Riiiiiiiiiiiiiggggghhhht . . .

Everybody is talking about Cosby, so what do I have to add? Not much, so here's 2 cents.

Maybe this is weird or maybe it's typical, but I don't recall ever hearing about these allegations until this week. Evidently they were reported earlier in a couple of places, but all of a sudden got major attention, purportedly due to a routine by a little-known comic that did the viral thing. Whether this heralds a New World Information Order seems to be one of the questions of the day.

I don't know about that, but I do think the zeitgeist is changing. Like the cultural landslide that is burying homophobia, we are suddenly seeing a massive change in prevailing norms about sexual assault. (Struggling mightily to keep my metaphor unmixed) the boulders started rolling in the military, rolled onto college campuses, and now are knocking down the privileges of the famous and iconic.

Is it a reach to say that we are finally seeing more payoff from the long, slow but very real expansion of the number of women in influential roles? Female senators had a lot of to do with the focus on the military, as do female faculty and administrators in universities, and now women in the news and entertainment industries. That's not all the credit obviously -- lots of men are on the right side. But it helped to get us to this tipping point.

As for the question of Cosby's innocence until proven guilty, come on. There will never be a trial but we're allowed to use our common sense to draw reasonable inferences. At the same time, this has no bearing on the soundness of his Booker T. Washington politics, which continue to stand or fall on the merits; nor on the value of his cultural contributions. Wagner's music is what it is, regardless of his antisemitism, and Pablo Picasso is widely thought to have been an asshole. (That's the technical term.)

Still, going forward, no-one will be able to suspend disbelief in the Cosby persona or find him amusing. (He was already pretty much anachronistic anyway, so small loss.) When the reality of the actor behind the mask is that overpowering, the act is bound to fail. So he is now gone from public life, and he'll just wither away.

What I'm about to say

I'm appearing on a panel tonight at our great university, entitled "Doctors reading race: how conceptions of race shape medical care." Since you probably can't attend, here's the sneak preview.

When I first began to study this issue, 15 or 20 years ago, there were quite a few influential studies that identified disparities in physicians' treatment decisions based on patients' race or ethnicity. For example, Latino patients with long bone fractures were less likely to be prescribed opioids in emergency departments. Doctors were less likely to take a sexual history from adolescent white adolescent girls presenting with abdominal pain than from Black and Latino girls. Black veterans in VA hospitals who'd had myocardial infarctions were less likely to undergo revascularization. (Interestingly, they were also less likely to die. This led the authors to propose that "process of care is a more specific indicator of quality than is outcome. Ha ha.) There were others.

Back then we had all sorts of calls for "cultural competence" in health care, and people sprang up who offered cultural competency training, generally for a fee. In its earliest incarnation this mostly consisted of people who would proffer interesting tidbits from medical anthropology about exotic health beliefs. They'd tell you that Puerto Ricans believe in the Evil Eye and rural African Americans are into rootwork and mojo, that sort of thing. Absolutely ridiculous. It's like teaching doctors that patients from California believe in the healing power of crystals. Maybe a few of them do but that's not what you need to be culturally competent.

So then we got a better class of cultural competency trainers who claimed, more plausibly, that the first step toward becoming culturally competent is to have insight into your own culture. What are your preconceptions and how do you understand the nature and meaning of health and illness, and medical care? The next step is to learn how to not make assumptions about the people you encounter, but rather to learn from them. Ask them! What do you want to know? What are you comfortable and not comfortable telling me about yourself? How do you understand your condition and treatment? How do you want us to relate to each other? Everybody is unique, your job is to understand each person.

This all sounds great but I haven't seen any evidence that this sort of intervention produces better results or more satisfied patients, though I don't suppose it can hurt. So what have I found in my own research?

First of all, using my structured methods for analyzing clinical encounters, we've noticed a couple of things. Black patients, on average, talk less than Latino or white non-Hispanic patients, but there doctors talk just as much. This has been observed by others, in a couple of different settings. The result is that the so-called verbal dominance ratio -- the proportion of doctor to patient talk -- is higher for Black patients. Of course I have no idea why. There are also some other indications of less rapport or patient engagement, including fewer so-called expressive utterances by Black patients -- those are expressions of desires, goals, feelings, intentions -- and less joking with Latino patients. But again, I don't know why this happens or what significance it has.

What I have observed is that where things tend to go wrong is doctors not understanding patients' lifeworlds. The fact is that most medical encounters are essentially cross-cultural. Physicians tend to start off as higher socio-economic status than most patients before they get to medical school. Being a physician is, in fact, often a hereditary condition in itself. Then they go through a socialization process in which they internalize a particular way of understanding human beings and the nature of health and disease. Then they ultimately go on to live in pleasant neighborhoods and have nice things.

This makes it hard enough to understand the experience, perceptions and needs of the typical patient who comes before them; But more social distance, be it of class, ethnicity, language and culture, just compounds the problem. The physician may make stereotypical assumptions about people, and may make other assumptions based on assuming that the patient or the patient's situation is more similar to the physicians than the reality. I have many fascinating examples but I'm only supposed to talk for 10 minutes so maybe I'll get to some of them in the Q&A.

So I'll just leave off with this. When I worked for the New England Coalition for Health Equity, I'd go around to various meetings and conferences where one way or another the idea of cultural competency was promoted. I can't tell you how many times I heard doctors say, "I don't need any training, I don't have any issue with cultural competency. I treat everybody the same." I'll leave it to you to ponder if that's a good answer.

Real Science

A commenter on my recent post on chronic pain calls attention to Dr. John Sarno. You can read a summary and a critique of Dr. Sarno's ideas here. Superficially, they resemble the current consensus that chronic pain with no corresponding physical lesion is generated in the brain. But there's a big difference.

Sarno has a psychodynamic explanation. He thinks that suppressed anger is translated into low back pain. The linked essay by Todd Hargrove offers good arguments why that doesn't make sense. But I want to use this example as a jumping off point for a broader discussion.

It is very common for someone to get an idea that perhaps seems plausible (sometimes it does not, even superficially, viz homeopathy), and then become very attached to it. Sometimes these people have strong scientific credentials. Nobelist Linus Pauling, with his supposed discovery that large doses of vitamin C are a panacea, is an excellent example. These people may gain large followings. But .. .

There is no credible scientific evidence for the idea. The originator and his (or less often her) followers are convinced that it works, but we never get past anecdotes and testimonials. Many precincts of the Internet devote substantial resources to debunking such claims. I recommend Quackwatch, which has a lot of fun stuff to read, and Science Based Medicine, a blog by rotating authors that reliably puts up a new essay every day.

I won't trouble to repeat here the extensive resources you can get to via those links to understand how to recognize pseudo-science, and the harm it does. But I do want to talk briefly about the whole problem of motivated reasoning.

The originators of quackery probably actually believe in it, most of the time. They aren't consciously lying. But they do, of course, have a lot at stake: their self-image as breakthrough thinkers, the gratitude and loyalty of their devotees, quite likely money, reputation and fame. So their thinking becomes dedicated to strengthening the belief, and the whole world is seen through the lens of confirmation bias.

Unfortunately the whole world largely works this way. Social psychologists have found that showing true believers evidence that contradicts their beliefs just strengthens them. Sen. Inhofe says he was at first convinced by the argument that burning fossil fuels is changing the climate but then he found out how much it would cost to do something about it. So he changed his belief. Creationists don't want to give up the myth of original sin and redemption through the sacrifice of Christ, which makes no sense to begin with but they make their living from the collection plate or the TV ministry. I could go on.

So why am I so sure my own beliefs are generally correct and rational? I suppose I can't be entirely, but I am aware of the problems of confirmation bias and motivated reasoning so I make a serious effort to continually re-examine my ideas and to insist on standards of evidence for my understanding of the world. The evidence that I do this is that I have frequently changed my opinion about matters large and small.

I grew up going to church and Sunday school and believing in a high church protestant version of Christianity. Once I was old enough to think for myself, I concluded it was bunk. I was never a Communist but as a youth I read romanticized accounts of the Chinese revolution and I thought that on balance it was a good thing. I had no appreciation of the depravity of Maoist tyranny but I do now. At first I wasn't at all convinced that the official version of the 9/11 attacks was accurate but I sorted through the evidence and the arguments and ultimately concluded that it is, essentially. (I think it likely that the government has deliberately covered up involvement by Saudi royalty, for reasons of geopolitics. I also find it plausible that the Bush administration security establishment expected something of the kind to happen, without having specific information, and had no interest in preventing it. But that's only a suspicion, I certainly can't assert it.)

In my professional work, I used to think that average people could be empowered to have a mechanistic understanding of their health and treatments that more or less corresponded to the ways their doctors think but now I believe that is unrealistic for most people. What I am striving for now is to understand the nature of the information people really do need and can use to make good decisions on behalf of their own health and well-being, but I think it has a small component of science and a bigger component of other kinds of meanings.

