The Nut Party

While Republicans are completely wrong, about everything, one of their weirdest wrongnesses has been the refusal of Republican-led states to accept the Medicaid expansion. While this obviously leaves a lot of vulnerable people unable to obtain medical care, it also does substantial economic and institutional damage to their states. That physicians and hospital owners and executives, who are well-to-do and often Republican, have been unable to howl loud enough to overcome the mindless ideological opposition to the Affordable Care Act, is disturbing.

Reiter et al, in Health Affairs, give us an idea where this might be going. States that refused the Medicaid expansion have a disproportionate number of poor, and rural residents. Since the ACA presumed that all the states would accept the expansion, it reduces federal funds that used to go to hospitals that served a disproportionate share of uninsured people. This means that those rural hospitals in the red states are coming under increasing financial pressure. They are financially vulnerable, often losing money, and may start to go our of business. As the authors write, "Policy makers need to formulate strategies for maintaining
access to care for rural populations residing in nonexpansion states."

Do yuh think? But that would mean, you know, spending money. Which Jesus specifically said not to do for the benefit of poor people. It's right there in the Republican Bible. But then what happens when the rich people who live in the same area lose their hospital?

The Ruling Class

I haven't posted here for a few days because I've been busy with events in Afghanistan, which have been quite outrageous. Anyway, I'm back here now with a different outrage.

You may recall a whiff of corruption affecting my employer, which I recounted a week ago. Well, the ever reliable BMJ is back with the subject for this Monday's post. It seems, according to Anderson et al, that of 442 publicly traded health care industry companies in the U.S. for which information on their Board members was available, 180 had at least one director who was affiliated with academic medicine. That includes 19 of 20 top NIH-funded medical schools. They include 8 medical school deans as well as 121 professors and 15 university presidents or provosts.

Oh yeah -- their average compensation was $193,000 per year. As far as I'm concerned, this is completely unacceptable. As David Rothman says in an accompanying editorial, if the companies want advice from these people they can get it without putting them on the board of directors and matching their academic salaries in exchange for attending a few meetings a year. This is bribery, and it has to stop.

A mighty wind

The current National Hurricane Center forecast puts the bullseye for hurricane Joaquin precisely on my ass. Fortunately for me, though possibly not for some other people, the meteorological blogger Jeff Masters at Weather Underground (no link because this is so ephemeral) explains that this is just splitting the difference between models that take it out to sea, and models that bury it in the mid-Atlantic. It's far too soon to know what will happen, but regardless they are predicting a lot of flooding rain and onshore wind.

That will cause a lot of damage, and maybe kill some folks, but it would be a lot less if congress didn't spend your money to encourage people to build houses in places where they will inevitably be destroyed. The National Flood Insurance Program is incredibly stupid for many reasons. Here, according to the General Accounting Office, is the first one:

The National Flood Insurance Program (NFIP) is a key component of the federal government’s efforts to limit the damage and financial impact of floods. However, it likely will not generate sufficient revenues to repay the billions of dollars borrowed from the Department of the Treasury (Treasury) to cover claims from the 2005 and 2012 hurricanes or potential claims related to future catastrophic losses. This lack of sufficient revenue highlights what have been structural weaknesses in how the program is funded. While Congress and the Federal Emergency Management Agency (FEMA)—the agency within the Department of Homeland Security (DHS) responsible for managing NFIP—intended that NFIP be funded with premiums collected from policyholders and not with tax dollars, the program was, by design, not actuarially sound. As of December 31, 2014, FEMA owed the Treasury $23 billion, up from $20 billion as of November 2012. FEMA made a $1 billion principal repayment at the end of December 2014—FEMA’s first such payment since 2010.

Another reason it's stupid is that it uses private insurance companies as intermediaries, rather than administering the program itself, and like all corporations, insurance companies are evil and they screw claimants even as 40% of premiums go to administrative expenses, most of that paid "to private insurance intermediaries who sell and manage flood insurance policies on behalf of the federal government but do not bear any risk."

Finally, of course, the sensible thing to do would be to retreat from the rising seas and allow salt marshes and barrier beaches to replace the shore front developments which keep getting wiped out and rebuilt with taxpayer dollars. That would also be good for the marine ecosystem, since the destruction of those regimes has meant loss of spawning grounds and marine biomass production. In the long run, it's inevitable.

But you know, people are stupid.

The Political Chronosynclastic Infundibulum

You Vonnegut fans know that is a distorted region of the space-time continuum where all possible opinions are true. Hmm.

Donald T. Rump continues to have a dominating lead among likely Republican primary voters even though, according to PolitiFact (yeah, yeah, they should fact-check themselves more often) of 100 statements by Trump they have fact checked, they find not one to be completely true and only 5 to be mostly true -- and those are mostly insults of other Republican candidates.

While Mitt Romney was running for president, he told 533 lies in 30 weeks. Yeah, he lost by 3% in the end but it wasn't because of lying, which the corporate media completely ignored.

Carly Fiorina just keeps repeating her lie about the "Planned Parenthood" video, which has a) nothing to do with Planned Parenthood, b) probably wasn't even made in the United States and c) does not depict an abortion but a non-viable pre-term delivery.

Obviously none of this matters to Republican voters, or to CNN or NPR. It doesn't matter if it's true, according to Cokie's Law, what matters is that "it's out there." In 2012, the New York Times "public editor" questioned whether the newspaper should be a "truth vigilante." It isn't the job of reporters to point out when politicians are lying, it's their job to channel the lies.

We are seriously screwed.

The Crazy Party

I'm finding it hard to blog these days because the country has simply gone mad. As Jonathan Chait tells us all too patiently and calmly, the U.S. Republican party is the only major political party on the planet that denies the reality of climate change and insists that nothing can or should be done about it. Obviously there are conservative parties all over the world, but not one of them takes that position -- even though many of them are in countries that have important fossil fuel sectors. (Of course the Middle Eastern monarchies don't have political parties per se -- he's talking about countries with representative government.)

As Chait also points out, even classic libertarianism recognizes the existence of environmental externalities and that there is justification for building them into the price structure. In other words, a carbon tax would be the conservative solution to climate change, in a sane conservative party.

Then there's universal health care, which is universally supported outside of the U.S. There's, you know, evolution. The cold fact that U.S. military power is limited in what it can achieve. That most people who get nutrition assistance are in fact working (or children or disabled) but their jobs don't pay enough to keep them fed. That fetuses are not babies. I could go on but these people are just completely nuts, and they control our legislative branch, most state legislatures, and get completely respectful treatment by the corporate media.

We are, in other words, in very big trouble. And I'm not sure how we got here.

More on the People's Car

Belle Waring agrees with me that a lot of VW employees must have known about the rigged emissions tests. The commenters, most of whom as far as I can tell don't have any particular expertise, are of varying opinions about that, with some claiming a small group of software engineers could have done it. I don't buy that, because the engineers who designed the engine would have known perfectly well what it was capable of. And executives, regardless of whether they came out of engineering or marketing or manufacturing, would have to know enough about the technology to have a pretty good clue, even if they maintained plausible deniability.

So CEO Martin Winterkorn, who either knew or didn't know, whichever you think is worse, walks away with at least $32 million and maybe twice that much. The poor man, he's out of a job. On the same day we learn that VW rigged the emissions test on 2.8 million vehicles in Germany.

"The manipulation of diesel emissions by Volkswagen is forbidden and illegal, there's no doubt about that," Alexander Dobrindt, the government's top transport official told lawmakers.

So guess who is going to pay for this world historical psychopathy. Employees who will be out of work as the company's sales collapse, shareholders who obviously knew nothing about it, and the thousands of people who are sick or dead from breathing UFP and NOx. Also the owners of the vehicles, whose property is now worthless and who may not even be able to get their registrations renewed.

Meanwhile, a woman is doing ten years for taking a single valium.

Fuckoververgnugen

I'll get to the evil part in a minute, but first I have to say that the stupidity of Volkswagen's executives is incomprehensible. Obviously they were going to get caught eventually. While corporate psychopathy is the norm, the billions of dollars drug companies make from fraudulent research and illegal off-label marketing far exceeds the fines they end up paying. They don't care about their brand image because people don't buy prescription drugs for the brand name, their doctors prescribe them.

This is different. VW is going to end up losing far more than any ill-gotten gains from selling a few more cars than they might have otherwise. I must also note that hundreds, if not thousands of VW employees must have known about this, but nobody ratted them out. That speaks to German efficiency and discipline, for sure.

