accepting the money would obviously boost their economies and tax revenues, while those same states will happily spend $45 billion in incentives to private business during that time. So they are, in other words, total hypocrites. (Hospitals and physician practices are private businesses, by the way. But evidently they don't count.)

There are only two reasons why the Republican state governments have rejected the Medicaid expansion. 1) The president is Barack Obama, and there's just something about him, what could it be? and 2) They want low income working people in their states not to be able to get health care, because they're just takers and the part where they make stuff by having jobs doesn't count. And note that it is mostly working people who are deprived because disabled people and parents without jobs are already covered.

Another way to put this is that they are psychopaths. Nevertheless that seems to be popular with their citizenry and they expect to do well at the polls this November. Explain it to me.

A catastrophe of our own making, and largely ignored

I am a long-time Iraq buff. I contributed to the blog Today in Iraq through most of its existence (it is now today in Afghanistan), and I have followed events in that country closely since then.

The situation right now is appalling. The Islamic State has captured predominantly Christian and Yazidi towns in the north and the inhabitants have fled in panic. (The Yazidi practice a pre-Islamic religion.) The Christians have fled to Kurdistan, while thousands of Yazidi fled to a mountain where they had no food or water. The UN now says that they have been rescued but that at least 40 children died of thirst. Update: It turns out the Yazidis have not been rescued,  but they are receiving airdropped supplies.

IS has captured the Mosul dam, which provides electricity to 3 Iraqi provinces. If the dam is breached, the ensuing flood would destroy Mosul and inundate Baghdad.

So, how did this happen? Iraqi Prime Minister Nuri al-Maliki systematically discriminated against Sunni Arabs, depriving them of government services and jobs, and leadership positions in the military. He replaced competent military leaders with his cronies. The army had a system in which soldiers' pay was given to commanders for distribution, and many soldiers cut deals whereby they would go home, take other jobs, and split their pay with the officer. So, when ISIL swept into Anbar and Ninevah provinces, the Iraqi army collapsed, and Sunni Arab militias joined forces with the Islamists.

The Kurdish peshmerga is a competent fighting force, and they held the dam and protected the Christian and Yazidi towns in the north, simultaneously moving in to territory they coveted for themselves in Kirkuk and environs. But they are lightly armed, and Maliki cut them off from ammunition and military equipment in the possession of the central government. Since Kurdistan lacks sovereignty, they have great difficulty purchasing military goods on their own. So, they ran out of ammunition and were forced to desert the towns they were protecting. They held on at the dam for weeks but were finally overcome. Note that none of this action is inside Kurdistan -- the Iraqi military would ordinarily be responsible for this territory but it is incompetent.

The United States initially supported Maliki's installation as PM, and has continued to support him ever since, despite his outrageous misrule. This is a predictable consequence of invading a country our political and military leaders knew nothing about, smashing the existing order, and grossly mismanaging the restoration.

I don't know a lot about the Islamic State or the socio-cultural forces that produced its genocidal ideology. They appear to have been shaped largely in the crucible of the Syrian civil war and are partly blowback from the Gulf monarchies proxy war with Iran. But there they are, filling the vacuum created by the hubris and evil of Richard Cheney, Donald Rumsfeld, and their weakling tool George W. Bush. Americans appear not to care about the people of Iraq, but this is our fault and our responsibility. Not sure what to do beyond humanitarian relief, but at least we need to be offering that. And we aren't.

By the way, Americans want to turn away a few thousand children who are seeking refuge here, whereas the much less wealthy people of Jordan, Kurdistan and Turkey are doing their best to house millions of Iraqi and Syrian refugees. That's American exceptionalism for you.

And speaking of theft . . .

Acthar is a drug approved in 1952 for a pediatric seizure disorder. Back then, the manufacturer didn't have to prove it was effective to get approval. But now Questcor is marketing it for multiple sclerosis, even though there is no clinical trials evidence that it works. It's expensive -- Medicare paid an average of $41,763 per prescription in 2012. It turns out that just 15 prescribers accounted for 10% of those prescriptions, and that most of them take money from Questcor.

Apart from human greed, the problem here is that Congress forbids Medicare from not covering any drug which has FDA approval, or from setting prices. This is because drug companies have lobbyists and you and I do not. Also, too, even today to get FDA approval you don't need to prove that your new drug is better than an existing, cheaper alternative. You only have to prove that it's better than placebo. So we finance all these ripoffs. 

Christianity is good business

I doubt I've ever linked to CNN before, but this bit on the palaces of the archbishops is worth a gander. As we know the new Pope is getting all humble and poor, but the princes of the church have yet to get the memo. Ten of 34 U.S. archbishops live in houses worth more than $1 million, and some of them a lot more. Archbishop Dolan of New York, one of the world's sleaziest scumbags, lives in a mansion on Madison Ave. that's been appraised for $30 million.

That's just the Catholics. You may have seen, between innings or while you were zoning out to Rachel Maddow, a scam called "Christian Mingle." You can "find God's match for you" but God is requiring you to pay these people money in order to perform the miracle. Now they're letting us know that sometimes we're waiting for God to make the move, but God is saying it's your time to act. They actually know what God is saying to me, even though I can't hear it!

Rick Warren, pastor of Saddleback Church, does not believe in wealth redistribution. That's probably because he owns $25 million. Can't be redistributing that shit, instead he's been pureeing camels and pushing them through the eyes of needles.

It's bad enough that it's all bullshit. It's also theft. We can begin by eliminating the tax exemption for religious organizations.

Don't confuse me with the facts, my mind's made up

That seems to be the basic attitude of Americans toward the affordable care act according to Harvard pollster Robert Blendon. The linked Bloomberg article piles another brick onto the now solid wall of Obamacare success -- specifically, that hospitals are seeing fewer uninsured patients and getting paid for their services. That's great for the profits and stock price of for-profit hospitals and for their presumably mostly Republican executives. The percentage of Americans who are uninsured is now 13.4%, probably the lowest ever. And health care cost increases have slowed nearly to the rate of inflation.

The law is actually more successful than even it's most optimistic supporters expected. And yet:

Americans' opinions on the measure may be too hardened for Democrats to see much political benefit this year, or to fight off changes to the act in the future, said Robert Blendon, a professor of health policy at the Harvard School of Public Health. Recent polls indicate that more Americans remain opposed to the health-care law than support it, although that includes people who think it isn't liberal enough.