I may well cling to some ideas due to confirmation bias, but I do recommend this exercise to you. Try to take an inventory of important ways in which you have changed your mind over the years. If you can't come up with very many, maybe you should undertake a critical assessment of one or more of your cherished beliefs and see what happens. Can you find reason to doubt? Make a serious effort to talk yourself out of what you think now. Go down that road and see where it leads. You might well decide you were right in the first place, but at least you will have put it to the test.

Things that aren't true

Two worthwhile columns in the NYT today, one by  the always reliable PK, the other by Steven Rattner. Let me put two and two together.

Krugman points out that contrary to Republican freakout, the Administration responded competently and effectively to the ebola outbreak, the Affordable Care Act is working just fine, the Department of Energy loan program that lost money on the Solyndra investment has in fact made an overall profit of $5 billion, and the deficit has in fact fallen sharply. In other words, government can indeed do things well.

Rattner is despairing, as economic inequality in the U.S. grows worse, and the incomes of people near the bottom are actually falling. But, it's worse here than it is in Europe. We have the lowest tax rates of the OECD countries, and the least generous social programs. Republicans constant screaming that our taxes are too high is just nonsense. And in fact, higher taxes are not associated with lower rates of growth. That's pretty simple: government spends that tax money, creating demand directly, and by giving people salaries that they in turn spend; meanwhile, wealthy people spend a much smaller portion of their income than do poor people. And they don't create jobs either. They won't invest in job creation unless they can sell stuff, and they can't do that if people don't have the money to buy it. Also, government makes essential investments that the private sector never will, because of the problems of free riders and common goods.

But the corporate media, not to mention Democratic politicians, don't seem to understand any of this. Republican claims that tax cuts stimulate the economy go unchallenged. Yes, the wrong kinds of taxes at the wrong time slow down the economy, but right now taxing the rich to invest in the present and the future would be good for economic growth, and particularly sustainable growth. Mass transit, basic research into renewable energy and conservation, creating a smart power grid, educating the children who will make our future, guaranteeing affordable health care for all -- these are all things government can and must be doing.  And anybody who says otherwise is a lunatic. Of course, they can always move to Kansas.

Just Pain

I'm working up a couple of research proposals having to do with chronic pain. This subject is actually challenging clinically and philosophically, which means it also very challenging for physician-patient communication and relationships.

There used to be great controversy over the very existence of fibromyalgia, or the usefulness of the label. It just meant people with unexplained, widespread pain. People also would present with unexplained localized pain, such as low back pain or temporofacial pain. They'd get MRIs and what not and doctors could find no physiological explanation. Many people viewed these situations as having a psychodynamic origin, in other words the person was in fact obtaining some sort of reward from being sick or disabled, or acting out guilt or self-loathing, or just generally nuts.

Now we understand that people with otherwise unexplainable chronic pain are experiencing what's called Central Sensitization Syndrome (CSS). Pain signals (there's a fancy word for them, "nociceptive" which the blogger spell checker doesn't even recognize) do originate at the site where pain is perceived, but the sensation of pain is constructed in the brain, with maybe some intermediate processing in the spinal chord. The brain can also send signals back down to dampen nociception.

So what happens is that the systems in the brain that signal pain to your conscious awareness become hyperactive. If you close your eyes and just pay attention to your body right now, you will notice that you feel a bit of discomfort here and there. Maybe you have slightly achy joints, or your tuchy is a little uncomfortable on the chair, you have an itch, whatever. But it's minor and you weren't even paying attention to it. So, it shouldn't be hard to imagine that the circuits that process these sensations could get out of whack and continually scream "Pain!" at your frontal cortex.

Now that we have functional Magnetic Resonance Imaging, this has been confirmed. Researchers can see the circuits light up excessively in people with CSS. That doesn't help us know what to do about it, but at least we have an explanation. We also don't know why it happens. Often, people have a real injury that causes explainable acute pain, but after the injury heals, the pain persists. Somehow the circuit gets stuck in the open position, as it were. CSS also seems to be associated frequently with severe psychological trauma. But we don't have a good mechanistic explanation.

That said, if you tell people with CSS that there is in fact nothing wrong with the places where they feel pain, and the problem is in their brain, they generally don't like that answer. They hear you saying that the pain isn't real, that they are crazy, that they're faking it, that you aren't respecting their very real suffering which they perceive to be happening in their back and their joints or wherever.

Drugs don't usually help much. Long-term opioid therapy is generally a bad idea, I shouldn't have to tell you why. Anti-depressants and drugs that are used to treat seizures or neuropathy (pain caused by damage to peripheral nerves) are often prescribed, but only a small percentage of people really respond to them, and they have side effects. NSAIDs help only a little.

What people with CSS should do is basically not to let it get them down. Do what they call graded exercise -- a little bit more than is easy each day. Keep moving, keep up with your activities of daily living, have hope for the future, and really believe that there is nothing wrong with the parts of you that are hurting. It takes a long time, but often symptoms do ameliorate and even resolve. But if the pain beats you and you retreat from life and social contact, and stop moving, they won't.

So, how doctors and patients can communicate constructively in this situation, and form a therapeutic alliance that really works, is a big problem. Hopefully I'll be able to contribute.

The American Nation

An interesting essay by Michael Konczal in Boston Review discussing three books, by Nicholas Parillo, Dana Goldstein and Radley Balko, and tying them all together.

Per Parillo, I never learned in my American history courses -- and I did take quite a bit -- that until the 19th Century, judges and government clerks and prosecutors and so on did not receive salaries. If you wanted your case heard, you had to pay the judge -- they worked on commission. Prosecutors were paid by the conviction. And if you wanted your homestead application or your deed processed, you had to pay the clerk, and he (always) could set his price. Really. Seems bizarre, but there was no idea of public service as a right of citizenship -- it was, by and large, for sale.

Per Goldstein, of course we didn't have universal public education for most of the country's history either, but as it began to come in, teachers had very low status. They gained more eventually, but now they are losing it again.

Balko discusses the militarization of the police, and the increasingly adversarial relationship between police and public, in recent decades. This kind of gets wedged into Knoczal's argument, because what he is really looking for are the civil forfeiture programs whereby police get to grab all kinds of cool stuff when they bust people, and the privatization of jails. We are also returning to the privatization of education, and of course rich people are buying judges and politicians.

The grand picture is that we are losing the consensus belief in national community that grew up in the 20th Century -- that all citizens have a stake in government and that government exists for the good of the people. Instead, whatever benefits government may offer are for sale to those who can afford them, while many services we used to depend on government to provide are no longer public goods at all. You get what you can pay for.

One would think this can only go so far before the civil order disintegrates. We shall see.

On denialism

It's a very frustrating problem. As the old saying goes, "Don't confuse me with the facts, my mind's made up," and that is indeed how most people work most of the time.

If you don't already know about it, and you're into deep thoughts, you might want to bookmark Massimo Pigliucci's webzine Scientia Salon. He discusses a recent conference on denialism at Clark University here. We are currently in a very dangerous historical moment (my point, not his) in which a basic membership requirement for one of the two major parties in the world's most powerful nation is to believe a whole lot of important stuff that is not true.

The trap is that facts, reason, critical thinking -- none of these are of any use. In fact, research shows that when confronted with contrary facts, true believers just did in deeper.. An endless parade of experts can testify in front of James Inhofe's committee presenting every possible proof that humans are changing the planet's climate and that the consequences will be catastrophic, and the denial will just grow deeper.

So what is to be done? Obviously if I had the magic bullet we wouldn't be in this mess, but I will say that the key to the problem is more cultural than it is intellectual. We have to make saving the planet something the cool kids do, in essence. I largely credit the entertainment industry with the astonishing cultural transformation regarding attitudes toward homosexuality. The only people who are really going to establish the truths of evolution, environmental threats, macroeconomics (no, cutting rich people's taxes does not create jobs), and the fallacy of "free markets" are movie and TV producers, fiction writers, comedians, celebrity chefs, and such. Scientists should keep saying what they believe and keep answering questions, but the only ones who are going to accomplish very much are also entertainers -- Neil DeGrasse Tyson and his ilk. He pays as much attention to his costumes and his hairdo as he does to his words, and well he should.

 

What happens if the Supreme Court loses legitimacy?

It appears well within the realm of plausibility that five justices of the Supreme Court have already decided to trash the Affordable Care Act by means of a preposterous legal maneuver. Paul Krugman discusses it here, and attorney Neil Seigel says pretty much the same thing here. So you have the perspectives of an economist, and a lawyer.

They, and many other sober observers, find the reasoning of the DC Circuit panel in Halbig v. King absurd. It will be reversed by the full court, and it has been resoundingly rejected by all other federal courts. The Supreme Court does not need to hear the case. Why have they chosen to do so?

As all our readers presumably know, the ACA has three main components, all of which are essential for it to work. It requires insurance companies to cover everybody for the same price, with an adjustment for age, regardless of their current or former state of health. In other words, you can't be denied coverage or charged a fortune because of pre-existing conditions. (That's called guaranteed issue and community rating, BTW.) However, if you do that, there's a danger that people won't bother buying insurance until they get sick. You need those healthy people in the pool to keep it affordable for everybody. Hence the individual mandate. Again, however, not everybody can afford insurance, so you have subsidies for moderate income people. (We'll leave the Medicaid expansion aside for now.)