Now, as for the evil part. I know that your average Republican thinks that regulating tailpipe pollution is tyranny, and that we have a God-given right to breathe oxides of nitrogen and ultra-fine particles. But here's the cold truth from my friends Doug Brugge and Wig Zamor. "PM2.5" means particles smaller than 2.5 microns. When motor vehicle fuel burns (gasoline or diesel, but diesel somewhat more so) vapor comes out of the tailpipe which then condenses into tiny particles -- you could call it hydrocarbon steam. Here's what Doug and Wig have to tell us:

[T]he most recent estimates still suggest that more than 100,000 Americans die each year, mostly from cardiovascular disease, from breathing in the (reduced) levels of PM_2.5 that remain in our air. Indeed, PM_2.5 appears to have health consequences similar to the effects of second hand smoke, an exposure that the public will no longer tolerate.

Most Americans are unaware that particulate pollution is the single most deadly pollution they face (and the pollutant of greatest economic consequence). Nor is there much awareness that existing regulations are inadequate. EPA is likely to propose lowering the PM_2.5 standard modestly as part of a legally mandated review, a reduction that would save lives, but not eliminate the hazard. Despite the cautious nature of this proposal, EPA is under attack for “killing jobs” rather than lauded for trying to saving lives.

So the regulations aren't stringent enough, but VW was grossly violating them. That means they were killing people. For money. Throw the bastards in jail.

You may become obssessed .. .

. . . with the open tree of life. The link leads to a page which you may find to be unprepossessing, but it is in fact the very broad outline of the evolutionary relationships among the three major kingdoms of the terrestrial biota. On the left is a node labeled "cellular organisms," which represents the last common ancestor. You will then see three more levels -- bacteria in the middle, archaea at the top, and scroll down for the eukaryotes. Click on a node and it expands to show the relationships further out on the tree, and of course you can keep going.

Want to find yourself? Click as follows: Eukaryota --> Holozoa --> Metazoa --> Bilateria and Placazoa --> Deutorostomia and Protostomia --> Tunicata and Chordata --> Vertebrata --> Euteleostomi --> Tetrapoda --> Amniota --> Mammalia --> Theria --> Eutheria --> Euarchontoglires --> Primates --> Happlorhini --> Simiiformes --> Cattarhini --> Hominidae --> Homininae --> Homo.

But you can digress anywhere along the way. This is dry stuff I suppose, and you won't know what most of the words mean, but they have a lot of other resources to explore. Just click around! Check out the blog, and the more accessible educational sites under construction.

This is put together from innumerable studies and is always growing. Right now it lists 1.8 million species, and all of their proposed evolutionary relationships. It took more than 3 billion years for all this to happen, but we've figured a lot of it out.

Aren't you lucky that you have the curiosity and imagination to understand and explore this, and don't have to live in the narrow, cramped world of creationists? This is the truth folks, and it's wondrous.

This is seriously ugly

And, it concerns my employer. A study published in 2001 reported that the anti-depressant paroxetine was safe and effective for treating depression in adolescents. Long story short, it isn't either one. The trial failed to show any significant benefit over placebo, and it failed to report on the very troubling association of paroxetine with increased suicidality and self-harm.

Although many critics recognized that the trial did not seem to support the conclusions, two million off-label prescriptions for the drug were written for children and adolescents in 2002 alone. In 2012, GlaxoSmithKline, the study's sponsor and the drug's manufacturer, paid a $3 billion fine for several criminal violations regarding off-label marketing, the most important of which pertained to paroxetine.

The occasion for this post is that the BMJ has published a re-analysis of the data establishing with precision and rigor that the original report was fraudulent. But, the journal has not retracted it, despite many calls to do so over the years, and the principal author's university has taken no action whatsoever and has stonewalled all inquiries. That happens to be Brown University.

There is a "circle the wagons" mentality in academia, unfortunately, which does a disservice to the public and to the mission of the university, obviously; but also to our students, and to our investigators who work with integrity. I'm disappointed to find it here.

Food for Thought

The online journal Democracy is one of the best free things on Your Intertubes. The new edition is up and as always, I recommend you check it out. While there are several far more important issues I could comment on, for now I'll riff off of Michael Tomasky's speculations on the future of Foobaw.

Like Tomasky, I'm a lifelong fan. It's just something Americans with Y chromosomes absorb through the pores, and I was into it as a little kid. But now that we know it's turning the players' brains into oatmeal, we have a major problem. We tell ourselves that the new concussion protocols that sideline players until their symptoms clear up will fix it. Well, at least with new rules and stricter enforcement to reduce the frequency of brain injuries. And maybe having kids start later, and have less full-contact practice, and new helmet designs . . .

But maybe not. Probably not. It's not just symptomatic concussions that cause problems, it's the cumulative effect of unnoticed milder head bumps. Maybe the proportion of players who end up with encaphalopathy and Parkinson's and Alzheimer's and chronic depression will be lower, but we don't actually know how much lower it can be. Can we comfortably sit in our living rooms snarfing down nachos, knowing that some substantial percentage of the young men performing for our mindless titillation are going to end up veged out or shooting themselves? Yes, this is a problem.

Tomasky envisions future political consequences, not only because of this minor question of traumatic brain injury but also because of the legal and ethical issues swirling around the college football business model and the compensation of college players. He foresees blue states banning first youth football, then high school football. And NCAA football with players getting paid can only work where there's enough revenue, and that mostly means the South and redder states of the Midwest. (Actually he does make one mistake, I think, which is that the liberal Pacific coast could probably sustain big-time NCAA football at such institutions as USC and Oregon.)

The result, Tomasky fears, is that working class families will blame liberals and Democrats for destroying their beloved cultural heritage. I think that's quite speculative, but I do see foobaw becoming more of a divisive cultural and political issue. As if we needed another.

Still, I'll be watching on Sunday.

Alternate Reality?

CBS News is not normally my go-to source but this description of the scene at the Rowan County courthouse makes me feel like I'm there, so props to the anonymous scribe.

Because most people are religious in some way, and I am unable to comprehend religious experience or understand why anybody would literally believe in religious teachings, I suppose I must have a form of disability. Maybe it's an autistic spectrum disorder. And it's not for lack of a proper education. My uncle was a minister and my mother taught Sunday school. We went to church every Sunday, I was in the Christmas pageants and I was even thinking about confirmation and then it occurred to me that it is all a total crock. Which should be obvious to anybody.

Let me just make a few points to Ms. Davis and her fans, which I'm sure would bounce off them like nerf balls. But what the heck.

In the first place, if God in fact doesn't like homosexuals (despite having, you know, created them) and doesn't want same sex couples to marry, why do you have to get involved? Can't God take care of his own problems? If all these sinners go to hell or whatever, it doesn't affect you. God's on the job, right?

In the second place, how do you know what God wants you to do? If you find it in the Bible, he wants widows to marry their brothers-in-law, as a second, third, or fourth wife. Also, men can have sex slaves ("concubines") in addition to their wives. So what are you planning to do about that?

In the third place, just for one example, same sex marriage has been happening in Massachusetts since May 17, 2004, and so far God has not gotten around to smiting what remains one of the most prosperous places on earth.

I do not see how anybody can avoid noticing that religion is just made up. There are thousands of different religions and not one of them has any way of distinguishing its truth claims from the claims of any other. The only reason you pertain to any given religion and believe what you believe is because you were indoctrinated as  child. The person next to you was indoctrinated differently, and therefore has a different religion. It's completely arbitrary. Some Christians think same sex marriage is fine. God hasn't smitten them either.

I could go on but I just don't get it. What I am proposing here is just common sense. How can anybody with an otherwise functional brain not see it?

Exodus

Our dean has asked us for our thoughts about the refugee crisis currently afflicting the world and what the School of Public Health can do about it. I'm not sure how to answer because this is, obviously, fundamentally a political problem, with three major dimensions.

It doesn't take any particular public health expertise to see that, in the short term, the 60 million or more refugees on the planet, need water, food, shelter and sanitation. As Nicholas Kristof points out today, regarding those 650,000 or so refugees currently causing so much turmoil in Europe, you ain't seen nothing yet if the UN can no longer feed the millions of Syrian refugees in Lebanon, Turkey and Jordan. Which it basically can't -- the World Food Program just cut off 229,000 refugees in Jordan because it ran out of money. So that's dimension number one. The multiple crises, with Syria and Iraq being the worst but far from the only major ones, are draining the coffers of the international humanitarian infrastructure. If the millions of people currently harbored in the countries neighboring Syria all get desperate enough to try to make it to Europe or somewhere, anywhere, that they can survive . . .

So that's the second political problem. Ultimately, we can't warehouse all these people in wretched tent cities and truck in flour and cooking oil to keep them biologically alive. They need to be settled in communities, as human beings, with the chance to make a living and make a home. But the influx is, predictably, bringing out the worst as well as the best in people. It's obviously bringing out the worst in Americans. John Kerry says we should accept 100,000 people next year, but don't hold your breath. Not when this is happening.

