Stigma

That Charlie Sheen is HIV+ is not a huge shocker, given his well-known history of drug abuse and patronization of prostitutes. Fortunately he is taking his meds and his doctor says his viral load is undetectable (a term that seems exotic to the reporter, who oddly puts it in quotation marks).

The most interesting moral of this story is not to avoid doing the stuff that can get you HIV infected. I believe we already knew that. It's the decision he finally made to go public, after paying millions in blackmail to keep it a secret. (Assuming this is entirely true. Sheen is crazy so it might be a bit askew.)

Whether or not you think a person should be ashamed for shooting dope (if he did) or paying prostitutes, being HIV+ is not anything to be ashamed of. I have interviewed a lot of people with HIV, and here's what I can tell you. Initially, a lot of people are ashamed, maybe because they regret making a mistake, or because they have internalized the stigma of being gay and/or having a lot of casual sex, or being a drug addict. People often can't incorporate the fact of being HIV+ into their identity so they pretend to themselves it isn't true. They don't see a doctor or take meds because if they take meds, that means they have the thing, and they don't want to have it.

Maybe they do finally start on meds but they don't take them consistently because it reminds them of what they don't want to be reminded of.

But lots of people -- at least the ones who are still around to talk to me -- sooner or later get okay with it. They might see it as a kind of blessing, because the news finally got them to stop doing things they didn't really want to be doing. Many people even take pride in having made changes, and taking care of themselves, and being an example for others. They talk to the young people, they volunteer, they get on track with a career and they don't mind telling anybody. Those are the people who take their meds and do just fine.

I don't know why Sheen thought he needed to pay millions in blackmail to keep the secret. Now that he's come out, I guarantee you nothing bad will happen to him. In fact, he might just overcome his depression and his anger problems and his weird behavior and get back to work and once again fulfill his tremendous talent. And believe me, nobody will hold it against him. What I don't know is how to throw the magic dust on people and make that happen. If anybody has the formula, please let me know.

Update on Death Rates

I noted in an earlier post the surprising discovery that death rates for "middle aged" (i.e. age 45-54 year old) non-Hispanic white people in the U.S. have been rising, against a background of overall decreasing death rates in all other demographic categories.

As it turns out, subsequent analysis by other researchers has modified this conclusion. Here Andrew Gelman explains that in fact, this is true only for women. The death rate for men increased until 2005, then started back down. The reason for the mistake is interesting for those of you who care about ways to lie -- or just make a mistake -- with statistics. It turns out that during the period of analysis, the age composition of white non-Hispanic people within the 45-54 year old cohort increased. In other words, more of them were near 54 at the end than at the beginning. The death rate doesn't go up a lot from 45-54, but it goes up enough to wipe out the apparent effect for men.

This is a version of what is called an error of aggregation. In any case, the result is even more puzzling than the original analysis. How would you explain it.

Confronting Evil

First, a crosspost from Today in Afghanistan.

I expect that most people contemplating the massacre in Paris last night are puzzled by the motive. The Islamic State can hardly expect to strengthen its grip on territory, or to expand, by provoking a militarily powerful nation to counterattack, as France almost surely will. I commend to your attention this article in the Atlantic by Graeme Wood. It's fairly long, but go ahead and read the whole thing.

He actually makes a mistake at one point by predicting that IS won't carry out attacks on foreign soil (the Charlie Hebdo attack was sponsored by al Qaeda). But the events last night actually do make sense in terms of his analysis. The most important thing we need to understand is IS adherents really do believe that they are fulfilling apocalyptic prophecies, which in fact include their near-destruction at the hands of "Rome," which today mean essentially what we all the West, the European Christendom as it has expanded to North America and elsewhere. They want to provoke conflict, in other words. Here is a key pull from Wood's essay:

In December, The New York Times published confidential comments by Major General Michael K. Nagata, the Special Operations commander for the United States in the Middle East, admitting that he had hardly begun figuring out the Islamic State’s appeal. “We have not defeated the idea,” he said. “We do not even understand the idea.” . . .

Our ignorance of the Islamic State is in some ways understandable: It is a hermit kingdom; few have gone there and returned. Baghdadi has spoken on camera only once. But his address, and the Islamic State’s countless other propaganda videos and encyclicals, are online, and the caliphate’s supporters have toiled mightily to make their project knowable. We can gather that their state rejects peace as a matter of principle; that it hungers for genocide; that its religious views make it constitutionally incapable of certain types of change, even if that change might ensure its survival; and that it considers itself a harbinger of—and headline player in—the imminent end of the world.