I'll tell you why this is. It's because Democratic politicians, as a class, are whimpering cowards who go hide in a corner at the slightest rustle of faux populist disapproval. If they would just stand up and make a full-throated defense of the law, based on the fact that it is a big success, the corporate media would have to stop pretending that it's a disaster and more people might start to figure out the truth. They have nothing to lose -- they did vote for it after all and their opponents are going to try to use it to attack them. Hiding in the corner isn't going to help. But they're just chickenshit. 

Deep Thought

Barack Obama will leave office in January, 2017 without having confiscated all the guns, interned the Bible-believing Christians in FEMA concentration camps, imposing Sharia law, or surrendering the United States to the UN One World Government.

What will the wingnuts say then?

I suppose I should say something about the Ebola outbreak

There's been considerable alarm in the blogosphere about the outbreak of Ebola virus in west Africa. Naturally, the occasion for people in the U.S. to take notice is that two U.S. citizens have become infected. It was no big deal that about 660 Africans have died from the disease. Yes, that's a bummer and horrific for the people affected. However . . .

We need to get a grip. The chances that this will become a global pandemic, or even a major cause of death in Africa, are infinitesimal. Why do I say that? Although I have heard the elocutionists on National Pubic Radio call Ebola "highly contagious," actually it isn't. Transmission requires direct contact with bodily fluids.

Yes, that's true of HIV which is a global pandemic but there's a big difference. You can't walk around with Ebola virus appearing to be healthy and unwittingly infecting people through unprotected sex or sharing needles. There is a brief period during which people are potentially infectious but not visibly ill, but during that time you won't catch Ebola by sitting next to the person on an airplane. You'd need to join the Mile High Club.

If someone were to come down with Ebola in a developed country, they would be taken to the hospital in an ambulance by EMTs who already use what are called "universal precautions" to prevent contact with bodily fluids. They would be placed in isolation and cared for by people who are rigorously protected. Any recent contacts they had would be isolated until it was clear whether they were infected, and if they survived (which many will with supportive care) they would remain in isolation until they were not longer infectious.

The outbreak is sustained in Africa because many cases are in remote locations, or if they are in the city people don't get immediate attention from adequately equipped, trained and resourced services. In the remote areas, funerary practices in which relatives wash and otherwise touch the body also result in transmission. With adequate public education and infusion of resources, the outbreak in west Africa can be contained, and I expect it will be. If it continues, it will continue to infect and kill people at a rate of maybe tens per week. That's a drag but it's close to being the least of Africa's infectious disease problems. Really. Hundreds of thousands of Africans die from Malaria, TB and diarrheal diseases every year. We should care about that more than we do, but this is actually much less.

And no, it can't happen here. At least not on any large scale. Now, if the virus should mutate and become transmissible by causal contact, we'd have a problem. But there is no sign of that. So I hope folks will keep this in perspective.

Good News to be Sure

Not sure if you wretched refuse are allowed to read this,  But the American College of Physicians now recommends against routine pelvic examinations. They do recommend that cervical cancer screening continue, but for you guys, that's much less invasive than the pelvic exam. For us, I suppose, the nearest equivalent is the digital rectal examination, which is no longer recommended as part of a routine physical. (In fact, the entire routine physical is no longer recommended, but that will be much harder to get rid of.) So, if your doctor wants to stick his finger up your ass, and you don't want him to do it, just say no.

The ACP says there is no evidence of benefit from an annual pelvic exam, "so the harms of fear, anxiety, embarrassment, pain, discomfort and false positives" mean don't do it. Obviously, if you're pregnant or have symptoms for which the exam is a useful diagnostic, that's a different story. We're talking about the concept of just doing it every year as a screening measure.

Naturally, the American College of Obstetricians and Gynecologists is still all for it because they make money off of it. And, the ACP isn't sure its recommendation will change practice. It's very difficult to get doctors to give up their bad but profitable habits. Anyway, you can take matters into your own hands and just not do it.

Reality Bites Denialists

That's the trouble with cynical denial of facts you know to be true, which is what the Koch brothers and their political allies are mostly doing with global climate change denial. We know it's cynically dishonest because they keep changing their premises: it isn't happening, maybe it's happening but people aren't causing it, maybe people are contributing to it but it isn't really bad, maybe it's a little bit bad but it isn't worth doing anything about it . . .

A recent arrow in the denialist quiver has been the claim that the planet has not been warming for 15 years. Either this means the whole claim about climate change is too a hoax, nah nah nah nah nah, or else it means the problem isn't really urgent so we'll just wait for the technology fairy to save us.

More sophisticated climate scientists have been saying all along that this is not true, the global surface temperature has been on a bit of a pause but that's because the heat is going into the oceans. This is kinda wonky, but a new analysis sets us straight. Climate models based on straightforward computation of how heat is trapped by greenhouse gases have tended to overestimate recent increases in global surface temperatures, i.e. they have failed to predict the recent slowdown. This has caused denialists to claim that climate models are worthless. Not so.

All you have to do is add the El Niño/Southern Oscillation phenomenon to the models and they fit reality just fine. In other words, for the past decade we've tended to have more La Niñas -- episodes of cool southern Pacific water -- than El Niños. Add that info to the models and they do predict recent surface temperature history. But now that's changing, with an El Niño predicted for later this summer or fall and guess what? We'll have an apparent acceleration in warming. It's already started, seemingly, with the warmest three months on record. Add to that the sparse coverage of the Arctic by weather stations, the Arctic being the region that has warmed the most, and we find the planet is even warmer than we thought. Already.

We're headed for a really obvious hot spell, folks, and the oceans will continue to rise, faster than before, the arctic sea ice to disappear, and the southwest U.S. to parch and bake until cities become uninhabitable. Yes. Then Sen. Inhofe and the Koch brothers will have to eat shit.

AIDS 2014

I'm not there this year, and of course, neither is Joep Lange. The linked remembrance by Laurie Garrett explains why the International AIDS Conferences are really unique. There is a lot of science presented there -- you get the usual PowerPoint presentations with socially awkward biologists droning on about viral lineages and the blood-brain barrier, as well as social science and program evaluations and every other possibly relevant discipline.