The literal language of the ACA says the subsidies are available to people who buy insurance through "exchanges established by the state." But Republican governors refused to establish exchanges in many states, so the federal government stepped in on their behalf. Elsewhere in the ACA this is clearly intended and the federally run exchanges are fully the equivalent of state-run exchanges. It's just slightly ambiguous language, but the intent of the statute is clear. Yet Halbig claims that people who get insurance through federally-run exchanges aren't eligible for the subsidies.

Krugman and Seigel both state, quite boldly, in their own ways, that if the court buys this absurdity it will prove that conservative jurisprudence is not about upholding the law, or any theory of law; it is purely political, adopting any form of sophistry in order to further the conservative political movement and the interests of the Republican party. That millions of people will lose their access to health care, and many of them will die, would apparently mean nothing to Scalia and Alito.

But what happens to the American polity if half of us are forced to conclude that the Supreme Court is a fundamentally illegitimate institution? I hope John Roberts is thinking about that.

Less, in this case, is a whole lot more

This study in NEJM has actually gotten a lot of attention, which I actually didn't expect when I decided to blog about it. (I believe it's behind the paywall but at least you can read the abstract.)

In a nutshell, the incidence of thyroid cancer in South Korea has increased 15 times since the 1990s. Is it radiation? Water or air pollution? A plot by the north? Nope. It's an epidemic of overdiagnosis. The death rate from thyroid cancer hasn't gone up even a tiny little tick. What's happening is that the country offers free screening for other cancers -- cervical, colon, breast, liver -- and they'll throw in thyroid for 35 bucks. So people go for it. They find these tiny little tumors that were never going to cause trouble, remove the thyroid, and the people have to go on pills for the rest of their lives. They may suffer other complications. It turns out that about 1/3 of people die with these "cancers" without even knowing it. All of the increase -- 100% -- is overdiagnosis resulting in iatrogenic harm and wasted money.

This is appalling but it's happening in the U.S. too, to a lesser extent. We don't do screening but people sometimes happen to have ultrasounds or CT scans that include the neck and these meaningless phenomena are discovered. So you're told you have "cancer" and it's all bad from there on. As I have discussed before, something very similar happens with prostate "cancer" but the appallingness is less extreme because prostate cancers are somewhat more likely to cause trouble.

I do have one new point to make based on this atrocity. Doctors are always discovering non-existent diseases that need treatment. Sometimes the people have actual symptoms but the putative cause is not really there. Chronic low back pain is an example. A couple of decades ago the Agency for Healthcare Policy and Research reported that surgery commonly performed for chronic low back pain was useless. Orthopedic surgeons persuaded congress to eliminate the agency. (It has since been restored as the Agency for Healthcare Research and Quality.) This surgery is still performed, though less often than before.

There are many other examples but I won't belabor the point. When the doctors went on strike in Saskatchewan to protest single payer health care in 1962, the death rate went down. Just keep that in mind.

Democracy

What can be very hard to see from the perch of someone with graduate training in public policy and a steady diet of journals of politics and public policy is that the great majority of people have a very limited grasp of public policy, and really for the most part don't understand how government affects their lives at all. Most Americans believe that the greatest share of the federal budget goes to foreign aid and "welfare," in which they do not include Medicare of Social Security. They think their taxes are too high even though their government services aren't good enough. They rationalize that because they think most of the money is either wasted or given to moochers. They are possessed of irrational fears while living in deep denial of real risks and problems.

These are the people who the Koch brothers are wooing with their billions in advertising. It's not that people actually want what Republicans want to give them. But if we are to do anything about this, we need more politicians who will tell the truth. The strategy of running away from president Obama instead of defending the achievements of the past six years was idiotic. If you pretend to be a Republican, there is no reason why people won't just vote for the real thing.

A BIG idea

So, we have a problem: technology is increasingly replacing labor. George Dvorsky has a wide-ranging discussion of the problem, just so you know I'm not just making this up. As he writes,

Another prominent thinker who has given this considerable thought is James Hughes, a sociologist from Trinity College in Connecticut. "We are now entering the beginning of an era in which technology has started to destroy employment faster than it creates it," he told io9. "The advance of information technology, artificial intelligence and robotics will eventually reduce the demand for all forms of human labor, including those dependent on 'human skills' like empathy and creativity."

He offers the example of Expedia. The online program may not be as creative at travel planning as an experienced travel agent, but it still displaces travel agents because it's considerably cheaper and more accessible. It's also an example of another impact of information technology, that of cutting out the middle man. 

"Eventually 3D printing and desktop manufacturing will cut out most of the work between inventors and consumers," says Hughes. "Alongside growing technological unemployment, we will also be living much longer, and will need to figure out an equitable solution to the growing ratio of retirees to workers and tax-payers.

At the same time, and probably related, is the much-discussed growing concentration of income and wealth among a smaller and smaller elite. If most people can't find work, two things will happen: a) nobody will be able to sell anything because consumers will mostly be broke and b) civilization will collapse. Otherwise, it won't be a problem.

The only solution -- an outcome Dvorsky thinks is inevitable -- is a Basic Income Guarantee. Everybody gets a check from the government, every month, that is enough to live on. Whether or not they choose to work, assuming they possibly can.

Hoo boy. Tell that to the Tea Party.

A thought experiment

Suppose my greatest fantasy is realized, and I invent teleportation. Several versions exist in sci-fi but let's say it's the kind where there are two capsules or chambers, and when you press the button the contents are swapped.

Distance doesn't matter, so I start by opening a service between Manhattan and LA. Ten people at a time, plus their luggage, can get into the machine at each end and badabing badaboom they're on opposite sides of the continent. Assuming they get on and off expeditiously, I can run it every sixty seconds. And it doesn't take a lot of energy. I can make an excellent profit charging 50 bucks a ticket. That's $1,000 a pop, 60 times an hour. I quickly have enough money to expand the service and create a dense network throughout the U.S., then go international, first to Mexico and Canada and then the whole world.

Apart from my own enrichment (not to be sneezed at), what are the consequences for humanity? It seems a great boon, not only because we save time and energy, and the world becomes more accessible and we all get to know each other and it ushers in a new era of peace and planetary cooperation (maybe, you can argue about that); but also because it creates an economic renaissance and stimulates a fabulous enlargement of prosperity.

Sadly, no. It will put the airlines, airports and aircraft manufacturers pretty much out of business, along with the intercity trains and buses. It will substantially reduce automobile sales. You still need them to get around town, but there will be many fewer long distance trips. All of this means massive unemployment. Instead of two or three pilots, six flight attendants, and time of baggage handlers, ticket sellers, air traffic controllers, airplane mechanics and what not, I employ a ticket seller, two schmoes to push the buttons, plus security and administrative resources, but again much less than it takes for air travel.

So what I have actually created is massive unemployment and the worst depression in history. With no evident way out for a long, long time. And this is a real problem we face today, without the fantasy. Technology that removes inefficiencies from the economy, and replaces human labor with technology, puts people out of work. So far, other forms of economic activity have come along so we haven't had massive, long-term structural unemployment, but there is no law of nature that says that has to happen. And maybe it won't this time.

There is plenty of argument going on right now about this question, but I think it's a real danger. And it has many possibly terrible consequences I won't take time to specify now. There is a solution -- income redistribution -- but our politics is dead set against that. I'll have further musings on these issues anon.

"We have gone terribly astray in the last 30 years. What went wrong?"

The title of this post is from Jan Bellamy, noting that 30 years ago Claude Pepper's subcommittee on health and long-term care published a report trashing the then-$30 billion a year health quackery industry. That's everything from naturopathy to acupuncture to homeopathy -- all fraudulent, then as now. And yet, instead of getting itself stamped out, this fraudulent enterprise has only grown, not only in size but also in acceptance. Quackery has wormed its way into medical schools and prominent clinics, from Harvard to the Cleveland Clinic. It even has its own institute within NIH.

But it isn't just health care fraud. The prestige of science has been demolished in this country. One of our two major political parties has denial of climate science as a central plank in its platform. Measles cases in the U.S. are now at the highest rate in 20 years because parents refuse to vaccinate their children. Creationism is an open and influential political movement. And now we have this outrageous and moronic behavior by politicians from Maine to New Jersey, plus the loathesome Andrew Cuomo in between, over ebola virus.

Let me give you the 4-1-1. Upon initially infecting people, the ebola virus is at such a low level in the blood that it is undetectable. Rather, it infects internal organs. It produces no symptoms, and it is not shed in urine, feces, sweat, saliva or for that matter in blood. People without symptoms are not infectious -- we aren't just talking low risk, we are talking zero, as in zip, zilch, nada, nothing, not happening. Note that Tim Duncan's family lived with him for days, while he was symptomatic, in fact, and not one of them became infected.