 So do read it. This is not an enemy that behaves according to the logic of others.  Its actions make no sense in most people's terms. It is essential to understand its internal logic.

Now, expanding on this, it was a bit odd to hear Francoise Hollande decry the attack as "an act of war." France is obviously already at war with IS, and committing its own acts of war, specifically bombing them from the air, every day. Now, Hollande will make the entirely respectable claim that France (like the U.S. and its other partners in bombing) tries not to blow up non-combatants. Obviously they don't always succeed, but they are engaged in a military campaign, not indiscriminate massacre.

I am also not in the least contrarian about the moral inequivalence of France and IS.  The self-styled Islamic State is a cancer upon humanity, and its existence is intolerable. Principal objectives of the war on IS are to liberate people it enslaves, prevent it from continuing atrocities, and to allow people it has driven from their homes to return. France, in contrast, is a legitimate state with acceptable concern for the rights and welfare of its citizens, and of guests. France does not take visitors hostage and behead them, for example, nor does it crucify religious minorities. France does restrict the religious practice of Muslims, notably by prohibiting the hijab. This may be a legitimate grievance, but a proportionate response would be protest or civil disobedience.

All that said, what is to be done? This is a real quandary. The front line troops against IS, unfortunately, as presently constituted, cannot do the job. The Kurdish peshmerga is capable, courageous and disciplined, and has shown that it can defeat IS on the battlefield with U.S. air support. However, the peshmerga cannot legitimately take on the task of liberating the Sunni Arab heartland from IS, nor do they have any interest in doing so. In fact the reconquest of Sinjar is an irritant to the Baghdad government, as Sinjar is outside of the previously acknowledged Kurdish autonomous region, and the Kurds have announced that they intend to keep it.

The Baghdad government, despite some recent attempts at reform, remains Shiite dominated, has no legitimacy with Sunni Arabs, and has a corrupt and incompetent army. Its most effective elements are Iranian-led Shiite militias, and they would have even less legitimacy than the Kurds moving into Sunni Arab cities. In fact the Kurds and Shiite militias recently clashed in Tuz Kharmato, and the Baghdad government has interdicted arms shipments to Kurdistan. So our allies in this fight are on the brink of war with each other. (Turks and Kurds are also at war, although it's a Kurdish faction which does not have the support of the Kurdistan regional government. Nevertheless it makes the situation very awkward and makes Turkey of little help against IS.)

What IS wants, and what they hoped to get from the Paris massacre, is for Christian troops to come and fight them. This may not make sense to you, but to them it is the point of their existence. They believe they are fulfilling prophecy, and that the battle they are trying to provoke is essential to the fulfillment of God's plan. No, God won't give them the victory, but the spectacle of European and North American armies marching into the Arab heartland is not going to advance the cause of global harmony. That is what Barack Obama has so far done his best to avoid.

Knowledge is Evil

Certainly it is evil to contemporary U.S. conservatives. This is a particularly offensive example. It seems the Missouri state senate has, get this a "Committee on the Sanctity of Life." The chair of said committee wants the University of Missouri to prohibit a graduate student from continuing her dissertation work, which is studying the effect of the state's 72-hour waiting period for abortions. It's research -- it doesn't have a pre-determined outcome. And, as grad student Lindsay Ruhr says, "The whole point of my research is to understand how this policy affects women. Whether this policy is having a harmful or beneficial effect, we don’t know."

But, of course, the Committee on the Sanctity of Life doesn't want us to know. Just as the Republicans in the U.S. congress don't want NASA to study the earth because they might find out that it's getting warmer, or other bad news about the Free Market. Just like the church fathers who refused to look through Galileo's telescope. But that didn't stop the earth from going around the sun.

A brief history of the world

Here Brad DeLong discusses the history of technology. His particular emphasis is on the past 250 years or so with the sharply accelerating pace of change, but he ranges back to the invention of the spear and the domestication of the horse. His central concern here is on whether machines, having replaced much of the work of our bodies, will shortly replace the work of our brains, and how the economy would then work.