But only about half the people there are researchers. The rest are activists and practitioners of one kind or another. And the presentations in the big hall sometimes feature science, (usually in a fairly popularized form), but are just as often political speeches, and even rallies and demonstrations.

Outside of the lecture halls and workshops, the corridors and exhibition halls are constantly enlivened with political theater, music and dance, and mobile polemical exhibitions. The conferences are an immersion into a special universe in which science, morality, and passion all collide, shattering and recombining unpredictably.

HIV is not like other diseases in being so freighted with culture, politics and morality. And Dr. Lange's career exemplifies that complexity. He was a scientist who was also compelled to be an activist and a campaigner. Of course his loss is no more egregious than the death of any other victim of war. As I said last time, I perhaps take it a bit more personally. But as a species, we just can't afford to keep fighting over tribalism. We have urgent work to do. 

MH17 and me, and us

As you likely have already heard, something like 100 of the passengers on MH17 were on their way to the International AIDS Conference in Melbourne. Of the names so far made public, I don't know any of them personally. However, I have attended two past International AIDS conferences, in Mexico City and Washington, D.C., and live-blogged them here. It certainly would not be surprising if some of the victims are people I have spoken with, or heard speak, or who have attended presentations of mine. Certainly they would have similar kinds of education, interests, and political and social commitments.

I don't have enough insight to say how this affects my feelings about the incident. I like to think of myself as a universalist humanist and want to claim that the degree of personal affinity I have for the deceased and their colleagues, friends and loved ones is beside the point in how I evaluate this atrocity. We don't yet know all of the facts, so I'll hold off the rant I have saved up for Vladimir Putin and the thuggish morons he is sponsoring in Ukraine. But I will say this.

As a species, we have only a very short time left to grow up, before we do ourselves in. We are now recognizing the 100th anniversary of World War I. Europe blundered into catastrophe due to exactly the kinds of tribalism, instinctive reliance on military technology and prowess, and the view of global affairs as fundamentally and properly a competition among nation states for power and primacy. The catastrophe this time would be incalculably worse.

So, remember that in 1988 a U.S. naval vessel shot down an Iranian civilian jet liner, while St. Ronald Reagan was president. That was just as awful, but unlike John McCain today, nobody started calling for World War III. 

Update: It turns out that 6, not 100 of the passengers were on their way to AIDS 2014. Doesn't affect my point, but for the record. 

Black Hole in the East River

The New York Times, for all it's flaws, is still indispensable as one of the last redoubts of journalism. This should make your blood boil. According to an internal study, which the New York City Department of Health and Mental Hygiene tried to keep secret, prison guards at Rikers Island assaulted and seriously injured 129 inmates over an 11 month period. That's "serious injuries" only, which means they were too severe to be treated in the prison clinics. More than 3/4 of the victims have mental illness diagnoses.

There have been a couple of recent incidents of mentally ill Rikers Island inmates dying from neglect. One guy cooked to death in an overheated jail cell, another died after ingesting detergent and then being ignored as he begged for medical help. But this is different -- this is guards beating the crap out of people, sometimes in revenge for having urine thrown at them or the like, sometimes to control people who are acting out, sometimes apparently just for fun.

So yeah, impunity for corrections officers, as well as terrible conditions in the jail and terrible working conditions for the officers, is intolerable. But here's the worse problem -- about 4,000 out of 11,000 Rikers inmates are diagnosed with mental illnesses, which exceeds the entire census of psychiatric inpatients in the state. Jail is where we send mentally ill people today.

And this has been building for a long time. Back in grad school I took a course called something like Social Control of Deviance Through the Courts, which was taught by a judge. We took a field trip to the Massachusetts high security prison, and we met with a group of lifers. Most of them were career criminals who had been in and out of jail for much of their lives until they finally got the big ticket. And they told us they had seen the change. You would know the guys, back in the day, one of them said,  but now half of these guys belong in the Pine Street Inn. That's Boston's big homeless shelter.

The judge explained what was happening: mandatory sentencing laws. It used to be he had discretion. Mentally ill people sometimes do things like trespassing, random destruction of property, aggressive panhandling, subsistence theft, inappropriate sexual expression, which gets them arrested. The judge could commit these people to treatment. Now he can't, he has to send them to jail. And that is obviously the worst possible place for a mentally ill person to be. Yeah yeah, criminals get a tautological diagnosis of sociopathy but that's not what we're talking about here. We're talking about psychosis, bipolar disorder, and the like, combined with social marginalization and deprivation.

It's a crime against humanity.

A couple of modest observations

My colleagues and I analyzed a whole lot of medical visits by people with HIV and we did find some differences depending on patients' race and ethnicity. (Click on the link and you also get to see an unflattering picture of me, engaged in the bizarre practice of neck binding.)

Black patients tend to talk less than do other patients in physician visits -- this has been observed before. And doctors talk to Black and Hispanic patients about medication adherence more than they do with other patients, regardless of whether there are any indications that the patient is non-adherent (which is the fancy term for not taking the pills on schedule). These docs are all white or Asian, BTW, except for two African American women at one site. So we can't sort out any effect of physician ethnicity or provider-patient concordance from this data. But on the other hand, that's the real world. There just aren't a lot of Black or Latino physicians.

Not sure what this means or whether these disparate communication patterns are a big problem -- just  worth noting that ethnicity still matters. The call for a "race blind" society is fallacious. We aren't race blind and we won't be any time soon, so pretending we are just evades the issue.

Ho Lee Crap

While cleaning out an old storage room, NIH found at least six vials of smallpox virus. Unsecured. Just sitting there. With no accompanying documentation.

Okay, so they've been found, and secured, and will be destroyed. By international agreement, the variola virus can be maintained at only two ultra-high security laboratories, one in Atlanta at the CDC, the other in southwestern Siberia. There has been considerable controversy about this and many people -- including  YT -- have argued that these samples should be destroyed. The problem is that since smallpox was eradicated in 1979, no-one has been exposed or vaccinated. And, there isn't a lot of vaccine available. If smallpox were to get loose in the world -- don't even think about it.