Kristof touches on the third political problem: we have to stop the war in Syria, and while he doesn't say so, obviously by extension the various other circumstances around the world that are forcing people to flee their homes. Patrick L. Smith has something to say about that. The Syrian civil war, the Afghan civil war, the anarchy in Libya, the desperate poverty in central Africa and Central America that have brought about civic collapse -- these are all the legacy of colonialism and neo-colonialism, the presumption by European civilization that it can and should run the world. This is a lot of complicated history and it's not the story we are taught in school or see on the nightly news. While Kristof is obviously right in principle, I very much doubt that the western powers will ever try the right solution, which doesn't involve freedom bombs or giving weapons to "moderates," meaning our bastards --  until they turn on us.

Oh yeah, climate change. It was actually drought that precipitated the Syrian civil war. If you think 60,000,000 refugees is a lot, just you wait.

The New Jim Crow

I didn't have today off, actually, because I facilitated what they call a "first reading" seminar for incoming freshmen. This is something a lot of schools are doing nowadays. The admitted students are all given a book assignment and then they meet with a prof to talk about it before classes start. Partly it's just an ice breaker -- a way for people to meet, get a little bit comfortable with college level discourse before there starts to be competitiveness and grade pressure, and an introduction to how professors interact with students.

In this case, there was I think an additional agenda. Brown is trying hard not to be the bastion of privilege and finishing school for the ruling class that Ivy League universities have been. Most of the kids still do come from privileged backgrounds, and they maybe need some consciousness raising; and at the same time the university is more diverse than it once was and the community has experienced tensions of various kinds, meriting discussion about racial, ethnic and other kinds of diversity and attendant prejudice from jump street. So this year the assignment was The New Jim Crow by Michelle Alexander.

If you haven't read it, or heard about it, it's a solid argument with a few moving parts that essentially views the War on [some classes of people who use some] Drugs as a mechanism of racial oppression, pretty much the essential means by which the racial caste system in the U.S. has been maintained after the passage of civil rights legislation and the elimination of de jure segregation. The great virtue of it, for this purpose, is the appearance of color blindness. It's not about race, it's about crime.

If you aren't conversant with these issues, or don't believe it, I won't take the bytes here to try to explain the entire argument. I will point out, however, that a) most people in jail or otherwise under criminal justice supervision are drug offenders only, users or low-level dealer/users; b) the vast majority of them are Black or Latino; c) the vast majority of low-level drug dealers and users are white.

If Weston, Massachusetts were policed in the same way as Harlem, with the police randomly stopping and frisking young men and searching motorists' cars, and then charging the people with felonies if they found marijuana or other illicit drugs, a whole lot of rich white high school kids and many of their parents, for that matter, would be felons. And in case you didn't know it, felons are largely unemployable, ineligible for public benefits, can't serve on juries, and can't vote. In some states, all of that is true for the rest of their lives.

This is true and cannot be denied. And that is why Weston and Harlem are not policed in the same way. Furthermore white high school kids who smoke pot or use ecstasy are not perceived as criminals, and they aren't treated like criminals even if they do somehow have the misfortune to be caught. But Black kids the same age, doing the exact same things, are, thereby destroying their lives.

Word.

This is very simple

If it's against my religion to sell bacon, I can't work in a bacon store. That's why Jehovah's Witnesses don't work for the blood bank.

The End

A brief digression about the Iran deal

Okay, I'm not exactly an expert on everything but I have followed the Middle East very closely for more than 25 years. Now that Barbara Mikulski has endorsed the agreement with Iran, it will happen -- Congress has no path to block it. But I'll let you in on a little secret -- they were never serious about blocking it in the first place. The entire "debate," as it is presented in the corporate media and indeed, by politicians moving their lips, is a shadow play. It isn't about anything they say it is about.

Somehow I got on the e-mail list of the Zionist Organization of America. These people are batshit crazy, which is to say they are in a permanent Vulcan mind-meld with Bibi Netanyahu. They continually bombard my in-box with panic over the existential threat to Israel which supposedly the Iranians have promised to eradicate and Obama just wants to give them the means to do so. So here's the first correction: some Iranian political leaders, notably the former powerless president Mahmoud Ahmadinejad, have made statements to the effect the state of Israel should not exist. This does not mean that the population of Israel should be annihilated, it means that the political entity should be replaced by a secular state. However, even if you think that the Iranian leadership would wish, for some reason, to attack Israel with a nuclear weapon . . .

Israel possesses from 100 to 200 nuclear weapons -- I'm betting on 200 -- and the means to deliver them by missile and bomber. Were the Iranians to smuggle a primitive nuclear weapon into Tel Aviv (obviously Jerusalem and anywhere near it, along with any location that could affect Gaza or the West Bank are completely immune no matter what you think about Iranian intentions) and detonate it, the Iranian nation and Persian culture would very shortly cease to exist. Every city, every shrine, every military installation, every ayatollah, would be vaporized. The only Farsi speakers left in the world would be expatriates. Full stop.

So, Bibi and the ZOA are not in fact worried about that. They also know perfectly well that without a deal, Iran will go ahead and make a nuclear weapon, probably within a year or two. So what is this really all about?

They do not want Iran to rejoin the community of nations. They want the sanctions regime to remain in place, forever. They would not accept any deal, of any kind, no matter it meant for the Iranian nuclear program, if it allowed Iran to freely sell its oil on the international market and participate in the international financial system. You may think this is a legitimate goal, but it is also unachievable because Russia, China and probably most of Europe would not go along with it, and the U.S., by itself, cannot impose meaningful sanctions on Iran.

Except for a few deluded wingnuts, the Republican congressional leadership knows this. Were they to succeed in stopping the deal, the sanctions regime would fall apart, Iran would make a nuclear weapon, and oh yeah, the dollar would no longer be viable as an international reserve currency because it could not be used to purchase Iranian oil. That would probably not make the Republicans or the ZOA look very good.

That is all.

Sunday Sermonette

Scientific American just came out with a special issue celebrating the 100th anniversary of Einstein's publication of the theory of general relativity. Special relativity, the description of the space-time continuum, the speed of light as a cosmic speed limit, and the equivalence of mass and energy, came 10 years earlier, in 1905. General relativity is the theory of gravity, which Einstein struggled with in the intervening decade.

I'm not a physicist so I would say that I barely have an intuitive understanding of this stuff. But I know enough about how physicists and cosmologists, with the information provided by observational astronomers, have put together the pieces of the puzzle that produce our modern understanding of the universe to believe it.

But a lot of people don't. I can understand why. First, the physicist's universe is sharply contrary to our intuitions and our experience. If you tell people that mass warps space and gravity slows time, that light is bent by gravity and that mass increases with acceleration, for example, it just sounds nuts.

More important, when we discovered the cosmos, the revelation destroyed the entire history of philosophy and culture. Many scientists are reluctant to say it, and some haven't accepted it, but religion -- at least anything resembling religion as we know it -- cannot survive cosmology. You can make up some new meaning for the word religion, I suppose, but Islam, Christianity, Buddhism, Hinduism, Zoroastrianism, you name it, are all destroyed. To believe any of them, you must believe that the actually existing universe does not exist.

Disposed with the bathwater of mythology is the baby of meaning. No, God doesn't care about us - or exist, for that matter - and we don't matter at all to any entity but ourselves.  Many people just can't live with that. The challenge for the cause of reason is to help them find a way.

Your tax dollars at work

Apparently having nothing better to do, the Department of Justice is prosecuting executives of Rentboy for promoting prostitution. Let us stipulate that yes, in spite of disclaimers on the web site, that is essentially what they do. But really, who cares? Let's see what the harm reduction coalition has to say:

The criminalization of sex work fosters violence, stigma, and marginalization. Harm Reduction Coalition affirms a harm reduction approach to sex work which prioritizes creating conditions that provide sex workers with information, support and resources that allow them control and autonomy over their labor to reduce their risks for violence, trauma, HIV, and other harms.

Now, I realize that it isn't all that simple. Many sex workers, actually most of them in some settings, are exploited, even enslaved. Others say they are making a free choice, which is obviously a matter of degree depending on their alternatives for making a living, but that's true for just about everybody who does what they may find to be unpleasant work.

And, if you want to stop exploitation and sex trafficking, and you want to improve working conditions, the first thing you have to do is legalize it. That way, you can regulate it, with licensing, safe sex regulations and regular testing requirements, workplace safety and wage law enforcement, regulations to protect quality of life and property values for neighbors, even the possibility of workers organizing. That's what they do in much of Europe, with variations on the theme, and it seems to work pretty well.