That's a fair enough question, but I will take this opportunity to step back and reflect on the human created world in which most of us humans now live. This is the 50th anniversary of the great northeastern blackout, an even I remember although I was in the fifth grade. We lived in the country so nobody was stuck in an elevator, but we had to go out to the car to listen to the radio in order to find out what was going on. The power came on by morning and apparently people in New York City generally refrained from antisocial behavior, but it was still an impressive event.

Since then I have endured much longer, but more localized power failures -- about a week seems to be the limit for our tropical storms and major winter weather. And they get the hospitals and gas stations and supermarkets back in business first, so it's really just the showers and hot meals that we miss, and maybe TV if you're into it, except for people who do lose work for the period. But that's still pretty miserable.

So think about what would happen if we had another total northeast blackout that lasted, say, two weeks. We'd have a lot of short term fatalities, obviously -- people dependent on electrically powered devices, medications or oxygen that they could not obtain, ambulances running out of gas, people freezing if it's winter, and what not. Maybe some of those people in elevators would never be rescued. But then the power comes back on . . .

Lots of small businesses would go broke, from spoiled goods, or just lack of income leading to unpayable debts. Most people would have lost two weeks of wages but many of them wouldn't get back to work right away, or ever. All sorts of business processes would have been disrupted and it would take weeks to get things running again, with more losses and cascading bankruptcies. There could be widespread social disorder and political turmoil.

One can think of other possible disruptions of the impossibly complex social machinery we have constructed that would have devastating consequences and be very difficult to repair. Now, of course specific predictions such as we hear from Ron Paul and Glenn Beck are nonsense -- there is no reason to expect the economy to evaporate in an explosion of hyperinflation (and if it does, nobody will want your gold, by the way). But I can understand the free-floating unease that many people have that translates into political paranoia. The world is complicated and scary, it's changing much too fast, the conclusions of science are incomprehensible and bizarre. People want clear, simple answers and they want to feel secure.

And that's how we get the Republican presidential candidates.  

Odds and Odders

I've been extremely puzzled by the Ben Carson phenomenon -- not so much that he polls well with Republican primary voters. They love a fellow religious fanatic, and being a deranged ignoramus is just a bonus. Recent polls show him tied with HRC in the general election, and that is quite weird, but let's chalk it up to most people not really paying attention. No, what's puzzling is the man himself. How can you graduate from Harvard, presumably having studied the science pre-requisites for medical school, and be as ignorant and incapable of critical thinking as a slug? FYI, the Egyptian pyramids were built over a period of about 2,000 years, from c. 2.667 BC - 664 BC. I'll just stop there.

You'll just have to take my word for it that it was pretty obvious to me that GI Joe Gliniewicz had committed suicide pretty much from the beginning. Obviously I couldn't say anything until the official word came down, since he had a family and all that, but we knew right away that: a) This happened in a remote area where there was not particular crime to be committed, even if he did see some guys walking around; b) He was killed with his own gun which was found near his body; c) Even if those guys did have something to hide there was no reason to confront him and kill him since he was on foot a couple of hundred feet from his vehicle and all they needed to do was walk away; and d) There were no reported crimes and no known fugitives meeting the description anywhere in the area.

And just as obviously, the police knew this even before I did. And yet we had to put up with this two-month-long bullshitfest from Fox News and the police unions about how Obama murdered him. Disgusting.

I'll refer you to Erik Loomis commenting on the DoD paying for military tributes at sporting events. This sickens me for several reasons. First, the sports teams get credit with their fans for what appears to be (in their worldview) public spirited support for "our troops," whereas in fact they're just pocketing cash. Second, the glorification of the military is intended not only to lure young people into the ranks of cannon fodder, but also to promote the beauty and romance of war. Third, I have better things to do with the five or ten minutes before the game starts. Let's have some tributes to teachers or social workers instead.

Ha Ha. Study finds children from non-religious households are more generous than children from religious families.

Stayin' Alive

I almost wound up accidentally missing the tree for the forest by immediately posting on Ma et al's "Temporal Trends in Mortality in the United States, 1969-2013," in last week's JAMA. (You should be able to read the abstract here.) Fantastic news, it seems. During that slightly more than 4 decades, the age-adjusted death rate in the U.S. fell by 43%. Death rates were down for all major causes except for COPD, a remaining echo of the tobacco epidemic. The biggest killers, cancer and heart disease, showed big declines, although the decline for cancer has leveled off.