It is not necessary to retain samples for any conceivable reason. Vaccine is made from a related virus, cowpox (hence "vaccine," from the Latin for cow). The genome is obviously fully described. Nobody is doing any research with variola nor is there any research that one can imagine doing. The only possible use of variola is as a weapon.

This discovery is disturbing because it suggests that there could be other overlooked samples somewhere -- or possibly not overlooked at all, but just kept in secret by some government laboratory somewhere. eww.

Les Izmore, continued

Friday's BMJ features a discussion of the Choosing Wisely campaign, which I have referenced here a couple of times. The essential question is whether we can substantially reduce wasteful medical interventions simply by moral persuasion and cultural activism, even without changing economic incentives. Author Richard Hurley says that a survey finds a majority of doctors will order unnecessary tests if a patient insists, and goes on to write "Doctors order unnecessary interventions for a multitude of other reasons, including fear of malpractice suits, to appear to be doing something rather than nothing, to try to demonstrate thoroughness, and because of how they were taught."

Oddly, he doesn't mention what would seem to be another important reason, which is they get paid to do it.

Anyway, what's more interesting about this essay is the discussion of the political background. Physicians don't generally think they have responsibility to reduce health care costs, and in the U.S., at least, the general public thinks that these efforts constitute "rationing," which is evil from the pit of hell, and that any effort not to give some form of medical test or treatment to somebody is all about death panels and murdering people to save money.

What we have so far not gotten across to enough folks is that medical tests and treatments can do harm as well as good, or just be useless. Money wasted on a useless test, drugs or surgery is money that can't be spent on something beneficial, and meanwhile people are directly harmed. But the cultural authority of medicine in the U.S., and the God-like status of physicians, prevents people from understanding or believing this. So the Choosing Wisely campaign has to go beyond targeting health care providers and effectively target the general public. Is anyone prepared to do that?

Brain Dump

For reasons I won't go into I watched a regular network news broadcast last night and one third of the entire broadcast was about (now) hurricane Arthur. This storm is expected to brush the Outer Banks as a minimal hurricane then decay in the cold waters of the North Atlantic while turning out to sea, possibly giving part of New England a rainy day. It would be news, of course, if Cape Hatteras and environs got through a summer without a hurricane. Why is the teevee news so obsessed with ordinary, mildly unpleasant weather? Well, for one thing I suppose they don't have to think or do any work.

As I have occasionally confessed here, I am a long time Red Sox fan. Last year's epic season, culminating in the Championship that Healed The City, has been followed by . . . Feh. The team is so incompetent, so lifeless, you'd think they've been zombified. And that's actually the only explanation I can think of. Other than the defection of center fielder Jacoby Ellsbury to the forces of darkness in New York, it's the same team. They replaced Ellsbury with what was supposed to be the second coming of Willy Mays, Jackie Bradley Jr., who indeed has great speed, a great outfield arm and can, as they say, steal every base but first. He's been struggling with the Mendoza Line* all season, but even so, one less bat shouldn't turn the team from champs to dreck. The fact is nobody is hitting. El Papi tremendo, El Papi enorme, El Papi largo y anchoso, El Papi que ocupe mucho espacio, El Papi de gran vólumen, El Papi de maximo tamaño, i.e. Big Papi David Ortiz can still hit home runs, but otherwise his production is nil. He used to hit timely base hits and doubles to drive in runs, but now he's dinger or bust. The rest of them can't hit anything. So why do the Sox Sux? The moral is that for all we obsess, sports don't mean anything, it's just shit that happens.

And yes, Tim Howard put on an astonishing performance in the World Cup, especially against Belgium, but that just covers up the main truth which is that otherwise, the team sucked a moose. The score should have been Belgium 10, U.S.A. 0.

I bought a tractor with an excavator so I can dig out stumps and otherwise landscape and make beautiful gardens. I expect to find it delivered when I get home today. I'll have fun! Other guys get BMWs and hair transplants to soothe their mortal angst, I got a backhoe.

I'll have a few things to say about health and health care in coming days. I mean it. Stay tuned. 

Mission Creep, Shmeep

Okay, so first Obama sent 300 special forces to advise the Iraqi military. Their mission was to make helpful suggestions such as "Don't abandon your weapons and flee." (I've always felt that's a good principle of military doctrine.) Apparently that advice was insufficient so Obama announced he was sending another 300 Marines to guard the Baghdad airport and the U.S. embassy, and the road between. Hmm, what contingency might make that a priority?

Reuters gives a good overview of the current situation. Notably, the Kurdish and Sunni Arab members of parliament walked out before a government could be formed; parliament will not meet again for a week. Meanwhile, government forces have been unable to regain any territory, violence is rising in Baghdad and to the south of city, which is now essentially surrounded by insurgents on three sides; Kurdistan has announced that it will hold a referendum on independence in three months; and mortar shells have fallen on the Golden Mosque in Samarra, the Shiite shrine which was destroyed in 2005 sparking the horrific civil war.

Iraq is irretrievable. It is no longer a viable nation. That is not, however, a defeat for the United States or a failure of the Obama administration. It is history. Once the hubris and incompetence of Dick Cheney and Donald Rumsfeld blew the country up, there was no turning back. The international borders of the Middle East, drawn in secret by France and Britain following World War I, are dissolving. The issue is not the Islamic State, which certainly cannot survive for the long term. It is only the immediate instrument of chaos.

The issue is that Iraq and Syria were never viable nation states to begin with. Our responsibility is to do what we can to limit the humanitarian catastrophe, and ultimately to contribute what we can to a settlement among the bewildering array of parties and guaranteeing the security of new boundaries. But the United States does not, and cannot, control events and there is no reason why the U.S. should try. The news is very bad for the people who live there but for now, it is what it is. Pushing in more weapons and more combatants means more people get shot and blown up. So let's not do it.

The Omega Man?

I wrote recently that I was losing no more than an hour of sleep each night over the prospect of a horrific global pandemic, mostly because we supposedly know what we are doing more so than the medieval folks who were decimated by the Black Death.

Well, maybe, but three essays in the new BMJ should give us pause. The problem is that scientific understanding of infectious disease isn't enough if we don't have global mechanisms for putting that knowledge to work in an emergency. I think you'll only get the first paragraphs, but it isn't hard for me to hit the high points for you.