Yes, I find it icky and I have no interest in participating. I don't even understand it. But it's never going away, so let's try to make it better. This DoJ action is just stupid. Now, if you're looking for a male sex worker in Providence, you have to go down by the wind turbines and find somebody on the street. Lots of bad things happen that way. 

Abolition

I'm not sure why I didn't get around to commenting on this earlier. As most will know, the Connecticut Supreme Court recently commuted the sentences of the 11 men on the state's death row.

This was an unusual situation in that Connecticut no longer imposes the death penalty, by statute. However, the legislature made the change only prospectively, meaning that crimes committed before the legislation were still subject to the penalty, and that existing sentences of death were still in effect. (At the time, there were 10 death row inmates. A later conviction for a crime committed before abolition added an 11th.)

The reason for this temporal distinction is telling. It is because the legislators felt it would be politically inexpedient to commute the sentences of two death row inmates, Steven Hayes and Joshua Komisarjevsky. For those who don't recognize the names, they are the perpetrators of the July, 2007 Cheshire home invasion, a crime sufficiently notorious that the phrase is essentially a proper noun. There's no particular reason for me to link to information about it, you can easily find it if you are interested. I wrote about it here quite extensively at the time.

That these two men, specifically, were the reason the legislation was not retroactive is indubitable. That was very much in the center of the political discourse at the time, as this contemporaneous account describes:

House Republicans, the minority party in the chamber,  focused heavily on how the bill is supposed to affect only future crimes and not the 11 men currently on death row, including the two men recently sentenced to death for killing a mother and two daughters in a gruesome home invasion in Cheshire. Joshua Komisarjevsky and Steven Hayes have been sentenced in the last two years to death row for killing Jennifer Hawke-Petit and her daughters, Hayley and Michaela.

 The question is why the debate was about this particular crime. Of the other inmates on death row, some had killed white people. (Sadly, that usually matters to public attitudes.) Some had tortured their victims. Some had multiple victims. At least one had raped and murdered a child, as did Komisarjesky. What was different about this case?

It was more recently in memory, but I think the main reason it got so much publicity and had so much political resonance was that it represented the invasion of an affluent, sheltered suburb by forces people presumed were confined to what to them was an alternate universe. Crimes like this happen in other places, and people in Cheshire don't pay much attention to them.

The Supreme Court's rationale in overturning the remaining sentences is hard to argue with. If the legislature, with the concordance of the public, no longer believes that capital punishment is appropriate, there is no reason why it would be appropriate for people who happened to commit their offenses before an arbitrary date. If it's in applicable to some, it is inapplicable to all.

Presidential candidate Lindsey Graham was exactly specific -- the outrage pertains to Hayes and Komisarjevsky, not to the other nine:

“Makes me want to throw up. Makes me want to throw up when I hear that putting these two guys to death for what they did to that family is somehow outside of the standards of decency,” Graham stated Monday to radio host Michael Medved. . . . If this doesn’t cry out for the death penalty nothing ever would and I don’t think you’re an indecent society when you take two men who broke into a family’s home, tortured two young girls, raped them, burned them alive — I don’t think that makes us indecent that they would be administered the death penalty,” declared Graham.

Well here's the bottom line. If you are for abolition, you are for abolition. Here there is no question of guilt, no evident extenuation, no question of insanity or capacity, and a crime of unimaginable depravity. But there's nothing to be gained by sinking to their level, like Lindsey Graham. We are better than that.

PS: Hayes has since claimed to be a serial killer and described killing 17 women and girls. The authorities have dismissed this as a fabrication. Prior to the event, both killers had extensive records of burglary and theft, but no convictions, or arrests, for violent crimes. Their parole to a halfway house -- where they met -- also became a political issue and resulted in some retrograde legislation. But that is for another day.

An avoidable catastrophe?

This is an observational study only, and it doesn't completely answer the question, but this analysis in JAMA Oncology certainly poses one. Understanding this is a bit complicated, and remember, I'm not a real doctor, I'm a doctor of philosophy, but let me tell you what it means to me.

Narod et al used a registry called the Surveillance, Epidemiology and End Results (SEER) database to see what happened over 10 and 20 years to women who were diagnosed with so-called Ductal Carcinoma in Situ (DCIS). These are clusters of abnormal cells inside the milk duct. Until the widespread use of screening mammography, they were essentially never detected. There's no lump to feel and no symptoms. But since mammography grew more and more sensitive, radiologists started seeing them frequently.

When one is found, the woman is told that she has breast cancer and the alternatives are presented as lumpectomy -- just removing the lesion, but it's a misnomer since there is no lump -- or total mastectomy. Some women have both breasts removed just to be on the safe side. And often they undergo radiation "therapy" as well.

But is this really cancer? And is it really the case, as assumed, that this is how breast cancer begins and these often go on to become invasive and then metastatic? What would happen if they weren't treated and we just waited?

Well, this study can't directly answer the last question because just about every woman with the diagnosis was treated. But it can tell us a few things. The easiest thing to understand is that the choice of treatment -- lumpectomy with or without radiation, or mastectomy -- made no difference in the risk of ultimately dying of breast cancer. The second observation is that Black women were at higher risk than white women of ultimately dying of breast cancer, but there didn't appear to be any difference in how they were treated, so the explanation for this is unknown.

The third observation is that invasive cancer could appear even after mastectomy. While a later occurrence of invasive cancer was associated with higher risk of death, the overall risk for these women was the same as the risk in the general population -- no higher and no lower. The exception is women who were diagnosed with DCIS at a young age. It is also the case that overall, the incidence of invasive cancer in the population has not gone down since doctors started treating DCIS.

What this suggests -- although it doesn't prove it -- is that DCIS is not in fact associated with a higher risk of ultimately getting clinically significant breast cancer, and the best thing to do is just watch and wait. There are other indications from observational data that these lesions often spontaneously remit or just sit there. What this would mean is that tens of thousands of women every year are subjected to fear, disfiguring surgery and frequent complications, at a cost of billions of dollars, for no benefit.

Right now few women are choosing to forego treatment and few doctors are recommending it. But in my view, this does create the so-called equipoise necessary to ethically undertake a randomized controlled trial, if enough women would enroll in it. If the suggestion turns out to be true, we have inflicted major damage on millions of people. Now, surgeons will find it very hard to live with that conclusion I am sure and they will certainly resist it. But it has to be considered.

Uglier and Uglier

The Trump phenomenon might have seemed amusing at first, but it's no joke now. Here's Ezra Klein on the only detailed policy proposal the blowhard possessor of inherited wealth has produced so far. In essence, it views illegal immigration as a collective crime of the Mexican people, and proposes to collect money from legal Mexican migrants and people who cross the border for legitimate reasons; and from people who send remittances to their families, in order to build his wall along the border. He also would withhold federal benefits (I'm guessing this means the earned income tax credit and dependent deductions, though Klein doesn't specify) from the undocumented parents of children who are U.S. citizens, in order to drive them out of the country. And he would implement various measures that would make it nearly impossible for people to gain asylum or refugee status.

Most undocumented immigrants, in fact, do not cross the border illegally. Rather, they overstay visas. And of course only half of them are from Mexico, and that number is declining. So singling out Mexico and Mexicans is obviously racist -- and it's worse than that since Trump insists that the Mexican government is somehow intentionally "sending" people, and selecting criminals, which is idiotic.

Trump also wants to eliminate birthright citizenship. This was originally established by the 14th Amendment for the benefit of freed slaves, but it is essential in the present context as well to prevent the creation of a subordinate caste. Look at the Dominican Republic, where Haitians who may be second or third generation residents are now threatened with deportation, and have never gained citizenship. Stateless populations of this kind also exist in many other countries, notably in the Middle East and Africa. Do we really want this here?

But we all know that Trump is a psychopath. What is terrifying about this is that it has only increased his popularity, and that other Republican candidates are lining up to endorse these proposals. It's a very sorry reflection on our culture and values. I have led a sheltered life with limited exposure to the racism at the dark heart of the United States. But that's what we are. 

Lead and Crime

It seems too pat, too reductionist, but the evidence is very powerful that childhood lead exposure has been the single most powerful driver of crime rates since the early 20th Century. The teevee still leads every night with the most lurid crime stories they can find, so the general public isn't aware of it, but the rates of violent crime, homicide, and burglary have fallen steadily and dramatically in the United States since the 1980s. Furthermore, rates of offending by young people have fallen even more sharply.

Yes, the criminal justice system continues to be racist and highly disproportionate numbers of Black and Hispanic people are incarcerated. But the prevalence of criminal justice involvement, even among minorities, is way down from its peak. This dramatic phenomenon is partly obscured by the continued high arrest and incarceration rates of older men. As Rick Nevin tells us in the linked post, from 1991 to 2013 the juvenile arrest rates fell by 63% for violent crime, and 71% for property crime. This can be entirely explained by exposure to lead from gasoline and paint.