The infectious stage of ebola disease happens when the person is very sick. That's when the virus appears in the blood stream and in bodily secretions in sufficient quantities to be transmissible. Ergo, a person who has potentially been exposed need only keep track of his or her temperature and note any possible symptoms of the disease, and present to a hospital as soon as they appear, and we'll all be safe. If you don't trust people to do that, you can have a public health worker visit them a couple of times a day. I can see justification for travel restrictions since you don't want to lose track of the person or have them come down with symptoms in a situation where an appropriate response is not close to hand, plus which a certain amount of irrational fear is inevitable and you don't want to burden authorities elsewhere with it.

But Chris Christie and Paul LePage are both claiming that they know better than Anthony Fauci, and the public doesn't believe him either. Listen up folks: scientists don't know everything, and indeed they are often wrong. But there are some things we do know. We know this.

Odds and Ends

Research Ethics: Poli-Sci profs at Dartmouth and Stanford sent mailers to voters in Montana, bearing the state seal, claiming to rate candidates in non-partisan judicial elections according to their ideological affinity Barack Obama and Mitt Romney. This is purportedly a research project to determine whether providing this information increases voter turnout.

Of course, leaving off the state seal, anybody is free to do this, but if the purpose is research you have a whole different kettle of ethics. First of all, while it might seem unobjectionable to increase voter turnout, we don't actually know ahead of time whether this will increase it or decrease it; we also don't know whether it will influence the results of the elections, and reasonable people can disagree about either the accuracy of the ideological ratings, or their relevance to fitness for judicial office. (The ratings were evidently based on the candidates' previous political contributions, and unspecified other publicly available information.) One would expect that in Montana, being linked to president Obama would be a disadvantage.

Research on human subjects must not predictably do harm, and there are lots of ways this can do harm. Toss in the state seal and dudes, what were you thinking? The Dartmouth Institutional Review Board is said to have approved this. Eww.

Elon Musk is only half smart: Apparently he fears the revenge of our robot overlords. Me, not so much. Here's the thing about artificial intelligence: actions require motivation. There is no reason why a computer program would desire, or for any reason strive for power or any action harmful to humanity. Computer programs carry out instructions. In order to interact with humans, they must be programmed to respond in particular ways to particular inputs. That is all. And, you can always just turn them off.

That said, we're nowhere near artificial intelligence. Watson is completely idiotic, it doesn't understand anything, it just makes predictions based on statistical associations with semantic content. I do work in computational linguistics and believe me, the way computers label speech acts and identify topics has nothing to do with understanding anything and they won't do anything with those labels other than print them out or create some sort of response to the human interlocutor which hopefully will be appropriate, such as listing the nearby pizza restaurants (when you actually wanted to know how to make a pizza). I am not afraid.

Chris Christie and Andrew Cuomo, however, are afraid, or more likely pandering to the irrational fears of voters as whipped up by Faux News. This crap just makes me plotz. Christie confined this heroic nurse in an unheated tent, with a porta pottie and no shower, having take-out food delivered by workers in moon suits. There is absolutely zero danger of her infecting anybody. Absolutely outrageous. The man is a clown.

Bizarre Obsessions

It's becoming something of a theme here that the obsessions of the forum are largely insane. For example, is Renée Zellweger really the first performer ever to have plastic surgery? So it would seem.

On to more serious matters, comes now the case of the son of a senior Canadian federal official, with a lengthy history of substance abuse and criminal offending, who was likely mentally ill if we can believe the reports that fellow residents of the homeless shelter where he was living that he was talking about the end of the world. This pathetic individual, acting entirely on his own, killed one person and was then killed by a security guard. He apparently claimed to have converted to Islam although I doubt he knew anything about Islam or had gone through any conversion process or ceremony. But this is the single most important thing that happened all week -- after all the other nothings that were even more important the day before.

Get over it folks.  

Yes, we Americans are weird

An essay in the new JAMA by health economist Uwe Reinhardt, which alas is for subscribers only so you pitiful rabble can't read it. He discusses the movement (much beloved by conservatives) to make people may more of their medical costs out of pocket, which Republicans call ""consumer-directed health care." Ha!

As Uwe informs, and as everybody should already know but hardly anyone does, in the civilized world health care providers - doctors, hospitals, nursing homes, pharmacies - are all paid the same amount for a given product or service based on published fee schedules. In countries where there are multiple insurers, they all pay the same price.

Here in nutso land, every private insurer negotiates with every provider, which means that different providers receive different fees from the same insurer, while simultaneously the same insurer pays different fees to various providers (or none at all if they can't come to an agreement in which case the provider is "out of the network.) If you don't have insurance, and couldn't get in on the negotiations, of course, you will be charged an outrageous amount. Also, too, Medicare and Medicaid don't pay enough to cover the full cost, which means costs get shifted onto private payers.

As wacky as this is, making people pay out of pocket just makes matters worse because a) many people can't afford their medical costs at all. If you have a high cost-share policy, you could end up spending more than $10,000 a year, which lots of people don't have. Second, telling people to shop for their own health care is ridiculous. There can be thousands of separate items on a hospital's or physician's menu of good and services, most of which are completely uninterpretable to almost everyone. And the only way we really know, or think we know, what we need or how much we'll benefit from a medical procedure is because our doctors tell us so. We can't meaningfully make our own choices as we can in markets for say, cheese. We know what we like and what we're willing to pay for it. In the case of medical care, not a chance.

There is no such thing as a "free market" in health care, and pretending that is like other goods and services is transparent nonsense.

We need universal, comprehensive, single payer national health care. Oh, have I said that before?

On the other hand, who cares about this?

Last month was the hottest September, globally, since record keeping began 135 years ago. 2014 will almost certainly be the warmest year on record. And next year will very likely be even warmer, with the developing El Niño.

But, Ebola. Migrant children. Benghazi! Are we all going to die? Yes.

Stupid Question

Now that the Ebola virus is extinguished in North America somewhere well short of the collapse of civilization, and there is even progress in Africa, will the wingnut politicians and pundits who took to Faux News and far right hate radio to fan hysteria and even accuse president Obama of trying to create an Ebola epidemic lose any credibility?

Why did I even ask.

Now this is truly getting ridiculous

A teacher in Maine has been placed on leave because she attended an educational conference in Dallas, 10 miles from Presbyterian hospital. Really. Bring on the killer asteroid, is all I can say.

Time to set some heads a-rollin'

I still maintain that ebola virus is a very minor public health concern in the United States, it is a very big public health concern in west Africa and possibly eventually elsewhere; and it is a very big threat to the global economy and to U.S. politics. But . . .

We will never persuade the American people or the ignoramuses in the corporate media that our attention and our resources should be focused on west Africa, not Kennedy Airport, if it does not appear absolutely and transparently true that our medical and public health infrastructure is fully competent to protect us. And no, it doesn't look like that. The medical director of Texas Health Presbyterian Hospital should be escorted to the door and banned from the premises, along with the director of emergency medicine and the director of infectious disease. Not only was Mr. Duncan sent home despite telling the nurse that just arrived from Liberia and having a fever of 103, we now learn that after he was admitted to the hospital upon returning, his care team did not wear full protective gear for two days.

Nurses all over the U.S. are now coming forward to say that they do not feel prepared, have not been adequately trained, do not have adequate equipment, that procedures and policies are not in place, and that they have not drilled. Again, the probability that any given hospital will encounter an ebola case is very small, but public perception of risk is what's at stake here.

Then there is whoever is head of the division at CDC responsible for telling nurses who have exposure liability that they can go ahead and use their round trip ticket to Cleveland. This is not a question of the actual risk to the public, although I must say that as this story has played out it is not in fact zero. But even if it were zero, the consequences are inevitable and unacceptable: schools closed, hundreds of air travelers terrified, money spent to sterilize school buses and an airplane, public health workers spending their days following people around in two states who ought to be doing real work such as tracing partners of people with HIV and STIs, tracking down sources of food poisoning, getting kids vaccinated. In other words we will have some additional cases of infectious diseases because of this.

Now it turns out that a pathology technician who handled some of Mr. Duncan's specimens is on a Caribbean cruise in Belize. Let me repeat myself: it is irrelevant if she or he is actually at substantial risk. This is so utterly, gobsmackingly boneheaded that it makes me shriek. The risk is obviously not zero and what the hell will they do if this person starts vomiting blood in her cabin, on a cruise ship, in Belize? And even if the risk is zero, how do you expect the public to react to this?

The authorities seem to be doing everything in their power to fan the flames of fear and build them into panic. A display of competency and enough excess caution to convince people that it's really enough are absolutely essential if this is not to turn into a disaster -- an economic and political disaster, which will gravely damage the U.S. and meanwhile prevent us from doing what must be done in west Africa, which only the United States has the resources to do.

President Obama is saying the right things, but the CDC is doing its utmost to sabotage him.

Update: Stupid crap like this, for example:

Syracuse University on Thursday disinvited a Pulitzer Prize-winning photojournalist who was scheduled to participate in an upcoming journalism program because he was recently in Liberia covering the ongoing Ebola crisis.