First, Ilona Kickbusch (yeah yeah) and Mathias Bonk (also too), went to the World Health Assembly in May and they didn't have such a great time. That's the annual meeting of the WHO, involving all 194 member states. It seems that the delegations from some of the poor states didn't have high quality presentations to offer, the communications and AV technology was poor, and there were too many people there and a lot of blather. Okay, well you have to take the thick with the thin.

Journalist Sophie Arie then asks if current arrangements are good enough to prevent The Big One. Following the SARS scare, global agreements were revised in 2007. All 194 countries signed on, pledging to report outbreaks to WHO immediately and to set up monitoring systems and designating "disease free" (i.e. vermin free) entry points where travelers can be checked. But a lot of countries haven't done this yet, mostly because they can't afford it, and just don't have the means to comply.

So, Devi Sridhar and friends explain the real problem, which is that major funders -- excuse me, mostly one major funder, that is the United State government -- has drastically cut back on its core support for the WHO. Instead, the U.S. makes what it calls "voluntary contributions" which means it gets to designate how they are spent. Right now the biggest funders are U.S. and U.K. voluntary contributions, and the Gates Foundation. These don't cover core operations and they don't help poor countries set up surveillance and reporting systems. The U.S. adopted zero nominal growth -- that is, a guaranteed annual decline in real dollars -- in its contribution to the core budgets of UN agencies in 1999. Joe Biden's name is on the bill, next to Jesse Helms. So when we all die in the zombie apocalypse, you can thank Uncle Joe.

The fact is, we all live on one small, shrinking (metaphorically) planet. If we don't get over this sovereignty fetish, we're screwed.

Same as it ever was

Via Brad deLong, here is Amartya Sen taking down the essential conservative economic argument in 1982. Sen is responding to P.T. Bauer, who way back then was making the same Mitt Romney 47 percenter teabagger case we're still hearing about today. Bauer was a "serious" economist so he does not, as far as I know, reference Ayn Rand, but it's the same basic idea -- economic inequalities are "largely the result of people's capacities and motivations . . . . It is by no means obvious why it should be unjust that those who produce more should enjoy higher incomes."

There you have it: the Makers vs. the Takers. But as Sen goes on to show, it is evident, transparently obvious really, that people's incomes are not proportionate to their productivity. (Even if they were, one could still make a strong moral case for limiting inequality, but that isn't even necessary.) For one thing, this assertion requires that owning productive assets constitutes personal productivity. Even if it did, it is hard to see how inheritance constitutes moral entitlement.

For another, incomes vary for all sorts of reasons that do not correspond to whatever it is that an individual personally produces, which is very easy to show.

Yet these nonsensical claims made Bauer one of the most respected economists of his time, and continue to bring prestige to professors today such as Greg Mankiw. How anyone can pay deference to such ridiculous arguments may seem hard to explain but of course it is not: wealthy people endow chairs in economics, and wealthy people dominate public discourse.

Do read Sen's essay, and arm yourself for the struggle.

"End of the World" plague

I happened across this today and it inspired me to write a post I've been thinking about for a while. The link is to a story about the so-called Cyprian plague of the Third Century, possibly an outbreak of smallpox, which is said to have given a boost to Christianity.

A couple of decades back there was a virologist or epidemiologist, whose name I forget, who firmly predicted that at some time in the coming decades, an emerging infectious disease would explode and decimate the global population. He generated immense controversy in part because it kind of sounded like he was hoping for it, part of his premise being that there are too many of us. Unfortunately this story doesn't have parameters that make it easily researchable, so if anybody can remember who I'm talking about please let me know. Anyway . . .

The argument in favor of this scenario seems pretty convincing at first. There have been plenty of instances in the past in which infectious disease outbreaks have caused crashes in human populations, albeit limited geographically because not all populations were in contact. The Black Death is thought to have reduced the European population by50% or more late in the 14th Century. While it is not possible to prove historical causation, there is a compelling story that this event ultimately brought about the end of the Middle Ages and the emergence of modernity. A sudden shortage of labor, and the availability of twice as much land and fixed capital per person, raised the status of the peasantry and hastened the end of serfdom. The introduction of hitherto unknown diseases to the Americas, notably smallpox, caused the so-called Demographic Disaster which reduced the indigenous population by some 90% and made the European conquest complete.

HIV and the hemorrhagic fevers, SARS and MERS, although none of them turns out to be the apocalypse plague for various reasons, do prove that new human pathogens will continue to appear frequently. These particular viruses have limited transmissibility, which is why our global population continues to grow, but the point is, with every city on earth connected by air travel that can get an infectious person from Nairobi to New York in less than a day, when the new smallpox does arrive -- highly transmissible, highly lethal -- we're screwed, lassoed and tattooed.

Well, maybe. The most important difference is that today, we understand infectious disease. We'll know how to take effective action, both in the short term through isolation and quarantine, and in the longer term through understanding the pathogen and coming up with effective treatments and/or prophylaxis. We hope. But the deeper point is, you can't understand the future by extrapolation. Will there ever be 8 billion humans alive at one time? I wouldn't bet on it. This is only one reason.

American Exceptionalism, once more . . .

This gets old, I know, but the Commonwealth Fund has once again released is report comparing U.S. health care to other wealthy countries and once again we are the pits. As in dead last, 11th out of 11. The competitors are western European countries and Canada.

Apparently its' good to be pinko. The United Kingdom, which is the only country on the list to have actual socialized medicine -- you know, government run health care, big gummint bureaucrats employing your doctor and telling her what to do -- is number 1. There isn't really a trend in that direction however. Switzerland, which has a version of Obamacare, is number 2.

Obviously, you can quarrel with the criteria. But the U.S. fares very badly on most of them, and that includes the bottom line -- the U.S. is dead last on "healthy lives," that is outcomes amenable to health care. The UK was not good on that one either, but they spend half as much as we do and still get slightly better results. And here is the main reason why we are for shit:

The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.

If it's really more important to your average moderate income voter that rich people not pay taxes than it is to solve this problem, then by all means vote Republican. They're on your side with that.