As a sociologist, I have of course been attracted to all of the theories about the effects of poverty and cultural milieus and discrimination and how the removal of jobs from the inner city and the legacy of slavery and the punitive responses of the state and what have you created the school to prison pipeline. And while all those are no doubt exacerbating factors, none of them has been fixed, and yet this miracle has occurred.

There is of course much more to this story. Industries that used lead fought just as hard as the tobacco and fossil fuel industries against the science, and succeeded in continuing to poison children for decades. But courageous scientists persisted and the result is a much better world. Keep that in mind as Republicans continue to inveigh against environmental regulation.  Sometimes it really is just that simple.

From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.Q10VWmMv.dpufFfr

The crime decline in recent years has been slower than the earlier decline in blood lead because steep arrest rate declines for youths have been partially offset by rising arrest rates for older adults. From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime, as arrest rates for adults ages 50 and older increased. In absolute terms, the violent crime arrest rate for juveniles was twice the rate for ages 35-49 in 1991, but the juvenile rate was lower in 2013. The property crime arrest rate for children under 10 was about the same as the rate for ages 35-49 in 1991, but the 2013 rate for children under 10 was just 7% of the 2013 rate for ages 35-49. - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.EZIGO3ET.dpuf

The crime decline in recent years has been slower than the earlier decline in blood lead because steep arrest rate declines for youths have been partially offset by rising arrest rates for older adults. From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime, as arrest rates for adults ages 50 and older increased. In absolute terms, the violent crime arrest rate for juveniles was twice the rate for ages 35-49 in 1991, but the juvenile rate was lower in 2013. The property crime arrest rate for children under 10 was about the same as the rate for ages 35-49 in 1991, but the 2013 rate for children under 10 was just 7% of the 2013 rate for ages 35-49. - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.EZIGO3ET.dpuf

The crime decline in recent years has been slower than the earlier decline in blood lead because steep arrest rate declines for youths have been partially offset by rising arrest rates for older adults. From 1991-2013, arrest rates for children under 10 fell by 83% for violent crime and 94% for property crime, and juvenile (under 18) arrest rates fell by 63% for violent crime and 71% for property crime, as arrest rates for adults ages 50 and older increased. In absolute terms, the violent crime arrest rate for juveniles was twice the rate for ages 35-49 in 1991, but the juvenile rate was lower in 2013. The property crime arrest rate for children under 10 was about the same as the rate for ages 35-49 in 1991, but the 2013 rate for children under 10 was just 7% of the 2013 rate for ages 35-49. - See more at: http://www.humanimpact.org/from-the-hip-blog/lead-poisoning-and-crime-why-the-pipeline-to-prison-is-running-dry/#sthash.EZIGO3ET.dpuf

11.2 billion?

The UN has released a revised projection of global population and they now project that there will be 11.2 billion humans alive in 2100. They expect the most rapid growth in the poorest regions:

Population growth remains especially high in the group of 48 countries designated by the United
Nations as the least developed countries (LDCs), of which 27 are in Africa. Although the growth rate of the LDCs is projected to slow from its current 2.4 per cent annually, the population of this group is projected to double in size from 954 million inhabitants in 2015 to 1.9 billion in 2050 and further increase to 3.2 billion in 2100. Between 2015 and 2100, the populations of 33 countries, most of them LDCs, have a high probability of at least tripling. Among them, the populations of Angola, Burundi, Democratic Republic of Congo, Malawi, Mali, Niger, Somalia, Uganda, United Republic of Tanzania and Zambia are projected to increase at least five-fold by 2100. The concentration of population growth in the poorest
countries will make it harder for those governments to eradicate poverty and inequality, combat hunger and malnutrition, expand education enrolment and health systems, improve the provision of basic services and implement other elements of a sustainable development agenda to ensure that no-one is left behind.

I've got news for you: if there's no way to feed those people, they won't be there after all. And I've got more news for you. The global population is concentrated in coastal areas and those people are going to have to move. At the same time, the hottest regions will become uninhabitable and the distribution of arable land and climate appropriate for particular crops will shift. There will be serious water shortages in many places. The result will be civil conflict, famines, and likely uncontrollable epidemics. So no, there won't be 11.2 billion people. There can't be.

The question is how we get to the lower number that is actually going to happen. The options are fewer babies, or more premature deaths. That's it. Take your pick.

Eliminate AHRQ?

I don't know how I missed this but it seems the current version of the budget for the Department of Health and Human Services currently making its way through congress totally eliminates the Agency for Healthcare Research and Quality. This is as deep as the Republicans have ever sunk into yahooism.

As Jeffrey Lerner explains:

AHRQ funds the studies and systematic reviews that objectively evaluate how well clinical procedures, quality approaches, and consumer satisfaction work. But AHRQ's approximately $400 million annual budget does more than pay for studies. It helps fund what has been the missing link of American health care: what treatments work best and how errors can be prevented.

It won't do any good for NIH to fund the development of new medical technologies and treatments if the health care system fails to deliver accurate diagnosis and the competent decision making and administration of treatment. That's what AHRQ is all about -- improving the delivery of health care. And believe me, there is a lot more potential there to improve patient outcomes, more quickly, and for less money, than there is in basic biomedical science. If we aren't doing what we already know we should be doing, we're wasting all of our research dollars.

This isn't the first time this has happened. AHRQ is the successor to the Agency for Health Care Policy and Research. In 1993, when an AHCPR panel concluded that surgery should not be a first line treatment for low back pain, back surgeons succeeded in getting congress to vastly downsize the agency and limit its mission. Really. And useless, expensive and dangerous back surgery continued to be performed for decades.

I must disclose that I personally have a proposal before AHRQ, to study diagnostic error in primary care. Don't you think its worthwhile reducing the incidence of misdiagnosis? Wouldn't you like to have more confidence that your doctor won't misdiagnose you? Or would that be a waste of taxpayer money? Think about it, then write your congressperson.



 

Strife and woe

I'm working on a project now which has to do with measures a certain state's Medicaid program wants to use to reward primary care providers for quality. For various reasons, which I may get into more deeply in the future, these measures are never really great. They basically reward care processes, in this case giving certain lab tests to people with diabetes, and that can get providers falling all over themselves to do things that shouldn't necessarily be the highest priority for a patient, plus getting dinged for circumstances beyond their control.

But my mission isn't to worry about that so much, it's to worry about the accuracy of the data. So I've been reviewing electronic medical records at various clinical sites to try to understand the difference between data and reality. And no, they are never the same, we just hope for a knowable degree of correspondence. Usually we don't even have that.

So, if you select for a pre-expansion Medicaid population, old enough to have a high prevalence of diabetes, you are filtering for people who are legally disabled. What you get is incredible co-morbidity. A typical person in my sampling frame not only has a diagnosis of diabetes (although, due to the vicissitudes of data, some of them do not, oddly enough), but also serious and persistent mental illness, COPD, heart disease, kidney disease, substance use disorder, liver failure, maybe HIV and/or HepC, arthritis -- sometimes basically all of the above. Many of them are frequently hospitalized, they are constantly on the brink of homelessness or starvation -- did you know that there is a diagnostic code for insufficient material resources? It's just appalling the afflictions with which so many people live.

So no, they can't take personal responsibility. They are unable to work because they are too sick. But the same hypocritical morons who were screaming about the non-existent death panels in the affordable are act want to leave these people to die in the street. Because they're takers.

A severe economic distortion . . .

is occurring as the store shelves are stripped of popcorn in anticipation of the Great Debate tonight. Actually, 9 guys with indistinguishable policy positions flanking a blowhard bubbleheaded egomaniac and each getting in about 5 minutes of yacking over an hour and a half is not a debate. But if I had the chance to be a disruptive force in political discourse (hopefully without the egomania) here are a couple of offensive gaffes I would kindly offer.

Bibi and the bomb: Benjamin Netanyahu, the Zionist Organization of America, and Mike Huckabee do not give the tiniest shit if Iran gets a nuclear weapon. Israel possesses 100 to 200 nuclear weapons, and the means to deliver them. That's supposed to be a secret that nobody ever mentions. If Iran were to exercise it's purportedly "existential threat" by somehow smuggling its one low yield, untested nuclear weapon into Tel Aviv, the nation of Iran would cease to exist along with every city, shrine, ayatollah, military facility, industrial plant, bridge, highway, railroad, cultural institution and most of the population. Persian culture would essentially become extinct. Everybody knows that.