The dean of Syracuse's S.I. Newhouse School of Public Communications, Lorraine Branham, spoke to News Photographer magazine about the decision to disinvite photojournalist Michel du Cille. "He was disinvited because of concerns that were generated by some students that led me to believe that it would lead to even more concerns," she said. "So it was in the best interest of the students for me to withdraw the invitation."

 He left Liberia more than 21 days ago, BTW.


 

The secret history of the world

By now, you have no doubt heard all about the New York Times report on the exposure of U.S. military personnel to discarded chemical weapons in Iraq. It is indeed a scandal that the Bush administration and its military kept these incidents a secret, failed to provide troops with the information and equipment they needed to stay safe, and failed to properly compensate or care for the injured. Yeah, that's bad, but it buries the lede.

Of course the wingnuts are already screaming that there were too Weapons of Mass Destruction™ in Iraq after all, but obviously that isn't true. The last thing W would have done is to keep that a secret. As the Times story says, "The discoveries of these chemical weapons did not support the government’s invasion rationale." These weapons were manufactured in the 1980s and mostly buried after Iraq abandoned its chemical weapons program. They were no longer usable, although the residues were dangerous. But . . .

The real story is that the U.S. and European nations supported Iraq in its war against Iran, so they made sure Saddam had these chemical weapons. German firms provided manufacturing plants, and U.S. firms sold Iraq the chemicals to make mustard gas. European companies provided the shell casings and rockets. The U.S. was well aware that Iraq was using these weapons against Iran, weapons which the U.S. and its European allies were supplying. In case you don't remember, the president of the United States was St. Ronald Reagan.

But the false accusation that Iraq had a current Weapons of Mass Destruction™ program provided the rational for an illegal war of aggression by the U.S. The use of chemical weapons by Bashar al-Assad was a "red line" that would have triggered a U.S. air assault if Vladimir Putin hadn't arranged a way out. The point is, all of our political discourse is hypocrisy and lies. The Times occasionally does a service like this and reveals the truth, but it pretty much sinks without a trace in the public consciousness.

Another goodie from the Times today, the not always reliable Frank Bruni. Like I said.

Proportionality

Sorry for my absence, I needed a few days to clear my head and the muse just didn't inspire, not for this blog at least . . .

Anyway, it's something of a repeating theme for me that we humans just aren't very good at deciding what is important, or what we ought to be worried about more than something else. So, of course the ebola virus is worrisome. Lots of people have already suffered and died and many more will. But the attention it deserves is mostly because the incidence is increasing in the fairly restricted geographic region where the outbreak is occurring, and nobody can be sure how it's going to play out.

Here, Andrew Ross Sorkin reports on calculations by the world bank that the economic cost of the outbreak will be $32.6 billion by the end of 2015 if the virus spreads to neighboring west African countries, which they consider to be a worst case scenario. That's a lot of money no? Well yes, it's probably about five times as much as the U.S. will spend bombing Syria and Iraq during that period. On the other hand it's about 1/300 of the trillion dollars we spent on the previous Iraq war. (Of course the U.S. will bear little of the cost of ebola.)

Yes, people are dying. Many fewer than died in the Iraq war of course, but it is also true that more Africans are dying right now of malaria, TB, HIV, and diarrheal diseases than of ebola, by orders of magnitude. Even in the worst case scenario, that will still be true.

As Sorkin's story tells us, the biggest economic risks are from overreaction, not the epidemic itself. Impediments to international travel and trade, useless spending, fearful declines in investment -- those are likely to cost more than $32.6 billion.

So why the wall-to-wall media coverage? Well, for one thing it's novel. That's what the word news means, after all. But this is a cognitive bias that's costly. Buried on page A-14, and nowhere to be found on the web home page, the NYT tells us of a new Pentagon report detailing the national security risks of climate change:

The Pentagon on Monday released a report asserting decisively that climate change poses an immediate threat to national security, with increased risks from terrorism, infectious disease, global poverty and food shortages. It also predicted rising demand for military disaster responses as extreme weather creates more global humanitarian crises. . . .

Defense Secretary Chuck Hagel, speaking Monday at a meeting of defense ministers in Peru, highlighted the report’s findings and the global security threats of climate change.“The loss of glaciers will strain water supplies in several areas of our hemisphere,” Mr. Hagel said. “Destruction and devastation from hurricanes can sow the seeds for instability. Droughts and crop failures can leave millions of people without any lifeline, and trigger waves of mass migration.”

On the front page, however, we do have the story of the single person who was infected within the U.S., a nurse who cared for Thomas Duncan in Dallas. A single, identifiable person is much more likely to get our attention than the probability that even thousands of people who aren't identified, who are mere abstractions, will suffer or die. That's another dangerous cognitive bias. It's what led to the counterproductive reaction of the U.S. and Britain to the grotesque beheading of hostages by the self-styled Islamic State. Yes, we need to seek justice for those individuals but we need to keep the threat posed by IS in proportion and respond in a way that isn't going to make matters worse. Until those identifiable individuals were killed, that seemed likely to happen. Of course, that's why they did it.

That river in Egypt . . .

Is it really this deep? Remember Jahi McMath, who died last December but whose parents think she's alive because she's hooked to machines that keep her flesh from rotting? (Yeah, yuck, I know.) They're still at it, petitioning a court to have her declared un-dead. Her body is apparently now in a house somewhere in New Jersey, where somebody has paid to have the necessary machinery installed and for personnel to keep it running and keep most of her cells alive.

It is not puzzling, of courses, that parents cling to hope despite the vast weight of reality, as did Terry Schiavo's parents. What is puzzling is that their understandable delusions are incorporated into an ideological crusade by people who think that keeping corpses with dead brains in a state of pseudo-animation using late 20th Century technology is mandated by God. I somehow missed that passage in the Bible.

I remember during the Schiavo brouhaha a priest organizing Catholic teenagers to demonstrate with tape across their mouths with the word "life" written on it. Sorry folks, but this is not life, and if it were, why would you want it? It is, of course, possible to do this with just about everybody who dies, as long as their circulatory system can hold blood. I don't need to point out the reductio ad absurdum. (Terry Schiavo was not technically dead when she was disconnected from life support, but that's a distinction based on the new definition of death that had to be invented in the light of new technology. She was in a state that I would be happy to call death, and she would have been dead in any and every possible sense of the word far earlier if the machinery had not been available.)

What seems even stranger is that the people who take this bizarre position don't even believe that death is real. They think it's the greatest thing that can happen to you, that you go off to Paradise to be with Jesus. Why don't Jahi's parents want that for her?

The times they are a'changin'?

I was reminded by Adam Liptak's report on the Supreme Court's historic punt on gay marriage that in 1967, interracial marriage was illegal in 24 states. Not only that, but a majority of Americans supported banning it. The SC took that case, and declared the bans unconstitutional -- you know, that pesky 14th Amendment -- but honestly folks, that wasn't very long ago.

This is a salutary reminder for me because I've lived in something of a bubble as a New Englander from a liberal, well-educated family. I entered high school in the same year that the court ruled on interracial marriage, and although I wouldn't call Andover (also attended by George W. Bush) a hotbed of pinkoism in those days overt racism was definitely out of bounds and I can't recall encountering it. The black kids even had a bit of cachet as the Civil Rights movement was broadly inspirational in that cultural milieu.

As a community organizer in Philadelphia's poor white Fishtown neighborhood I encountered profound, grotesque racism, pretty much for the first time. So yeah, I knew it existed but that was a brief phase as I went on to graduate school and spent most of my adult life traveling in progressive circles and working in multicultural environments. So the real world out there, full of racists and creationists and homophobes is exotic to me. It's really hard for me to appreciate how commonplace ignorance and bigotry really are.

Ergo, I always struggle to understand why people vote for lunatics who believe, or claim to believe, in crazy ideas and are fully and publicly committed to working against those voters' best interests. It's sobering. On the other hand, who would have thought just 5 years ago that there would be majority support for same sex marriage in the U.S.? Racism has been very slow to fade, if it's fading at all right now, but for whatever reason, this particular form of irrationality is dying fast. Maybe there's hope for the rest of the reality agenda.

Bobby Jindal is still an idiot

He wants the U.S. to ban all flights from nations where Ebola virus has been found and, he says:

[T]he Obama administration keeps saying they won’t shut down flights. They instead say we should listen to 'the experts.' In fact, they said it would be counterproductive to stop these flights. That statement defies logic. How exactly would stopping the entry of people potentially carrying the Ebola virus be counterproductive? This seems to be an obvious step to protect public health in the United States.

 Okay doofus, it's time for you to listen to an expert. In the first place, the Dallas patient arrived on a flight from Brussels. I don't even know if there are any direct flights from Liberia or Sierra Leone to the U.S., but even if there are, it's easy enough for people to take connecting flights, even to travel over land to Lagos or wherever. So it would be pointless. Furthermore . . .