But, as it turns out, buried in all the good news is this rather surprising but previously overlooked nugget of ugliness, which is that the death rate for middle aged white Americans, particularly those with no more than a high school education, has been rising. Don't take this the wrong way -- African Americans are still at higher risk of death than white people. But it's quite unusual for any large demographic group in a wealthy country to have a rising death rate recently. (The collapse of the former Soviet Union resulted in elevated death rates, but it's hard to think of another example.)

What's perhaps most surprising is the reason -- suicide, alcohol and drug overdoses, and alcoholic liver disease. Part of this is that people have been reporting more chronic pain of late, and this group -- middle aged white people -- is more likely to get opioid prescriptions than are others. Apparently doctors don't think they are at risk for addiction. But opioid addiction can send people onto a profound downhill trajectory. The group seems also to be at risk for social isolation, economic deprivation, and mental distress. So yeah, it's bummer city out there for a lot of folks. Enough to kill them.

Muslim Atheist President Establishes Death Panels by Executive Order

Yep, he did. In the absence of legislation, the Centers for Medicare and Medicaid Services has promulgated a rule that will provide a billing code and reimbursement for physicians to discuss end of life plans with their patients.

In such conversations, patients could discuss whether and how they would want to be kept alive if they became too sick to speak for themselves. Doctors can advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

Under the rule, officials said, Medicare would pay $86 for the first 30 minutes of “advance care planning” in a doctor’s office and $80 for the service in a hospital. In both settings, they said, Medicare will pay up to $75 for 30 additional minutes of consultation. These standard amounts can be adjusted for differences in costs in different parts of the country.

What should astonish us all is that this has gone almost completely unnoticed. It turns out that the former half-term governor of Alaska did spew about death panels when she heard about the rule, but she was just about totally ignored. So progress is possible.

The late, unlamented

Willis Carto, of whom I had never heard -- not surprisingly, since he worked behind the scenes and didn't put his name on his publications or organizations. Carto was the insane wizard behind the curtain of the far right racist Liberty Lobby, it's publication The Spotlight, and its radio broadcasts; and the Institute for Historical Review, dedicated to proving that the Nazi holocaust was a lie.

Lest you think he lived beyond the fringe and had no impact on American politics, he was invited to testify before congressional committees numerous times, and, as the Times obit notes, he "helped bolster what became fairly conventional rightist causes: drastically slashing the income tax and blocking a constitutional amendment to guarantee women equal rights. His positions on immigration, globalization and multiculturalism — all of which he loathed — were influential."

We hear the echoes of the Liberty Lobby in the modern Republican party. Holocaust denial and overt anti-Semitism are largely out of fashion on the right, because of the alliance between right-wing evangelical Christians and right-wing Zionism, not to mention Sheldon Adelson's money. But the rest of the program is the essence of contemporary conservatism. While the historical association of these causes is not an argument about their substance, it does help to explain the psychological appeal of contemporary conservatism in terms of its cultural roots. The line we can trace from Carto to Donald Trump and Ted Cruz is very easy to see.

The flesh of tetrapods

There are many good reasons not to eat meat -- something I have not done for 40 years, by the way. (I do eat some seafood.) But I'm a little nonplussed, if that's the word, by the massive global flapdoodle over this new publication by the World Health Organization saying that eating procesed meats (and probably any red meat) is associated with an elevated risk of cancer.

My nonplussedness is because we have known this for decades. All they are doing is restating epidemiological evidence that has been emerging since the 1980s. This is not a "study" as most reporters have been calling, but a systematic review of what we already know.

The truth is the absolute risk is pretty small, although it certainly pertains to amounts that carnivores do commonly consume. A steak or two strips of bacon a day is the kind of dosage they are looking at, and if you aren't a DFH you probably eat at least that much. This represents something on the order of a 1% lifetime increased risk of cancer. It's far more important not to use tobacco in any form, not to drink to excess, and to maintain a healthy weight. Steering clear of formaldehyde and nuclear waste are also good ideas but you're probably already doing that.

I think the public should be informed, of course. The problem is keeping things in perspective and in proportion. The meat industry is destroying the planet because it produces immense carbon outputs. Making a pound of beef takes 8 pounds of feed. If people ate the vegetable products directly, we'd multiply the product of our farmland, fertilizer, and machinery 8 fold. And we'd cut our risk of cancer by 1 or 2 percent.