No, Bibi just doesn't want Iran to have the opportunity to rejoin the international community. He wants no agreement with Iran of any kind, and he wants the sanctions to remain forever. We can argue about why he wants that and why that is or is not a great idea, but that's what this is really all about. If Bibi gets his way, Iran will develop a nuclear weapon. That doesn't bother him.

Investment in health research: Yes, I have from time to time complained about the slow but steady shrinkage of the National Institutes of Health, which is hard on me personally. But you know what? That's not the most important place for us to be investing if we want to have a healthier population. As Ronald Bayer and Sandro Galea lay it out in NEJM, the comparatively poor health of the U.S. population has nothing to do with high tech medicine and everything to do with our severe underinvestment in the social goods that actually determine people's health. As they write:

[T]here is now broad consensus that health differences between groups and within groups are not driven by clinical care but by social-structural factors that shape our lives. Yet seemingly willfully blind to this evidence, the United States continues to spend its health dollars overwhelmingly on clinical care.

Everybody who works in any capacity in public health knows this. It's the central, obvious, undisputed fact of health policy, which is really all policy. Everything we do as a polity directly and powerfully affects people's health, from our tax code to our transportation infrastructure to our law enforcement practices. But we almost never talk about policy that way.

I could throw out a few more. The basic idea is, our political discourse consistently and pervasively misses the point. It's always a feint, a misdirection, from the real issues. Sometimes that's pretty transparent, as with the personality-driven and horse race focused coverage of electoral campaigns. But it's also true when politicians and pundits purport to be talking about substance. It's a shadow play to distract you from everything that really matters. Never forget that.

Note: Sorry for the absence over the past few days. I've been busy. But it should give me a few interesting things to write about.

Hunting

As I may have mentioned once or twice, I live in a rural area and my property abuts state forest -- or, more properly, a "state wildlife management area," which means a wilderness in which hunting is allowed. (In season, with a license, of course.) Hunting deer in the state forest is an arduous endeavor that requires considerable knowledge and skill. The land is rocky and steep, full of brambles and almost impenetrable stands of mountain laurel. It is infested with ticks, mosquitoes, and biting flies. The deer are elusive and they can move through the terrain much faster and more easily than humans.

Nevertheless, guys go up there and take on the challenge. If they succeed, they put food on their table. I'm all for it. I even gave my neighbor permission to pursue them onto my property. There are more deer in New England today than there were when the first English settlers set foot here. With the Indians, cougars and wolves gone, somebody has to hunt them. And hunting animals for food is the natural human condition.

Walter Palmer, however, is not a hunter. The technical term for him is an asshole. He hired some guys to lure a lion with bait, and shine a spotlight on it, so he could stand there and shoot it. Oh yeah -- it was a bad shot, and it took the animal a day and half to die. And obviously, he didn't eat it. I have no idea why anyone would enjoy this activity, and even less how anyone could take pride in by displaying a "trophy." Why didn't he just buy an old lion from the circus, chain it in his back yard, and shoot it there? Seems like pretty much the same concept. It doesn't matter to me that the animal had been given a name, actually. What matters is that the act was utterly pointless.

The worst thing about the problem of climate change . . .

. . . is that it's impossible to adequately express its magnitude and urgency. Here's Joe Romm writing about James Hansen's latest offering, and the measured prose just rolls by. If they were to read that aloud on the nightly news, it would just be too much to register. Want to see what I mean?

[T]he New York Times reported last year on the news of the accelerating collapse of the West Antarctic ice sheet that “The heat-trapping gases could destabilize other parts of Antarctica as well as the Greenland ice sheet, potentially causing enough sea-level rise that many of the world’s coastal cities would eventually have to be abandoned.”

That would include, hmm, let's see -- oh yeah, New York City. But, are Arthur Ochs Sulzberger Jr. and Dean Baquet worried about it? Not nearly as much as they are worried about Hillary Clinton's e-mails. What is to be done?

The sorry state of the "profession" of journalism

Maybe you noticed a few days ago a flurry of news stories about an impending "mini-ice age." I did, on the front page of the CNN and CBS news web sites, among other places. The story claimed that a study predicted a "60% fall in solar activity" by the 2030s, which would produce an effect similar to that of the "Maunder minimum" in the 17th Century, which was associated with a cold spell in Europe.

This was, in fact, totally bogus, as Michael J. I. Brown explains for phys.org (which is a science news aggregation site that you ought to bookmark).

The predicted 60% decline is in sunspots, not solar radiation. The study made no prediction at all about the impact on climate, but:

a) The relative solar quiescence of the Maunder minimum may not have been the main cause of the cold spell in the first place;

b) Any effect of a repeat of a similar solar minimum in the 2030s would be overwhelmed by the higher concentration of greenhouse gases in the atmosphere today, resulting in at most a temporary slowdown in global warming, not a "mini-ice age."

What is most disgraceful about this is that the reporters apparently made the false deduction on their own, after a little Wikipedia research, and without consulting any relevant experts. And of course, climate change denialists jumped all over the completely false story and will, I am quite sure, never give it up.

And now the New York Times, apparently motivated by a corporately pervasive and completely irrational hatred of Hillary Clinton, puts out a false story about her stupid e-mails. Apparently the Justice Department has asked for a criminal inquiry into how a FOIA request for the e-mails was handled, with respect to classified information, and the NYT reporters assumed that the target was Ms. Clinton -- who obviously didn't even work for the State Department at the time the events in question occurred and had nothing to do with them.

Stuff this bad and worse happens every day, of course. It drives me crazy. I didn't go to journalism school, but I know how to get these stories straight. Really, they're just lazy and unaccountable.

My quality of life has greatly improved . . .

by blocking Adobe Flash Player. You must do the same. Life will become so much sweeter.

Brave New World

Prediction is hard, especially about the future, but something is going to happen with the technology called the CRISPR/Cas9 system. I've linked to the Gizmodo summary which is reasonably accessible, but it's very easy to come up with a whole lot more info using your favorite Internet search engine.

In a pistachio shell, this is a fairly new method for editing genes which provides higher efficiency (i.e., percent of targeted cells in which the desired edit is made) and accuracy (percent of cells in which an additional, undesired change occurs) than previous methods. If you're interested, it's derived from an immunologic system in bacteria and archaea that cuts up the genomes of invading viruses.

I was inspired to write about this today because of recent advances that improve the accuracy of the method. Even without fantastic accuracy, CRISPR/Cas9 will transform both biological research and biotechnology. We'll be able to learn a whole lot more about how specific genetic changes affect phenotypes. It will be possible to create designer organisms with much more specificity and detail than can be done today. You can speculate on the possible good and bad that may come of that but . . .
There is a specific organism called Homo sapiens that presents specific concerns. Right now, there is a voluntary international moratorium on genetic engineering of human germ cells and embryos. But, Chinese scientists recently tried it anyway on non-viable human zygotes (specifically, cells made for in vitro fertilization that had 3 sets of chromosomes) to see if they could fix the defect that causes the genetic disease beta thalessemia. They concluded that the technique wasn't ready for use in humans yet because it wasn't accurate enough.

However, what we are seeing today is that it's going to keep getting better. Moratorium or no, international ethical consensus or no, somebody is going to do it. They'll already be making meatier steers and milkier cows and goats that pis rayon. So why not make a smarter or taller or prettier person? It is true that we don't know enough about the multi-genetic determinants of most important human characteristics to do this yet, but we will. And people will do it.

Try to tell me why not.

The TPP: It's worse than you thought

Amy Kapczynski, in the new NEJM (Don't know if you'll be allowed to read the whole thing) manages to exponentially increase my bafflement over president Obama's push to get the Trans-Pacific Partnership signed. Even Paul Krugman has pretty much shrugged at it, saying it's not really a trade agreement, it's an intellectual property agreement, and who cares about that?

As Kapczynski says, the draft is a secret, and even members of congress can only see it if they agree to a gag order and not to carry even a pen into the room. But some chapters have been leaked and, Whoa!

For a bit of background, the only reason it is now possible to provide essential pharmaceutical treatments to millions of people in poor countries is because India, a major center for drug manufacturing, has comparatively liberal provisions on drug patents, not allowing patents for "me too" drugs or new uses of existing drugs. The TPP would outlaw such limits on patents. While India is not a party to the treaty, it is quite odd that the draft targets India's laws, "sometimes word for word" says Kapczynski, given that it is intended to gain additional signatories in the future.

The draft would also essentially override president Obama's own initiative to reduce the "data exclusivity" period (which prevents marketing of generics) for biologicals from 12 years to 7, which would cost U.S. consumers and taxpayers $4 billion over the next decade. Other provisions would also increase drug prices.