In order to combat the epidemic in west Africa, it is necessary to bring in personnel and supplies. Airlines obviously can't fly in if they can't fly out. It is also important to limit the economic collapse in those countries, and to limit fear and civil unrest. Closing them off from the outside world is about the worst thing we can do. Furthermore . . .

As you presumably know if you are conscious, there have in fact been several people in the U.S. with Ebola. We bring our citizens here when they contract it. Not a problem. Mr. Duncan's contacts are being carefully monitored. It wouldn't be surprising if one or two of them do come down with the disease -- particularly his family members who he was living with -- but it will stop there. The screwup at the hospital that allowed him to go home will not be repeated.

So again, Ebola is a problem in poor countries that lack medical and public health infrastructure. It is not a threat to become an epidemic in the United States or any other country -- even a middle income country like Mexico or Brazil -- that has the resources to deal with it properly. So please stop pissing in your pants.

Oh yeah, about the conference . . .

I'm not going to bore you with any of the specific presentations (okay, except for mine) but I will try to give a sense of the overall state of research into communication in health care. Yes, this is a scientific field and we do empirical research, as rigorously as our usually quite limited funding will allow. But it's impossible to separate facts from values.

The goal of health care is to make money improve patients' well being. But that presumably means different things to different people. Do you want to live as long as possible or enjoy yourself more? Do you want to take a chance on surgery that will probably fix your arthritic hips and let you get back out on the golf course, but might just possibly go wrong and leave you worse off? And so on, including many even more complicated and stress inducing situations.

Furthermore, your doctor might think that you will unambiguously be better off if you take some course of action, but for various reasons of your own you don't do it, one possibility being that if you take pills you will have to think of yourself as sick but you don't want to be. Is it the doctor's job to use our research to manipulate you into doing what the doctor thinks is best? To take a more concrete example, I feel that my orthopedic surgeon somewhat downplayed the pain and disability I would endure after thumb arthroplasty, but I'm not mad at him. I now feel that it was worth it in the long run but I might not have gone through with it if he'd been totally honest. Of course he also had the ulterior motive that he gets paid to do surgery.

The fact is that most patients will never understand the biomedical reasoning behind treatment decisions, and even if you strip the decision down to relative probabilities of understandable outcomes, most people don't really grasp the concepts of mathematical probability and they have all sorts of cognitive biases. A 90% chance of a good outcome and a 10% chance of a bad outcome are evaluated very differently, even though they are of course identical.

So, the value now is "shared decision making," which even has a standard presentation as SDM. The doctor is supposed to be the expert the probabilities of various outcomes of various courses of action, and the patient is supposed to be the expert on what she values the most among that landscape of probabilities and so we decide. But that is merely aspirational, Nobody knows how to accomplish it consistently in the real world in a meaningful way.

It's only over the last 20 or 30 years that we have even had this aspiration as the standard in medicine. It used to be that doctor knew best and we were supposed to follow doctor's orders. As you can imagine, it is a very complex problem to establish the relationship between features of clinical communication and outcomes because, pretty much by definition, what constitutes a good outcome is undefined going in. We can arbitrarily say it's life expectancy, or quality adjusted life years, or some specific reduction in some pre-specified symptom. But if we don't get there because the patient chose a course that didn't maximize that outcome, is that a failure? And asking people to evaluate decisions retrospectively is not very helpful; we have powerful cognitive biases in doing that.

So, we have to start by trying to measure what people understand after a clinical encounter, whether they feel their questions were answered, and how confident they feel in their ability to make choices that affect their health. Then, if we can define a patient centered good outcome, we can eventually find out if it's achieved --but we might have to follow them for years, and that costs a lot of money, and they aren't giving it to us, yet, for this kind of research.

I'll tell you exactly what I'm doing anon.

I am sterdam

The headline of this post is the ridiculous slogan of the tourist board. Nobody even knows what it's supposed to mean. (No, it doesn't mean anything in Dutch.) But that's about the only thing I have to complain about.

The single most notable feature of Amsterdam is not, in fact, that it's Waterworld, which it is. It's that on dry land, everybody gets everywhere by bicycle. There are wide, perfectly maintained bike lanes everywhere, that interweave skillfully with the streets and wide sidewalks. The traffic lights are set up to safely direct bicycles, pedestrians and motor vehicles. The actual volume of traffic is in that order. There is a continual torrent of cyclists everywhere: school kids, blue collar workers, guys in business suits, old folks, families with their kids, every conceivable category of human getting to work, to school, around town on errands. The style is to sit up very straight, and nobody wears a helmet. Also, nobody is fat.

Such few cars as there are include plug-in electrics, and there are charging stations on the street. Yep, you can grab one of the regular parking spaces and plug in your car. There is also a fantastic network of street cars that goes everywhere, frequently, and knits together the whole city. So the air is clean, there is no traffic congestion, and it's easy and safe to cross the street. The stream of cyclists however is a bit scary.

I'll have more to say about the city, and the conference. For now, however, I'll say this. It seems the deepest fear of conservatives in the this country is that we'll end up like Europe. Check it out, folks: it's actually better.

The jet set

I'm off to Amsterdam this afternoon for the International Conference on Communication in Healthcare. I'll be presenting a poster and a talk. With luck, something interesting will happen at the conference for me to tell you about. But my schedule will of course be disrupted.

You may think this is a glamorous life but it's pretty much a PITA. I have to spend the minimum possible money which means no extra nights in the hotel, economy class in the cheapest possible flight, and the upshot is I'll get a brief impression of Amsterdam and that's about it. But I'll do the networking and presentationalizing necessary for academic success. Maybe even learn something.

Howzzat again?

A couple of days ago I heard Neko Case on National Pubic Radio recalling that as a child, she heard the Rascals Hit "Groovin'" as "That would be ecstasy, You and me and Leslie, Groovin .. . " She thought that was great that they could hang out with Leslie. Actually I heard it the same way, but I thought, "Who the fuck is Leslie?" Is it a menage a trois? Do they have a kid? A dog?

Actually it's not "and Leslie," it's "endlessly," but the singer (that would be Eddie Brigati) for some reason put the accent on the wrong sillobble. It's weird because endlessly scans just fine with ecstasy. If you look for the song lyrics using your favorite search engine (and no, Kleenex isn't the only brand of tissue either) you will find that even some official-looking versions drag Leslie into the picture.

I've come across a lot of similar mis-hears in my young life. Somebody, can't remember who, said they heard Jimi in Purple Haze sing "Excuse me, while I kiss this guy." That would be interesting news about Jimi, but the fact is he never hid anything. It's kiss the sky.

I was on a shuttle bus between a low-rice Marriot in an industrial park and a conference venue in Manchester, CT when a fellow sufferer told me that she heard John C. Fogarty singing "There's a bathroom on the right." Apparently John was in a hotel and needed to relieve himself, but in fact there was a bad moon on the rise.

My mother heard the old hymn "Gladly the cross I'd bear" as "Gladly, the cross-eyed bear." Funny name for a bear.

Anyhow, you may have a few of your own but I should go on to more serious matters. As you have likely heard, CDC thinks it's possible there could be 1.4 million cumulative Ebola virus cases in Liberia and Sierra Leone by the end of January. This is based on the assumption of no increase in the current level of intervention, and doubling every 20 days. So will this be the Big One, that plunges the planet into a new Black Death?

As I and most knowledgeable commenters have said, no. The catastrophe is happening because these two countries are among the poorest in the world and they lack adequate health care and public health infrastructure. Liberia has 1 physician for every 100,000 people. There aren't enough hospital beds for infected people so most of them just end up remaining in the community where they can infect others. The disaster multiplies because health care is unavailable for people with other endemic diseases such as malaria, while those few health care workers there are, lacking adequate personal protection, flee the field. Even the relatively poor countries of Nigeria and Senegal have so far successfully contained the outbreak because their infrastructure is just good enough. 

But, smug and safe as you may feel in your First World citadel, you should not. Ebola happens to be transmissible only in ways that make it controllable where resources are adequate, but the next emerging infectious disease might not be. It's likely to start in a poor country where initial containment fails, and then yes, given that people can be in Freetown in the morning and eating lunch in London the same day . . .

So, while it's easy to raise the money to bomb stuff, it's apparently impossible to raise the money to build an adequate public health infrastructure in poor countries. Maybe someone can explain that.

Let's you and him fight

U-Cal prof As'ad AbuKhalil breaks down the Syria clusterf* for you.

Point number 1 (and I said it here before), the "moderate, progressive" Free Syrian Army is and always has been bogus. They are a small conglomeration of various people who ducked under the umbrella in order to get U.S. support. Many moderate factions are actually allied with the Assad regime (which was always secular, NB). For the most part, the contending rebel factions represent various strains of Wahabism.

Then you have and Iran vs. Saudi proxy war, a Saudi vs. Qatari proxy war, the Sunni vs. Shia thing which was mostly conjured up by the Saudis as part of proxy number 1, U.S. vs. Russia but that's inoperative now because it was about deposing Assad which is no longer the issue, Lebanese factions, Moslem Brotherhood vs. localized factions . . .