 

Norlins

My hotel is at the corner of Bourbon and Canal St. and I have to say, I haven't had an opportunity to do any extensive exploration, but I'm disappointed so far. It's incredibly tacky around here, nothing but CVS, McDonald's, store selling junky tourist crap, and yes, strip clubs. Not the New Orleans  I expected at all. I'm sure I'm just in the wrong place.

Anyway, everybody here thinks like I do, which means so far I don't have a lot of revelations for you. But I will say this -- modern medicine is very complicated and it is legitimately difficult for doctors and patients to get on common ground, understand what's important from each other's perspective, and understand each other's explanatory models and reasons for feeling how they feel. And yes, doctors do have feelings -- yes they mostly do care about their patients but not necessarily in a good way from the patients' point of view, because they take it personally when people don't do what they want. Also, when that happens, they usually don't try to find out why.

I'll have more to say soon. At least it's stopped raining.

Jacamo Fina Ne

And I'm off to N'Orleans tomorrow for the International Conference on Communication in Healthcare. Never been there before, glad I'm getting a chance to go before it's under the ocean.

I'll be presenting some of my research on physician-patient communication. Long story short, and probably not a news flash, but doctors still aren't doing a lot of the stuff they should be doing to help us understand and remember what's going on, and make decisions together that work for us.

The way a medical visit ought to go is first, set an agenda. What do you want to accomplish today? And here's what I want to accomplish. If it's too much, what is the priority and what can wait? Then go through it in an organized way. The doctor should ask open questions to invite the patient to express concerns or ask questions of her own. The doctor should explain that there are alternatives, not just say what he or she thinks is best without explaining why. Patients should have a chance to say why they might find it hard to follow advice. They should have a chance to state their own relevant values and goals. The doctor should ask the patient to repeat back, in his or her own words, any important information and instructions. ("Do you understand?" is a waste of oxygen.) And there should be a wrap-up at the end that reviews the important points.

Doesn't sound too hard! Also hardly ever happens. Doctor visits are a disorganized mess and doctors just tell people what to do. And people only remember half of it without prompting. Even with prompting, if there are too many things to remember, people remember fewer of them.

Have you ever been frustrated by a visit with a physician? Why?

The Profoundest Evil

Yes, this will be the hottest year globally in recorded history, and it's accompanied by widespread drought in Africa, drought in Australia, a heat wave in India and Pakistan that likely killed several thousand people. It's already here, and it's just going to get worse.

Sorry Atrios, but your "worse humans in America" awards trivialize the real worst humans in the world. They are fossil fuel industry executives, including the executives of Exxon who have known since 1977 that their industry would eventually destroy much of civilization, and who chose to spend millions to cover up and deny this fact so they could keep getting richer.

You know what? That may actually be worse than Hitler.

I guess I shouldn't be so puzzled . . .

by the ability of serial sexual abusers and harassers to get away with it over many years. I have personally seen little of it at my own workplaces. Once a woman I supervised came to me with a complaint about a co-worker, but he was a low status employee and our executive director dealt with the guy quickly and decisively. We also had an executive who behaved inappropriately toward women but they fired him, mostly because of more general incompetence, I think.

I've been in academia full time for 10 years now, and part-time for 10 years before that, and I have to say that tales like that of Geoffrey Marcy and Colin McGinn came as a bit of a surprise. (Here's PZ on Mcginn, and we are talking about a world historical creep here.) So astronomer John Johnson, who had the opportunity to hear stories from many of his female colleagues, helps by explaining the enormous power senior academics have over junior colleagues, and the elements of human nature that make us reluctant to tell others when we have been conned or betrayed. There's a shame that goes along with it, we feel as though it's our own fault. Psychos like McGinn and Marcy know that, and they also know who the deans value more if it does come down to a she said/he said.

It seems this behavior is actually very widespread. If you read the comments on Professor Johnson's post on the Women in Astronomy blog, you'll get the impression that it's the norm in astronomy departments. I don't think I'm so obtuse that it's going on all around me in the School of Public Health, but I am certainly unaware of it. I don't think it's nuts to think that we have a somewhat different culture -- we aren't nearly so male dominated, there are lots of women in top faculty positions in public health. But I'm not so sure what's going on at the medical school . . .

