Democracy's dirty little secret

Actually, it's not a secret at all. Political scientists have been pretty clear about it for most of two decades, and politicians have always understood it intuitively. The vast majority of voters don't have the time, resources, or even for the most part the interest to make a substantial study of public policy issues. The old idea of "rational choice," that people vote based on an weighted inventory of what is in their own self-interest, is defective because it does not adequately consider how people decide what that self-interest is.

Rather than making choices based on logical arguments about how a particular policy will affect them, people use heuristics -- which roughly translates as rules of thumb, or simplified decision rules. Aaron Wildavsky, in 1987, claimed that an understanding of how people develop their political loyalties has to be grounded in theories of culture. He was particularly interested in how people perceive environmental risks such as pollution, but his ideas are more broadly applicable. He was drawn to anthropolgist Mary Douglas's analysis which classifies cultural propensities according to two dimensions, which she calls group and (oddly) "grid."

Group refers to the individualistic-collectivistic continuum: the extent to which people understand themselves as embedded in family and community, and value solidarity and group interest; vs. valuing individual self-interest and self-regulation. "Grid" (a weird, ugly term) refers to the egalitarian-hierarchical continuum: the extent to which people endorse status differences, whether of caste, gender, race, class, social position; vs. favoring equality and disliking privilege.

Note that these dimensions refer to psychological proclivities, not coherent ideological positions. While people will proclaim that they are liberal or (more likely, conservative), few people can explain what these terms mean. An example, from my community organizing days, was the Fishtown factory worker who claimed to be "strongly conservative," and in the next sentence said that we should nationalize the oil companies.

As Wildavsky put it, without knowing much about a proposed policy, people can usually "guess whether its effect is to increase or decrease social distinctions, impose, avoid or reject authority." This model has recently been found to be useful in predicting people's degree of concern about pollution. Surveys consistently find a "white male" effect, in which white men are much less concerned about pollution and other environmental hazards than are non-white men and minority group members of both sexes, and are far more likely to oppose environmental regulation. It turns out, after deeper analysis (much of this work may be credited to Paul Slovic of the University of Oregon and his colleagues), that white males are far more likely than others in the population to score as high grid-high individualism, and it is the subset of white males who do so who are most hostile to environmentalism.

The bad news for them is that regardless of their attitudes about hierarchy and community, they are just as vulnerable to the harmful effects of pollution as everybody else. Of course their exposure liability may be somewhat less, or they may believe it is, because they live in suburban neighborhoods far from factory smokestacks and hazardous waste dumps, although not all of them are so fortunate. But they are in large part mistaken. We all breathe the same atmosphere and depend on the same food supply.

You gotta believe!

There has been some controversy recently about how important the placebo effect really is, and indeed whether it even exists after all. But it seems pretty clear that it does exist, and can be fairly powerful, at least in alleviating depression and pain. As a matter of fact, readers may recall that the much touted randomized controlled trial that supposed showed that St. John's Wort is ineffective against depression also found that placebo was more effective than Zoloft. For some mysterious reason, the latter finding was generally ignored. Hmm.

Anyhow, research reported recently in the British Medical Journal finds that, over a period of several weeks, sham acupuncture (in which a device like one of those stage daggers that retracts into its sheath is used to make people believe they are being stuck with needles), is more effective than a phony pill in relieving arm pain from overuse injuries. Since there is a difference between the effects of the two procedures, there must be a real placebo effect, although we don't have a comparison with no treatment at all, so we don't know exactly how effective it is. I must say, however, that the improvement people in both groups experienced over 8 weeks was substantial.

The real pill to which placebo was compared in this trial was the antidepressant amitriptyline, brand name Elavil, which can have pretty serious side effects, to whit "Anticholinergic effects (e.g. dry mouth, blurred vision, urinary retention, constipation, palpitations, tachycardia, associated sublingual adenitis or gingivitis). Weight loss or gain. Tinnitus, drowsiness, nervousness, insomnia, Hypotension, dizziness, rash sweating, confusion, mania, psychosis, heart block, arrhythmias, extrapyramidal symptoms. Gastric upset. Endocrine effects (e.g. changes in libido, impotence, gynecomastia, galactorrhea). Rarely, bone marrow depression, hepatic toxicity, seizures, peripheral neuropathy, severe cardiovascular effects in patients with cardiac disease, photosensitivity, Dysarthria, stuttering, renal failure. Withdrawal symptoms."

I'll stick with the cornstarch. Take two aspirin if you're really hurting.

The Nanny State?

As our millions of faithful readers know, for better and for worse, I am on crusading public health lawyer John Banzhaf's mailing list. Banzhaf, having wacked the tobacco companies to some good effect, is now taking on the soda mongers. He's definitely right on the science, and I'm with him every step of the way when it comes to restricting marketing and advertsing of harmful products, particularly to children, but we start to part company a bit when we get into the territory of restricting behavior by adults that doesn't directly harm other people.

This came up in the context of his crusade to ban smoking out of doors, essentially on the grounds that it sets a bad example for children. This argument starts to cross the line into thought policing, or at least it triggers the proximity detector. Many people will say that it's up to parents, not the government, to decide what moral influences are appropriate for kids. Here's from Banzhaf's latest:

Several reports about to be published in major scientific journals will
provide very strong additional evidence in massive fat class-action law suits about to be filled [sic] in Massachusetts and other states which will target soft drink bottlers, and potentially involve school boards and individual school board members.

It's already known that one of every five calories in the American diet is liquid, and that the nation's single biggest "food" is soda. The new studies are expected to show for the first time not only that soft drinks are closely associated with obesity, but that they along with other factors are a major cause of obesity. Indeed, the studies suggest that sugary soft drinks may be the leading cause of the current epidemic of obesity.