And there's this:

In March 2015, a third bombshell dropped: a draft chapter on “investor-state dispute settlement” (ISDS). It would empower foreign companies to sue member countries for hundreds of millions of dollars in damages in a wide range of cases in which they argue that their expected future profits have been undermined. These challenges would be heard by “arbiters” — typically private lawyers, many of whom cycle in and out of industry — with no prospect of independent review by a national court. . . . Firms have already used provisions like these to challenge an astonishing range of laws, from minimum-wage laws in Egypt, to tobacco regulations in Uruguay and Australia, to core aspects of patent law as they apply to medicines in Canada. The ISDS provisions alone could interfere with domestic health policy for decades to come. Under their auspices, policies covering a wide range of issues, from food and tobacco labeling, to patent law, to drug-pricing rules, to environmental protection could be challenged in participating countries — including, of course, the United States.

What are you thinking, Mr. President?

No good options for chronic pain

In some not so good news, the FDA has substantially strengthened its warning on the risk of non-steroidal anti-inflammatory drugs, NSAIDS. Although aspirin is literally a non-steroidal anti-inflammatory, and has overlapping mechanisms of action with these drugs, it is not formally classified as an NSAID, basically because the term is designed to exclude it, as I will explain.

NSAIDS include ibuprofen, naproxen, and celecoxib, which was at one time heavily advertised based on safety claims. These are widely used by people with osteoarthritis and other chronic pain conditions. The problem, as the FDA now concludes, is that they strongly raise the risk of heart attacks and ischemic strokes. The risks are mostly reported in relative terms, so it's hard to pin down the absolute risk for an individual. But the risk is substantial even for people without heart disease or risk factors. And obviously, you really don't want a stroke or a myocardial infarct. The risk increases with dose and duration of use, which means that the kinds of regimens people take for moderate to severe arthritis are the most dangerous.

Aspirin actually lowers the risk of heart attacks and ischemic strokes, which is terrific, but it creates a risk of bleeding, including (comparatively rarely) hemorrhagic strokes and more commonly gastrointestinal bleeds. You might say, well, that's better than a heart attack, and I tend to agree with you, but doctors are very concerned about these events because it can be hard to find the bleeding point and they can be fatal  -- although they can also be fixed and Bob's your uncle. Anyway, for that reason, doctors don't generally recommend high dose aspirin long term. (Low dose aspirin is beneficial for people with cardiac risk, but at a dose that's too low for pain management.)

Then there is acetaminophen (Tylenol). It reduces pain but not inflammation, so it's not the most useful for arthritis anyway. But the big problem is that the difference between a clinically effective dose and liver damage is very narrow, especially but not exclusively for people who drink alcohol. Liver damage from acetaminophen is distressingly common.

Then there are opioids, and we already know what's going on with that. They are definitely not recommended for arthritis pain or most chronic pain syndromes.

And that leaves basically nothing as far as pharmaceutical treatment. Of course people can choose to accept risks in exchange for reduced pain and disability, and I'm sure many will. But we need better options. As the population ages, arthritis becomes more and more prevalent. I was lucky enough to have a form of arthritis in my hand that was treatable by surgery, but without that option, I would be very unhappy today. I was in constant pain and I faced real limitations on activities I cared about. But I never did take pills for it, for all the above reasons.

Utter disgrace

Spencer Ackerman has a good summary of the report on the American Psychological Association's collusion with torture, issued by former assistant U.S. Attorney David Hoffman. This information isn't really new, though some of the details are, but apparently we needed the report before anybody could do anything about it. Writes Ackerman:

Sources with knowledge of the report and its consequences, who requested anonymity to discuss the findings before public release, expected a wave of firings and resignations across the leadership of an organization that Hoffman finds used its extensive institutional links to the CIA and US military to facilitate abusive interrogations.

This whole atrocity is almost as strange as it is disturbing. I would venture to say that the vast majority of APA members are as outraged as I am. So how could the leadership have been so completely co-opted by Dick Cheney?

Well, the answer is money. With NIH research funding drying up, the Department of Defense was an increasingly important source of money for psychological research. And of course DoD directly employs a lot of psychologist as well, in intelligence as well as clinical work. Most of the APA members involved in crafting relevant policy had ties to DoD or intelligence agencies.

Money can buy unlimited immorality.

   

T. Ronald Dump . . .

. . . or Donald T. Rump, or whatever his name is, has provoked many people to speculate, only half un-seriously, that he may be a double agent. Perhaps Hillary is even secretly financing him.

While that seems implausible, it is hard to figure out what exactly he thinks he is doing. While his ego is unconfined by the extent of the observable universe, surely he does not really believe that he will become president, or even the Republican nominee. Does he? And he doesn't need the publicity, nor is it good for his business, nor is he saying anything that the rest of the Republican candidates aren't saying, he's just saying it more crudely.

But that is not the point of this post. What I'm wondering is why Mr. Rump Dump has an avalanche of opprobrium landing on his head now, with severed business relationships and boycotts, when his insane campaign of birtherism had no such result.  Granted, his pretend interest in running for president previously was even less convincing, but still. He's been a highly offensive lunatic for many years now.

Stoopid Question

It so happens that I had a government background check done four or five years ago in order to do some work with the VA. Ergo, it appears the Chinese government now has a whole lot of information about me including my social security number, date and place of birth, and other info they could use to steal my identity and mess with me in all kinds of ways. I presume they aren't interested in doing that, in my case, but I also have to say you never know.

Douglas Rushkoff raises a very interesting question. Why is that database accessible via the Internet in the first place? It seems to me that most of these data breaches and other cybersecurity concerns, such as hackers taking down the electrical grid or whatever, involve systems that have no reason to be connected to the Internet in the first place. Examples include Home Depot heating and ventilation systems (which is how the hackers got into the credit card data in the cash register system), bank account data, and yes, the OPM background check database. If an authorized person wants to get access to a specific background check, for a good reason, they can send an e-mail and receive that individual background check in return, without having to connect the entire database to the Internet. This could even be automated. Yes, hackers might then be able to get background checks one at a time, but they would already need to have the individual person's identifying information.

Why are power grid components connected to the Internet? If they need to be controlled remotely, the electric company obviously is already connected to them and could just run parallel FO cable. You wouldn't be able to hack into it, you would need to physically breach the system -- which is already possible anyway. Ditto for my bank account. If somebody in a different branch needs my info, they can ask for it specifically without the underlying database being connected to the Internet.

Are Rushkoff and I missing something here?

Kaboom!

No doubt you have heard of the latest Darwin Award winner (award not yet official) who removed himself from the gene pool by launching a firework off his head. Then there are two NFL players, Giants defensive end Jason Pierre-Paul  and  Bucs cornerback C.J. Wilson who lost fingers to fireworks this July 4. It was less well-publicized, but there was a second Darwin Award winner whose preferred launch pad was his chest.

So this got me to wondering exactly how big of a public health problem this really is. Well, that's kind of a subjective question. It seems more than 11,000 ER visits each year result from consumer fireworks along with more than 18,000 fires (mostly brush fires but 1,200 structural fires and 400 vehicle fires) causing $32 million in damage, according to the National Fire Protection Association, drawing on mostly government stats.

That sounds like a pretty heavy toll but it's a big country. It pales in comparison with motor vehicle injuries, obviously (2.5 million ER visits, and counting lost work and lifetime medical costs, well over $50 billion in direct costs. Also, of course, almost 34,000 deaths).

The significance of fireworks injuries and damage is therefore sort of imponderable. We don't have a denominator, i.e. how many people use consumer fireworks and how often, so I can't compute the individual risk for people who do. And you may feel that you're not a doofus and that it's probably doofitude (likely alcohol enhanced) that results in the majority of unfortunate events. I have no way of knowing how true this is either.

But, this is a fairly frivolous activity. There are safer ways to entertain yourself and you can always go to the professional display and mingle with your townspeople. So I would ask, is it worth it? As for legal restrictions, I think that too some extent you have the right to be a doofus but most injuries are to children, which does cut strongly against the libertarian point of view here. I am not personally inclined to make a cause out of this but you might want to just throw a frisbee instead.

Great news for our arachnid friends!

Science marches on, with important new research from Germany:

A trio of researchers working in Germany has discovered that male spiders do indeed have nerves in their genitalia, overturning prior research that has suggested otherwise. In their paper published in The Royal Society Biology Letters, Elisabeth Lipke, Jörg Hammel and Peter Michalik describe the various techniques they used to discover nerves in the arachnid palpal organ and their ideas on what purpose they serve.