The point is, it doesn't have a damn thing to do with the U.S. or Islam vs. Christendom or any of the other bullshit you have been told. And it certainly is not the job of the U.S. to straighten it out, with bombs or otherwise. So just stop it.

Bombolicious

Very interesting to hear that Saudi Arabia somehow "participated" in the attack on the Islamic State in Syria, since, as we noted on Sunday, IS was originally a project of Saudi intelligence. More confirmation of that here. Of particular note is John McCain praising the Saudis even as Bush family pal Prince Bandar was financing and organizing ISIS.McCain is the single individual in the United States who is most ignorant of world affairs. That's why he gets to talk about the subject so much on TV.

According to the linked article by Steve Clemons, King Abdullah has apparently decided this wasn't such a good idea after all and has relieved Bandar of the intelligence portfolio. All I can say is at this point, you poke a hornet's nest, you should know what to expect.

The fact is the Arab states that are said to have "participated" in this action probably just lent their names to it, like the honorary committee on the stationery. They're still expecting the U.S. to clean up their messes and the result is just going to be an ever bigger mess. The U.S., with an occasional extra kaboom from France, has been bombing IS in Iraq for a few weeks now, and while the activity has helped the peshmerga hold on to territory and recapture the Mosul dam, that's about all it's accomplished. There is no comparably effective and credible proxy force in Syria as of now, so this is unlikely to have any substantial territorial consequences for a long time to come.

Whether King Abdullah can stop his 247 half, quarter and 8th brothers from writing checks to IS, and whether the Turks can shut down the black market in IS petroleum, remains to be seen. Those are the only measures that are likely to matter. Oh yeah. John McCain needs to STFU.

What Matt Stoller says . . .

Here. Thou shalt read.

Al Qaeda and the Sept. 11, 2001 attack on the U.S. were financed by Saudi princes. So was (and probably is) the so-called Islamic State. The Saudis are great friends of the Bush family. The 9/11 Commission report apparently names the financiers, but that part of the report is classified. It would not be in the national interest, it seems, for you to know who paid for the attack.

The entire basis and rationale of U.S. foreign policy, as represented by the corporate media, is horseshit. And yes, it's all about petroleum and the money that flows to the places from which it comes. It's not that long of a story; please do follow the link.

Dr. Innumerate will see you now

I don't know if you riffraff are allowed to read this, but anyhow Christopher Martyn in the new BMJ points to some jaw dropping findings. If you've been a long-time reader you will recall that I have discussed Bayes Theorem many times. It's really important to critical thinking to understand it. He refers to: Manrai AK, Bhatia G, Strymish J, Kohane IS, Jain SH. Medicine’s uncomfortable relationship with math: calculating positive predictive value.JAMA Intern Med2014 174.

I won't bother with a link because I know you can't read it. But I'll tell you what it says. They presented physicians with the following proposition:

There is a disease which has a prevalence in the population of 1 in 1,000. There is a test for this disease which has a false positive rate of 5%. If your patient has no symptoms of the disease, but the test for your patient comes back positive, what is the chance your patient has the disease?

Think about it. (Jeopardy! music plays.)

Okay, if your answer was 95%, you're thinking like  doctor. Which means you're wrong. That's how most physicians answered the question, but the right answer is about 2%.

This is easy if you just take a minute. One person in 1,000 actually has the disease. Of the other 999, 5% (in the average trial) will have a false positive test. That's actually, on average, 49.95 people but close enough to 50. So to be exact, there is a 2.002% chance that your patient has the disease.

This test is said to be 95% specific. Sounds really great, doesn't it? But if the condition is uncommon, it's pretty much useless. It's because doctors, patients, and advocacy societies can't seem to understand this that we have too many screening tests and too many people walking around with disease labels and getting unnecessary additional tests and treatments. And it is so blatantly, obviously, fucking simple. Aarrrggh.

A bit more about domestic violence

If  you inhabit the same precincts of the blogosphere as I do, you have probably read plenty of late about the Men's Rights Movement and Men's Rights Activists. Their basic claim seems to be that they have a right to be jerks and they are oppressed by people who claim otherwise; and they seem to favor tactics such as death and rape threats against women who disagree with them. I'm sure there are people who consider themselves MRA's who behave better and make more credible claims, e.g. that men are discriminated against in child custody disputes, but it's the former category that's been getting the attention.

Anyhow, I'd like to discuss a specific area of controversy. Linking to Wikipedia is maybe an easy out, but in this case it's a good place for an overview. The fact is, as I mentioned in my last post, surveys generally find that violent acts by domestic partners occur at about the same rate by women against men as by men against women. An academic who is well known for loudly proclaiming this fact is Murray Strauss who complains, rightly perhaps, that it is widely ignored. However, although he tends to bury the lede, he also notes in the journal Partner Abuse (2010, sorry no link available):

The exception to gender symmetry is that the adverse effects of being a victim of PV are much greater for women than for men. This can be considered a difference in context, but the fact that adverse effects are consequences rather than causes of PV needs to be kept in mind.

Attacks by men cause more injury (both physical and psychological), more deaths, and more fear. In addition, women are more often economically trapped in a violent relationship than men, because women continue to earn less than men and because, when a marriage ends, women have custodial responsibility for children at least 80% of the time. On the other hand, the adverse effects of emotional abuse, while not a focus of this article, are often greater than those of physical PV, with a comparable impact on both men and women victims (Hamel, 2009; Lawrence, Yoon, Langer, & Ro,
2009; Taft et aI., 2006)

Still, the greater adverse effect of physical PV on women is an extremely important difference, and it indicates the need to continue to provide more services for omen victims of PV than for men victims. In addition, as will be explained later, the greater adverse effect on women is one of the things that underlie denial of theevidence on gender symmetry.

In other words, you can lie with statistics. Strauss comes in for a lot of heat from feminists, but he really doesn't deserve it. He's trying to get us to work with the true facts, which actually forces us to think more deeply.

About those foobaw players

I haven't done primary research on intimate partner violence, but as a sociologist I have studied a bit about it and taught the subject. It is possible for couples to get into the occasional fight, push or hit each other, throw things -- surveys find that the percentage of relationships in which that happens are pretty high, and the gender direction is actually pretty symmetrical. That said, since men tend to be bigger and stronger than women in most cases they have an extra responsibility to forebear.

But abusive relationships are something different. These are characterized by a pattern of coercive control. The abuser is obsessively jealous and possessive. He -- and in these situations it is indeed usually he -- uses all sorts of tactics to maintain control, not just physical violence but humiliation, economic coercion, spying, selective withholding of affection, lying, threatening, you name it. Women often end up staying in these relationships out of fear -- if they leave, he might kill her. He may well have made credible threats to do so. She may have no economic resources and fear for her children's welfare. You get the idea. (This can happen in homosexual relationships as well, by the way.)

So what about Ray Rice? We don't have any evidence, that I know of, that the incident in the elevator was anything but isolated. However, the video is deeply disturbing because he is so callous. He shows no concern for her welfare, drags her out of the elevator like a sack of potatoes, and seems not in the least upset that he has just struck his fiancee in the face and knocked her unconscious. That is very odd, to say the least. And given that he spends hours in the weight room and his muscles are nearly bursting out of his suit, see the last sentence of paragraph one.

Now, if the average accountant or material handler is accused of domestic violence, he ordinarily won't lose his job unless he winds up in jail. In fact, his boss probably will never even learn about it. With public officials it's different obviously. A Massachusetts state legislator was recently convicted of domestic violence, refused to resign, and the House expelled him. So what about athletes?

It seems to go without saying for most commenters that professional athletes, and for that matter prominent college athletes, must be held to a high standard of conduct away from their jobs.  The reality is that athletes throughout their youth, including college, are entitled and can get away with a lot of bad behavior. The fans seem to love their bad boys regardless. At least this has historically been true, but now the zeitgeist is changing, and more and more people are reacting against the tradition. There is a strong feminist strain in this reaction but there are plenty of men who feel the same way not only because they are feminists, but also because they don't like the old definition of proper manhood.

I'm not exactly sure how I feel about this. Obviously athletes should be held to the same standards as everybody else, and be as accountable. But should they be more accountable? Public officials have to make and enforce the law. Eliot Spitzer properly resigned because as Attorney General he had prosecuted prostitution rings and as Governor he was responsible for enforcing laws that he violated. We can't have that, as far as I'm concerned. But are athletes really role models? Have they ever been? Some are, in some ways. Jackie Robinson, for example. But generally speaking, they're just entertainers, and we certainly don't disqualify actors or musicians for bad behavior. Rice probably should have been prosecuted, given the egregiousness of the assault, but should he never play football again? I think that may be a category error. He's just a guy who plays a violent game.

In case you haven't been following the existential threat . . .

It's not actually from religious fanatics (unless you count the Christian right).

August, 2014 was the hottest August globally since records have been kept starting in 1880. Our relatively cool summer here in the northeast U.S.? Actually no, it was normal. It's just that we've gotten used to it being hotter. Also, too, no El Niño so far, which is normally associated with high temperature anomalies. And the biggest temperature anomaly? West Antarctica, where the ice sheet is already collapsing.