More on gun violence

Lawrence Gostin, writing for the JAMA forum, makes many of the same points I did recently about the framing of gun violence as a mental health issue. Sure, most mass shooters have diagnosable mental illness but a) most mentally ill people are not violent, b) most gun violence is not mass murder (in fact it's only a tiny fraction), and c) the only good predictor of future violence is past violence. To remind us:

Although most mass killers are mentally ill, only a small minority of persons with mental illness is violent. Overall, only about 4% to 5% of overall violent crime can be attributed to persons with mental illness. At the same time, it is exceedingly difficult to predict violence based on a psychiatric diagnosis: psychiatrists’ predictions of violence are no better than chance. It is true that mental illness can be a risk factor for violence, but often only with comorbidities, such as alcohol or drug abuse. The latter are far more powerful predictors of violence than the diagnosis of mental illness. Still more powerful is a history of violence, particularly threatening or using a lethal weapon such as a firearm.

Like I said. Nevertheless, Gostin still wants to tighten the background check system so that people who have been committed to a mental institution can't buy guns easily. I'm not even sure what he means by that -- if you've ever been committed, you should lose your rights for life? If you're currently committed, you can't buy a gun anyway. Anyway, civil commitment is a somewhat arbitrary process and there is no evidence, certainly none that Gostin provides, that it is predictive of violence. After all, if psychiatrists' predictions of violence are no better than chance, why should their decisions to have people committed as a danger to themselves or others get any respect? His proposal is transparently self-contradictory.

He goes on to propose that people with a history of violence be banned from gun ownership. That makes more sense, but I despair of it working. The country is so awash in firearms that it is easy to obtain them illegally, and people who have been convicted of violent crimes do not have a proclivity to obey the law.

The only hope, it seems to me, is cultural change. People need to understand that guns are dangerous; having them around makes you far more likely to kill yourself or inadvertently kill someone you wish you hadn't than it makes you likely to somehow defend yourself; and the more guns there are in the environment, the more violent death there will be. Make it the cultural norm, what the cool people do, that if you have some good reason to won a gun, keep it locked in a safe and only take it out when you want to hunt or shoot at paper cutouts of Barack Obama or Trayvon Martin. Require licensing of gun owners based on taking safety training and passing a test, and registration of guns, just like motor vehicles. But saying Joe is allowed to buy a gun and Fred is not, just isn't workable.

Why is marijuana illegal . . .

in most states, while chewing tobacco is not?

Tony Gwynn wasn't just a hall of fame baseball player, he was universally regarded as a really nice guy. He repeatedly eschewed the chance to make bigger bucks in order to stay with the Padres for his entire career. As baseball coach at San Diego State, his alma mater. A hometown guy who cared less about getting rich than he did about his community. Also, he leaves a wife and two kids. He was 54 years old.

And yes, it was cancer that started in his cheek, caused by tobacco. The people who market that stuff are murderers. The wrong guy died.

Mass assault of bullshit

You knew it would happen. The headline on the CBS News web site this morning: "Is the violence in Iraq Obama's fault? The worsening fallout from the Iraq war Obama ended is casting a long shadow over his foreign policy." NPR this morning featured Vali Nasr of the Johns Hopkins School of Advanced International Studies arguing that the partition of Iraq would be a disastrous failure for U.S. foreign policy and that "we" have to take responsibility for maintaining the Shiite government's control over all of Iraq. (NPR didn't bother to mention that Nasr grew up in Iran. Relevant?) And similar dreck is all over the place, coming from Republican politicians of course but also as the unexamined assumption of the corporate media. The Iraqi government that the U.S. installed, and the Iraqi army that the U.S. armed and trained, are a fortiori U.S. allies and assets and we have to continue to back them and defend them.

Funny thing -- Iran is already sending Revolutionary Guards to Iraq. Wait a minute, I thought Iran was the bad guys? Now we're supposed to fight alongside them? What's going on here?

Here's the truth. The United States has absolutely no national interest in preserving the arbitrary map of the Middle East that was drawn by departing European colonial powers. Iraq is an artificial creation, and its territorial integrity is already fictitious. Iraqi Kurdistan was de facto independent before the U.S. invasion. The Kurds have taken advantage of the current chaos to expand their own territory. If there ends up being a Sunni Arab state in part of what is now Iraq and Syria, why would it matter to the United States in the slightest? It wouldn't. This has nothing to do with us, there is no national interest at stake, and there is no conceivable reason why it should be a goal of U.S. foreign policy to prevent it or a failure of U.S. foreign policy if it happens.

ISIS is bad guys who we don't like. True. But the population of Anbar and Nineveh provinces also feels the same way about the Iraqi government, and they won't defend it. We don't know how the political situation within the breakaway Sunni region will evolve -- it may well be that ISIS, having spearheaded the secession fight, will ultimately be unable to maintain political control. Or it may be that Iraqi and Iranian forces will be able to re-exert some degree of control over the territory. But whatever happens, it is not our problem, and there is nothing constructive we can do about it except stay the hell away.

Obama was right to get out of Iraq. The Iraqi people didn't want the U.S. military there, and the government would not allow it. So they left. What happens next is just something for us to watch.

Understanding Iraq

The corporate media, and for that matter U.S. politicians of all stripes, are fundamentally misunderstanding what is happening in Iraq. The collapse of the Iraqi army in Mosul and cities to the south along the Tigris is not essentially about the rise of ISIS (aka ISIL) as a powerful extremist force; it is fundamentally about the sectarian misrule of Iraqi Prime Minister Nuri al-Maliki and his allies in political Shiism. Former U.S. diplomat Wayne White (oddly appearing here in an Iranian web magazine), has a sharp analysis. ISIS is successful because the largely Sunni population of Anbar and Nineveh provinces hates the government more than they fear the extremists; and because ISIS has allies of convenience in Baathist revanchists and other Sunni militias and vigilante forces. As White says:

Maliki’s refusal to capitalize on Sunni Arab assistance brokered by the US was a missed opportunity of vast importance. Back in 2007-08, most Sunni Arabs were profoundly war weary after several years of bruising combat with US forces. As a result, a community previously determined to resist US forces and a government dominated by Iraqi Shi’a and Kurds, reluctantly accepted new realities. In exchange for ending their resistance and helping to battle AQI, Sunni Arabs expected a fair share of Iraq’s political pie, more government employment, and an appropriate slice of the country’s revenues. This, however, was not to be.