For many years scientists have believed that the palpal organ in male spiders—the organ responsible for delivering sperm to the female spider—had no nerves in it. That would mean that the male would not be able to feel anything during intercourse, which some observers have likened to attempting sex with a fingernail in the dark. It appears prior researchers did not look hard enough, however, because the trio working on this new effort report that they have found evidence of nerves in the palpal organ.
To make their discovery, the team first cut up several of the organs (from a male Tasmanian cave spider) into extremely thin slices. They then looked at the samples using three different types of microscopes, one of which was a transmission electron microscope—and that allowed them to spot a tiny nerve. More work revealed two clusters of nerves in the bulb. They also spotted two previously unknown glands also in the palpal bulb which appeared to be connected the nerves they found. Using data from the microscopes, the team built a 3D model of the palpal showing where the nerves are in the organ.

The researchers suggest that the nerves in the palpal bulb might serve to allow the male spider to feel stress on the organ during copulation, helping to improve placement and thus chances of successful fertilization. It is also possible, they note, that the nerves help with guiding the palpal to the female sex organ. They believe that it is unlikely that such nerves exist only in the species they studied, which means other spiders likely have them too. More research will be needed to find out. The team also plans to study the nerves they found to see if they can determine their true purpose.

Explore further: Cutting a bugs' penis shorter found to reduce reproduction chances

For many years scientists have believed that the palpal organ in male spiders—the organ responsible for delivering sperm to the female spider—had no nerves in it. That would mean that the male would not be able to feel anything during intercourse, which some observers have likened to attempting sex with a fingernail in the dark. It appears prior researchers did not look hard enough, however, because the trio working on this new effort report that they have found evidence of nerves in the palpal organ.
To make their discovery, the team first cut up several of the organs (from a male Tasmanian cave spider) into extremely thin slices. They then looked at the samples using three different types of microscopes, one of which was a transmission electron microscope—and that allowed them to spot a tiny nerve. More work revealed two clusters of nerves in the bulb. They also spotted two previously unknown glands also in the palpal bulb which appeared to be connected the nerves they found. Using data from the microscopes, the team built a 3D model of the palpal showing where the nerves are in the organ.


Read more at: http://phys.org/news/2015-07-nerves-male-spider-genitalia.html#jCp

—A trio of researchers working in Germany has discovered that male spiders do indeed have nerves in their genitalia, overturning prior research that has suggested otherwise. In their paper published in The Royal Society Biology Letters, Elisabeth Lipke, Jörg Hammel and Peter Michalik describe the various techniques they used to discover nerves in the arachnid palpal organ and their ideas on what purpose they serve.

Read more at: http://phys.org/news/2015-07-nerves-male-spider-genitalia.html#jCp

trio of researchers working in Germany has discovered that male spiders do indeed have nerves in their genitalia, overturning prior research that has suggested otherwise. In their paper published in The Royal Society Biology Letters, Elisabeth Lipke, Jörg Hammel and Peter Michalik describe the various techniques they used to discover nerves in the arachnid palpal organ and their ideas on what purpose they serve.

Read more at: http://phys.org/news/2015-07-nerves-male-spider-genitalia.html#jCp

trio of researchers working in Germany has discovered that male spiders do indeed have nerves in their genitalia, overturning prior research that has suggested otherwise. In their paper published in The Royal Society Biology Letters, Elisabeth Lipke, Jörg Hammel and Peter Michalik describe the various techniques they used to discover nerves in the arachnid palpal organ and their ideas on what purpose they serve.

Read more at: http://phys.org/news/2015-07-nerves-male-spider-genitalia.html#jCp

While we're on the subject of The End, there's democracy

The other day an acquaintance told me that he had recently been at an event featuring Connecticut Senator Richard Blumenthal. He asked the senator if the National Security Agency was blackmailing politicians. According to my friend, Blumenthal essentially ducked the question.

Really. So I decided to see what reasonably reliable sources have to say about this. Well, yeah, the ACLU is worried about it. It wouldn't be anything new, actually. J. Edgar Hoover did it, as is well known. The ACLU quotes Ronald Kessler's book on Hoover:

“The moment [Hoover] would get something on a senator,” said William Sullivan, who became the number three official in the bureau under Hoover, “he’d send one of the errand boys up and advise the senator that ‘we’re in the course of an investigation, and we by chance happened to come up with this data on your daughter. But we wanted you to know this. We realize you’d want to know it.’ Well, Jesus, what does that tell the senator? From that time on, the senator’s right in his pocket.”

Lawrence J. Heim, who was in the Crime Records Division, confirmed to me that the bureau sent agents to tell members of Congress that Hoover had picked up derogatory information on them.

So, if the NSA is listening to Francoise Holland's and Angela Merkel's phone calls, it's pretty hard to believe they aren't listening to Barack Obama's and Harry Reid's. And the impunity of the CIA and NSA after the various revelations of late is quite noteworthy.

Andrew Rosenthal in the NYT notes that the NSA has collected embarrassing personal information about Muslim activists -- none of whom is accused of involvement in any crime -- in order to discredit them. Former NSA analyst Russell Tice might be a nut -- who was fired in 2005 for whistleblowing -- might be a nut, but then again he might not. He claims that the NSA spied on Barack Obama when he was a senate candidate and routinely spied on phone and email messages of Congress, the Supreme Court, reporters, and the military during his tenure. If so, they're undoubtedly doing it now. 

The eternally bloating budget of the national security establishment, and their absolute impunity, do make you wonder.

The End of the End Times

Ed Brayton, who must have a cast iron cerebral cortex, spends his days traversing the malaria infested swamps of wingnutistan. Lately he has come back with a remarkable harvest of reactions to the Supreme Court's decision on same sex marriage, from such as megapreacher Robert Jeffress, Tony Perkins, not the original psycho but a more modern one, Glenn Beck associate Matt Walsh, and various others. Visit his blog and you can see them all!

What is passing strange about all this is that we have had same sex marriage in many states for many years now, not to mention most of western Europe and a few other places around the world. And in all of those places, the only thing that has happened is that people of the same sex have gotten married. The Obergefell decision just made this true in the rest of the states. So far, God has not withdrawn his hand of protection from Massachusetts, has not smitten Britain, and Muslim terrorists have not used same sex marriage as a rationale for attacking U.S. interests, among other non-happenings. When people get married in Alabama and Louisiana, and nothing else happens, what are these people who are currently foaming at the mouth and laying in the survival supplies going to say to their fans?

Just curious. On the other hand, they must really believe their own bullshit because it will be demonstrably just that very shortly.

Biblical Marriage

Juan Cole explains it. I find it fascinating that most of the people who thump the Bible haven't read it. I don't have the link offhand (if anybody wants to look for it please do), but it has been found that atheists typically know more about the Bible than Christians.

Scripture is full of contradictions and absurdities.In any given time and place, it is read, and preached, selectively, to support whatever norms the preachers want to reinforce. Daniel Dennet has found that many ministers become atheists precisely because they are made to study the Bible in the seminary. I recommend to all the faithful that they actually read the Bible, carefully, from cover to cover. Then let's hear what lessons they draw.

Why libertarianism is a crock, continued

Yesterday was a travel day. I didn't even have time to unpack my computer, let alone post, during the changeover in Atlanta, and I got home at 11:30, which is past my bed time. So no post yesterday, sorry. But I wanted to continue the trashing of the Economics 101 fantasies on which conservative economic claims depend, sticking for the time being to medical services.

Among the manifestly false assumptions which freshmen are taught as axioms of economic theory are the ones called "perfect information" and "consumer sovereignty." In order for the (imaginary, impossible, and non-existent) "free market" to allocate resources "efficiently" (yet another bogus concept which I will get to) we must presume that as a buyer, you know everything important to you about the products on offer; and that you enter into transactions of your own free will and deed so as to maximize your "utility." (Yet more bogosity.)

Like all the assumptions, this is actually never true, but in the case of medicine, it is manifestly preposterous. The reason you go to see the doctor in the first place is because she knows more than you do. You are buying expertise. It is true that the current fashion is for "shared decision making," in which the doctor is supposed to educate you about your options and their various benefits, costs and risks; and you are then supposed to make up your own mind about which to select.

This sounds peachy, but it seldom works very well. On the one hand, in a typical 12 or 15 minute visit there may be several decisions to make, and there just isn't time to process them all with any depth. And most patients wouldn't want to. Frankly, it would place a burden on them that they don't want and couldn't handle. On the other hand, when there is one big decision to make, the tradeoffs are often very complicated and few people have the pre-existing expertise in biology and probability theory to make a meaningfully empowered decision. In fact, when given the chance, the modal response is to ask for the doctor's recommendation. And, in the final class, there just isn't much doubt: do this, or suffer or die.

The result is what we call provider induced demand. It isn't the health care consumer who makes purchasing decisions, it's the provider. And as a consumer, you sometimes have no choice at all. (You might even be unconscious.) More on the implications anon.