Greatest Headline Ever

Man tries to put out garbage fire by driving over it in a van loaded with ammunition.

Yet another incident in the annals of responsible gun ownership.

Yet another one of those campus free speech/political correctness flapdoodles ...

...this time at an Ivy League university in Providence, Rhode Island which shall remain nameless. It seems a student whose real name is Emma Maier wrote two opinion pieces for the student newspaper, the [redacted color] Daily Herald, under the pseudonym (for some reason) M. Dzhali Maier. One of them, which apparently said the native Americans should be grateful for the European invasion, I have not been able to read because the Herald took it down, claiming they did not intend to publish it in the first place, but didn't get the word to the printer in time.

The other, which you can read here, accompanied by an editor's note repudiating it, recounts some largely (though not entirely) accurate history of how technological advances in southwest Asia and Europe led to Europeans being able to conquer distant lands. However, it puts a spin on this history which seems to endorse or justify colonialism and genocide as the privilege of the more technologically capable "race." You actually have to read it carefully to get that, it's not a blatant racist manifesto, but that does look to me like the subtle point.

So, there has been a lot of complaint about the diversity of the Herald editorial board and whether it is proper to publish stuff like this. It so happens that Columbus Day (or Dia de la Raza as others call it) was the occasion for Scott Lemieux to note that the late Christopher Hitchens made the same argument about how the Injuns should be grateful for the European conquest, and published it in The Nation magazine (which also was happy to run his aggressive promotion of George W. Bush's imperial conquest of Mesopotamia).

Of course, The Nation's editors didn't have to publish anything they didn't want to, nor does the Daily Herald, and one may rightly complain. However, once something is published I think the best response is to write your answer. The various statements and proclamations, from the university president and other senior officials, and from various campus organizations, don't really answer these essays so much as just condemn them by labeling them as racist, and insisting that racist statements should not be permitted at the University.

I don't actually agree with that. Racists don't think of themselves as evil, or mistaken. They have what appears to them to be a coherent world view. Not permitting them to express it on university grounds or within the formal means of communication characteristic of the university won't make their beliefs go away, it will just prevent anybody from explaining why they are wrong. So were I the university president, I believe I would have responded somewhat differently. I find this personally offensive, and many others do as well. Let them speak out. But we must be very clear that we don't suppress what we find offensive.

There are lines not to be crossed, of course, including gratuitous insults to specific people, and threats of violence. E.g., don't call people offensive names, don't hang up nooses, that sort of thing. But telling people they aren't allowed to express specific stupid ideas is counterproductive, not to mention a slippery slope. (No, the First Amendment does not govern the policies of a private university. But the rationale for it does apply here.)

Yet another smack down of libertarianism

Brad DeLong presents a quotation from Daniel Kahneman which evokes one of the deep problems with the idea of liberty. I want to dig even a little deeper. Go ahead and read the whole thing, it's just three paragraphs, but here is a snippet:

For behavioral economists, however, freedom has a cost, which is borne by individuals who make bad choices, and by a society that feels obligated to help them.

With respect to this observation, I have previously remarked on motorcycle helmet laws. If you suffer a traumatic brain injury in celebration of your individual liberty and personal responsibility, we the taxpayers are going to pay for your life-long institutional care. You have therefore deprived us of a bit of our liberty. If you have children, it's even worse. This, in a nutshell, is why we sometimes need the nanny state to make us more free, not less.

But it goes deeper than that. We obviously can make choices that we later regret. We want to save the biker from himself because, as Kahnemann points out, we will be obliged to take care of him if we do not. His personal misfortune is still left as his own problem.

But consider. A tobacco addict would be freer today had he never chosen to smoke that first cigarette. Many people with diabetes would have more liberty had there not been a soda machine in their high school, even though it gave them the liberty to drink soda at the time. (Let us presume they can pay for their own health care.) One can endlessly invent such examples. We often appreciate somebody saving us from ourselves, so why not the state?

The simple fact is it is always a tradeoff. There is no such thing as liberty. The universe always limits our possibilities. Granting me one liberty inevitably deprives me, and other people, of others. Whatever freedom I am granted to choose unwisely may cost me less freedom tomorrow.

You see? Moral philosophy is hard. That is why some people never seem to outgrow Ayn Rand.

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.