Securing a freer hand to deal with Iraq’s Sunni Arabs more harshly appears to have been one reason Maliki and his Iraqi allies backed away from the immunity agreement needed to allow a limited US military presence to remain behind after the American withdrawal. Both the Bush and Obama administrations tried and failed to secure this. Then, within 48 hours of the departure of the last US troops in mid-December 2011, Maliki had an arrest warrant issued against Iraq’s most senior Sunni Arab official, Deputy Prime Minister Tariq al-Hashemi, charging him with alleged involvement in “terrorism.” .. . .

The Kurdish army (peshmerga) has taken advantage of the chaos to seize control of the city of Kirkuk, disputed between Arabs and Kurds. The ISIS advance toward Baghdad is unlikely to get far -- despite the mass desertion in Mosul, the Iraqi army outnumbers the insurgency by an order of magnitude, has vast superiority in heavy weaponry, and has helicopters. Worryingly, however, Maliki is raising Shiite militias to join the battle, which will only intensify the sectarian character of the conflict. The peshmerga, a formidable and disciplined force, also do not like ISIS and will probably help succor the Maliki government if it comes to that, although for now they are taking care of Kurdistan. There is also concern, however, that Iran will enter the fray and their are reports that Revolutionary Guards have already gone to Iraq.

All of this creates a likelihood that the relatively few Sunni Arabs in the Iraqi army and other security services may defect, and that full-scale civil war will erupt, perhaps drawing in the Sunni Gulf monarchies to confront Iran. Should the U.S., at this stage, intervene to rescue Maliki and the Shiite government of Iraq? Doesn't seem like it to me, but whatever the U.S. does, the situation is very dangerous. Oh yeah -- fill up your tank, gasoline is about to get  lot more expensive.

Update: Emirates News has a much more detailed factual report  than you'll get from U.S. media. Apparently ISIS has managed to get a couple of captured helicopters into the air, which definitely suggests defection by Iraqi army personnel. They also see it as going without saying that this is essentially a sectarian civil war. 

March Hauser: The Denoument

I missed it at the time, but it turns out the Boston Globe obtained Harvard's internal investigative report a couple of weeks ago and it's about as ugly as can be.

To whit:

The 85-page report details instances in which Hauser changed data so that it would show a desired effect. It shows that he more than once rebuffed or downplayed questions and concerns from people in his laboratory about how a result was obtained. The report also describes “a disturbing pattern of misrepresentation of results and shading of truth” and a “reckless disregard for basic scientific standards.”

In a pistachio shell, when his experiments didn't get the results he wanted, he changed the data.

I find this very difficult to understand. Post docs competing for the dwindling share of faculty appointments, assistant professors desperately striving for tenure, frustrated non-entities seeing no chance for glory, yeah, they have motives to cheat and you can make all sorts of arguments about how academic culture, the social organization of science, the competition for grant funding as public support for science yo-yos, all contribute to scientific misconduct.

But none of this applied to Hauser. He was already tenured at Harvard, already famous, already positioned to suck up all the funding he needed. He had no discernible motive for fraud. And his general program of research does not appear to be a tissue of fraud; it's just some particular experiments that didn't go his way. People often write that an experiment "failed." There's no such thing. If it's well done, then the result is informative, no matter what it is. Maybe it turns out that your idea for a warp drive won't allow you to travel faster than light after all, but now you know something that you didn't know before. Maybe your monkeys can't figure out how to do division, but now you know. It still counts, and it has the virtue of being true.

Evidently Hauser is out on Cape Cod somewhere working with at risk youth. I hope he isn't purporting to be a role model.

Isn't there anything we can do about this shit?

I'm guessing you're probably like me, and you're starting to get a little bit tired of wackos committing random acts of mass murder. Yeah, it's a bad thing.

So everybody's got a diagnosis and a prescription. Better mental health services. Rooting out misogyny and delusional extremism from the culture. Making it harder for nutcases to get guns. All that sounds good, if not necessarily evidently possible, but . . .

Here's the problem, looking at this from a public health perspective. We really don't know how to predict that somebody is going to be violent. Well, that's not quite true -- past violent behavior is a useful predictor of future violent behavior. There is an elevated risk of violence among people who are simultaneously seriously and persistently mentally ill, and also have substance abuse disorder, but even there it's only a minority. But being mentally ill, as a general category, is not predictive of violence. Most people who commit bizarre acts of violence against strangers could be said after the fact to have a diagnosable mental disorder, but that's really tautological. Whether you want to say that people who behave in extremely deviant ways have a disease or not is really just a semantic argument, it doesn't mean anything. The point is, we can't predict.

And that's really nut. We aren't about to start restricting political speech in this country, and we shouldn't. Direct threats of violence can be against the law, but Glenn Beck's conspiracy theories and George Will's endorsement of rape and Bill O'Reilly's provocations against abortion providers -- you just can't draw the line. If the culture is full of angry, hate filled people with ideas that they use to justify violence, there isn't any law you can pass against it.

And, we can't start taking rights away from people who get a diagnosis of mental illness, that we extend to everybody else. In case you didn't know it, the vast majority of people qualify for a psychiatric diagnosis at some point in their lives, if not all the time. Getting a psychiatric diagnostic label is pretty much a random event that doesn't mean anything.

Finally, by now, the U.S. is saturated with firearms. We're never going to recall them. I'm all for reasonable regulation, just like we regulate cars and drivers, but that's not going to stop a nutjob.

So, if we could improve our ability to predict who's going to go postal, we might be able to do something. But until that happens, I despair.

Campaigning against motherhood and apple pie

Republicans are still insisting that the Affordable Care Act is a disastrous failure, and they still plan to build this year's congressional campaign around repealing it. But a funny thing happened on the way to the trainwreck. As Krugzilla shows, it's working just fine, thanks, in fact at the high end of expectations. The number of uninsured people in the U.S. fell sharply after the main provisions of the law went into effect, and gains in employment jumped at the same time.

But, most voters still don't know what's in the act, how it works, and why it works the way it does. They just know they're supposed to hate it, but they don't know why. I actually don't think it will be a winning issue for Republicans, but that it isn't yet a winning issue for Democrats is largely because of our dysfunctional corporate media, that dutifully transcribes politicians' fact free commentary without bothering to explain the reality. Until that changes, the long decline of the United States will continue.