I actually won't feel terrible when Miami Beach is under water. It's kind of an abomination. But it's too bad about Back Bay and East Boston. I have a certain affection for those places.

War! What is it good for?

What David Frum says.

Speaking for myself -- and I've sort kinda said this before -- yes, these Islamic State characters are evil doers. But so are our Saudi and Qatari "allies" (when they aren't actually financing al Qaeda and similar) and so, for that matter, are we. I suppose you could say it's a matter of degree and that counts for something, but still it must be acknowledged.

That acknowledged, the following perhaps less controversial points.

1) The only substantively interesting statement in Obama's speech last night was that we are going to arm Iraqi and Kurdish forces. In diplomatic terms, that is extremely significant because it explicitly admits that the peshmerga are not part of the Iraqi armed forces and Kurdistan is not part of Iraq. That said . . .

2) It is ridiculous to pretend that this has anything to do with protecting the territorial integrity of Iraq or the preservation of national borders more generally. That ship done sailed. Which is inevitable because these are borders drawn arbitrarily by European colonial powers 100 years ago. Nature is taking its course . . . 

3) And, since the Iraqi army is in fact a sectarian Shiite army, we are also going to arm and train Sunni Arab militias, which means we're just going to further encourage the breakup of Iraq because we know the Sunni Arabs aren't about to join the Iraqi army, since it's not their army and that's the whole reason IS has been successful in Iraq in the first place .. .

4) That said, this bullshit about an "inclusive" Iraqi government is obviously just that.

5) The Islamic state is a threat to the region, to be sure -- and mostly immediately to regimes we claim not to like, i.e. Iran, Bashar al-Assad, and the totally non-inclusive Baghdad regime. Obviously they also make the Kurds and Turks nervous, but Turkey has already said it's not going to join the coalition of the willing. They make the Saudis nervous but that's their own blowback, now isn't it? So . . .

6) We now find ourselves in a weird alliance with Iran, the Shiite Baghdad government, the Saudi and other gulf monarcho/theocracies, and a motley crew of ideologically diverse warlords in Syria, plus the Kurds, for the purpose of protecting the interests of all of them at our expense.

This is completely nuts. IS is 7,000 miles away from the closest point of the U.S., which I believe is Provincetown, Massachusetts. This is a problem, and it's partly our fault, so we owe people something. But it's not a problem we can fix, and it's certainly not a cause that the U.S. can lead.

We owe humanitarian aid to the refugees. I'm not knee-jerk averse to a bit of bombing here and there at the request of the Kurdish or Baghdad governments to avert further catastrophe and maybe help them roll back IS where they can. We do owe them any help that will actually be useful. But a war between the United States and Muslims of any kind is just playing into the hands of IS. That's the world they want to portray, and the last thing we ought to do is make it real. The Saudis and Iranians actually have powerful militaries with plenty of air power. Yeah, they hate each other. That's not our problem either. Let them do what they think is best.

Also too. According to the sacred Constitution of the United States, the Congress has the sole power to declare war. Anybody still remember that little detail?

Tranks

One of the difficulties with pharmaceutical regulation is the length of follow-up in clinical trials. Typically, drugs are approved based on trials of no more than six months duration. This is true even for drugs that people may take for a long time, even for many years. Sometimes the FDA requires post-marketing surveillance or longer term follow-up studies after a drug has been approved, but they often don't, and these requirements aren't even enforced in many cases.

Benzodiazepines are very commonly prescribed tranquilizers. Very common brand names are Xanax, Librium, and Ativan. (Rohypnol, also in the class, is a popular date rape drug. Sorry to bring that up.) They are addictive, and are often drugs of abuse. Many people doctor shop for them just as they do for opioids, they are often sold on the street, and they are often found in conjunction with opioids in overdose victims. They are prescribed for anxiety, but as I often say, anybody who isn't paranoid nowadays is nuts.

Well now, it turns out that a carefully done case-control study links even moderate-term consumption of benzos to Alzheimer's disease. By moderate term I mean more than three months worth. By links I mean an elevated odds ratio of 1.84 for more than six months of consumption.

The odds ratio is not the same as the risk ratio -- since math is hard I don't want to digress to explain this here. A case control study does not allow for computation of the actual relative risk in the population, but in this case, we can figure out that it translates to an approximately 50% increased risk. There are other studies that point to the same conclusion; the strength of this study is that it attempts to account for the possibility that people who have symptoms that might be associated with a higher risk of Alzheimer's are more likely to be prescribed benzos. (That's called confounding by indication.)

This is a very disturbing finding. If someone is anxious for a reason, such as the fact that we live in a dangerous world, taking a pill is not going to fix the real problem. If there is in fact a disease that causes people to feel anxious all the time and we don't understand why and can't do anything else about it, having them take a pill for the rest of their lives that causes drowsiness, dizziness, lack of coordination, decreased libido and amnesia -- even without the Alzheimer's disease --- is probably not a good idea. In fact, they are recommended only for short term use -- alcohol withdrawal, termination of seizures, brief (2 - 4 weeks) treatment of anxiety. There is no condition for which long-term use is helpful or indicated. Yet these investigators had no trouble finding 22% of people in a sample from Quebec who had been prescribed benzos for more than six months. (That was the rate of long-term prescribing in the controls, in other words. The rate in the cases was 33%.)

To reassure you, there was no finding of increased risk of Alzheimer's associated with short-term use. That indication is not affected by this study. The point is, doctors should not be doing this.

Looking forward, not back

It turns out that tomorrow is the 40th anniversary of Gerald Ford's pardon of Richard Nixon. For any not-olds who may read this the act was greeted with widespread outrage at the time, but now we're all supposed to believe that it helped bind up the nation's wounds and let us move forward yadda yadda yadda.

Well, while we're on the subject of looking ahead and not back, there has been almost no attention paid so I may need to remind you that the Senate Intelligence Committee has prepared a report on the CIA torture program which has yet to be released to the public because the administration is trying to censor the nasty bits. For some reason, a British newspaper, the Telegraph, has to do the journalistic enterprise to tell us what they are. This came out last night but I have not found a single U.S. media outlet that has covered it. Take it away, Peter Foster:

The CIA brought top al-Qaeda suspects close “to the point of death” by drowning them in water-filled baths during interrogation sessions in the years that followed the September 11 attacks, a security source has told The Telegraph. The description of the torture meted out to at least two leading al-Qaeda suspects, including the alleged 9/11 mastermind Khalid Sheikh Mohammed, far exceeds the conventional understanding of waterboarding, or “simulated drowning” so far admitted by the CIA.

“They weren’t just pouring water over their heads or over a cloth,” said the source who has first-hand knowledge of the period. “They were holding them under water until the point of death. . ."

Despite the destruction of video evidence, however, a third source familiar with the still-classified accounts of the most severe of the CIA interrogations, said that the practices were much more brutal than is widely understood. “They got medieval on his ass, and far more so than people realise,” the source told The Telegraph referring to the treatment of Mohammed and Nashiri, but declined to provide further details because of the still-classified nature of the material.

The destruction of video evidence refers to destruction of video tapes of the torture sessions by CIA Officer Jose Rodriguez, who was severely punished by a sternly worded letter. B. Hussein Obama has already promised not to prosecute anybody for torturing prisoners. Congress did impeach Bill Clinton for receiving fellatio, however, so there is still a spirit of accountability in the land.

Could this be the most outrageous thing I've ever heard of?

Just about. I mean, it's not the holocaust but it's pretty damn evil. Graham Cole and Darrel Francis in BMJ tell the horrific tale.

It starts with one of my least favorite things, scientific fraud. A schtickdreck named Don Poldermans published a series of clinical trials testing whether giving beta blockers before surgery reduces the risk of mortality. The trial reports said it did, by a lot. Even though other studies didn't find this, the European Society of Cardiology relied on Poldermans's studies to recommend the treatment, which is not surprising since Polderman chaired the task force the developed the guidelines.

Only problem: Polderman made it all up. There were 5 trials in the series. He made up patients, made up data, even made up collaborators. Without his trials, meta-analysis shows that giving beta blockers increases the mortality rate. Cole and Francis calculate that something like 800,000 people have died because of the fraud. Polderman of course has been fired, but I haven't heard anything about a murder prosecution.

Anyhow, the first trial in the series, DECREASE 1, was more than ten years old at the time of the investigation so it was not reviewed. But as Cole and Francis show, it is obviously bogus as well. It contains impossible data and internal contradictions. However, the ESC continues to rely on it and has not reversed its recommendation! The guideline setting process is secret. The Society's journal, the European Heart Journal, has resisted accepting the new meta-analysis. There is more detail about the whole contretemps that I won't go into.

Arrogance, secrecy, vested interests, lies -- and people die. I don't know what the guidelines are for this practice in the U.S. or how the situation has played out here, but guidelines committees are certainly plagued by conflicts of interest and lack of transparency. This must change. It's your life that's at stake.