PETA Bait

You'll often see people who I agree with about a whole lot of important subjects defending the importance of animal research to the advancement of medicine and the relief of human suffering and disability.

The picture most people, including scientists have of the typical course of biomedical research is that you first create an animal "model" of human disease; you study the animals to try to understand the disease better; then you test treatments in the animals. Ones that seem promising then get clinical trials in humans. According to this putative reality, If PETA gets its way, and we can't do this any more, we will never find cures for multiple sclerosis and Alzheimer's disease and pancreatic cancer and all those other horrors. It's too bad for the animals, but human welfare and survival are more important.

According to Pandora Pound and Michael Bracken, writing in BMJ, not so. In order to make the best judgments about what treatments work in humans, we do systematic reviews and meta-analyses to pull together information from all the available studies, assess its quality, and combine the highest quality information to generate conclusions and assess  how confident in them we can be. Lately, investigators have worked hard to overcome the problems of publication bias, cherry picking of results and other flaws in the scientific enterprise that often lead to overuse of treatments without good evidence. We have a long way to go, but we're getting better at it.

In animal studies, however, there is far less accountability for quality and synthesis of results. Pound and Bracken cite one survey that found only 12% of animal studies used random allocation and only 14% had blind assessment. Selective analysis and publication bias result in distortion of "entire bodies of research," according to another reviews. Meta-analyses are rare.

When treatments enter clinical trials in humans based on animal research, they are overwhelmingly likely to fail. P&B also note that decades of research have failed to yield a single treatment for stroke, ALS, and other conditions.

Not only are there problems with research quality, reporting and synthesis, but it is questionable how useful animal models are for understanding human health or predicting human responses to treatment in the first place. There are just too many differences between humans and rodents, or even other primates, for treatments to translate in most cases.

There is an enormous vested interest in animal research, and you know these claims will generate massive yelling and screaming. Note, of course, that this is unrelated to the conduct of basic research intended to understand the animals themselves. We're talking about biomedical research purported to ultimately benefit humans. That relationship is far more tenuous than most people believe, and the effort generates enormous waste and massive failure much more often than it generates anything useful. That's what Pound and Bracken are arguing. This is a debate that people need to approach with an open mind.

About those carbon emission regulations . . .

How important are the proposed EPA regulations on power plant emissions? Actually not too shabby, I would say. Ben Adler at Grist runs down the content of the proposal, which is more than your average newspaper or talking head has bothered to do. The regulations bind the states to reductions based on their (2005) baseline, defined as emissions per megawatt hour of generation, however they want to do it. The 2005 baseline is cheating because emissions are already down from that year, due to abundant natural gas and the recession, mostly. So there's a head start, and the target -- a 30% reduction by 2030 --is considered unambitious by environmentalists.

But -- this will establish a national policy and give the U.S. more credibility in international negotiations. That is if and only if a Democrat is elected president in 2016, of course, because the regulations probably won't even be implemented until then. As Ezra Klein explains, Republicans were actually for controlling carbon emissions until recently. In fact, John McCain and Sarah Palin ran on a platform of a cap and trade system that would reduce emissions by much more than Obama's proposal. Really. In 2008, John McCain said this: "Whether we call it 'climate change' or 'global warming, among environmental dangers it is surely the most serious of all." But then the Koch brothers purchased his withered soul.

The proposed EPA regulations are far too little by themselves to save us from catastrophe. But they will force a substantive public debate, for a change, and at least we're starting to do something. Dangerous and costly warming is inevitable, but we can still keep it to the low range of awful.

Highly Misplaced Fear and Trembling

It's been amusing (I guess that's the word) watching Republican politicians freak out over the exchange of 5 Taliban prisoners for a U.S. soldier. Yes, these guys were high ranking -- actually they were mostly civilian leadership of the Taliban government. They are described as "hardened killers" but that's because the Taliban regime was violent. The only people they ever bothered were Afghans. They can't be prosecuted because they haven't violated any U.S. laws. They were prisoners of war, which means they have to be released some day.

The U.S. has been trying for some time to arrange a peace deal in Afghanistan, as has the Afghan government. Qatar has been acting as intermediary all along. This is just part of that process, a necessary clearing of one obstacle which may help get to a result that will end the violence in that long-suffering country. Meanwhile, there are thousands of Taliban fighters. Adding five old guys to their numbers isn't going to suddenly make the Taliban more dangerous. It's inconsequential.

But we seem to view "terrorists" (which they actually aren't) as having supernatural powers. It's ridiculous. And oh yeah, whether Bowe Bergdahl deserted or was derelict in his duty is completely irrelevant. Get a grip, folks.

Progress report

For anyone out there contemplating arthroplasty of the thumb,  I can tell you that after nearly 8 weeks I am slowly regaining good use of my left hand. Wednesday and today I used the weed wacker, which actually doesn't require a contribution from the left thumb -- you pretty much grab the handle with the fingers -- but even so, that would have put unbearable pressure on the sore spot not long ago. I also used a chainsaw, briefly, yesterday and today, but decided not to resume major combat operations just yet.

So yeah, I'm hopeful that this will work in the long run. Still, it's a really violent intervention. They remove the trapezium -- the bone at the base of the thumb -- and stuff the cavity with tissue harvested from a wrist tendon. There has got to be a better way, but I'm guessing they figured out how to do this by experimenting with trauma reconstruction. You would never inflict it on someone with a useable hand, no matter how painful, purely on spec. That means they started out with people whose trapeziums were destroyed, so that's what they know how to do. There is, obviously, no animal model for the human hand so PETA will be glad to know that's out.

There are some slightly different approaches to this surgery but they've never had head-to-head trials. My surgeon does it his way and that's that. Unfortunately, this is true of many medical interventions. That's why there's a lot of emphasis these days on comparative effectiveness research but we have a decades long agenda ahead of us. I expect few people are really aware of how much we are still struggling with an insufficient evidence base for medicine. Obviously, we've learned a lot and medicine is getting more effective, but we still don't know, in many cases, how to make the best use of the technology we already have, nor do we necessarily understand what we're doing.

In the case of osteoarthritis, why is bone-on-bone contact painful in the first place? There are no nerve endings in bone. Yet we can only fix it by removing and replacing entire joints. I think we're missing something here.