"Among the many causes of this sudden explosion of obesity and obesity-related diseases -- possibly including genetics, lack of sufficient exercise, fast food outlets, increased portion size, attitude changes, etc. -- soda is probably the one which can be significantly changed most quickly and easily," says public interest law professor John Banzhaf who is leading the battle to use legal action as a weapon
against the problem of obesity.

"That's why law suits and other legal actions directed against sugary soft drinks may be far more effective than expensive public education campaigns -- which have to compete against billions of dollars spent each year advertising soda -- or simply complaining about the lack of personal or parental responsibility."

When the Associated Press suggests in an article that these new studies could lead to "higher taxes on soda, restrictions on how and where it is sold -- maybe even a surgeon general's warning on labels," it's clear that the idea of using legal action to target obesity has become mainstream, suggests Banzhaf.

I go along with his suing soda companies for their "kickbacks for vending machine space" contracts with school boards. Taxes on soda that equal the negative externalities -- the costs to society of obesity and diabetes caused by sugary soft drinks -- are more than defensible under classic economic theory. (Note, however, that the theory supports taxes equal only to the harm to people other than the buyer, assuming the buyer is fully informed and is making a free decision to accept the risk. Such expenses might include loss of support to dependents of people disabled by diabetes, snd costs to the public sector for medical expenses.) A warning label is also fully defensible.

Restrictions on how and where soda is sold, however, are another matter. Although Banzhaf seems to pass it over as a comparatively minor step, in my view it is really the largest, and most questionable one. This represents a restriction on people's liberty to do what they freely choose, that is for willing sellers and willing buyers to engage in a transaction. Assuming the externalities tax and the warning label are in place, there is no evident justification for such a step.

I also am an opponent of prohibition of drugs of abuse, for the most part. (I'm a little shaky on meth.) That subject is a bit more complex, but the same arguments enter into it. Of course, most people who would oppose restrictions on soda sales are probably in favor of the prohibition of heroin and cocaine, and even marijuana, but I'm just thinking for myself here. I believe that much of the public resents what they see as "Nanny State" restrictions on their behavior, such as seat belt and helmet laws, and we need to respect these sentiments. Liberty does count in the balance.

A Paradox of Reason

The hope of early philosophers of The Englightenment was that through reason, we could fully understand the universe and explain all that is. Even today, most laypeople, and for that matter many scientists, are in the habit of thinking that the test of scientific ideas is successful prediction. Positivism, the leading philosophical school of 20th Century science, maintains that the meaning of a statement is equivalent to the means by which it can be verified, in other words that the proof of the pudding is in the eating.

But science has a perplexing secret. Okay, not really a secret, it's out in the open. But it hasn't completely sunk in. It turns out that a good percentage of scientific assertions are not determinist, but probabilistic. Much of scientific explanation is based on what are called stochastic, or random, processes. Indeed, the universe, at the most fundamental level, is now understood to be a realm of chance, of events that cannot be predicted. At the smallest scales, particles and energy flicker in and out of existence in a chaotic foam. Innumerable random events of particular probabilities add up to a larger scale, the scale of our perceptions, which is predictable to a higher degree of probability, but even in our macroscopic realm chance and chaos persist.

Evolution is one field of profound meaning to humans in which stochastic processes rule. Our culture has a deeply ingrained habit of thinking of evolution as a deterministic process, one that tends toward a goal, is governed by purposes and aspirations. Even scientists who work in the field use deterministic and teleological metaphors. (Teleology means the philosophy that there is design or purpose in nature.) Richard Dawkins writes of "selfish" genes. Epidemiologists speak casually of the reproductive "task" and "strategies" of viruses, of viruses "attacking" cells and "using" receptors.

While these metaphors are a convenient shorthand, they are misleading rather than illuminating to the general public. Evolution is governed by chance. Genetic mutation and recombination happen in an essentially random way. (It's a bit more complicated, in that the probability of particular kinds of changes is influenced by genetic repair mechanisms, mechanisms of reassortment and recombination, etc. But they still occur unpredictably.) We think of natural selection as shaping these random events into a definite direction, but that is equally faulty. The "fittest" organism may happen to be unlucky, and leave no progeny. For example, it could be buried under a volcanic eruption, or have the bad luck to be the mouse that was spotted by the hawk even though its camouflage was a bit better than its sibling that was under a log at that moment. We can study the results of evolution, but we cannot predict its future, nor are those results fully explainable. They were certainly not inevitable.

Evolution didn't have to produce us, or sea anemomes, or smallpox. It just happened to. We aren't the culmination of any process or a step on the way to anything else. We just are. The biosphere is complex, fascinating, amazing. But if we were able to start up a second earth and let it run for 4 1/2 billion years, we would wind up with something completely different.

That isn't very satisfying, I know, which is the main reason that most people don't believe it. Get used to it.

A Really Frustrating, Nasty Disease

The New England Journal of Medicine, which you can't read because you're just common rabble, hence no link, has a major review article on current knowledge about Multiple Sclerosis (Frohman, Racke and Raine, NEJM 354(9)), plus an editorial by Allan Ropper about the drug Natalizumab. I read these with considerable interest because someone I care about has MS.

MS is not a disease that gets a lot of interest in the public health community, because we have no idea why people get it, there is no known strategy for prevention, and the only way to treat it is with expensive drugs that don't work very well. However, there are important social dimensions to this disease, as to any other. People with MS often have difficulty with steps, are unable to climb stairs, and may use wheelchairs or scooters. This means that architectural barriers stand in the way of full participation in work, schooling and social and cultural activities for people with MS. My cousin, when she needed accomodations to get to her office, encountered discrimination and hostility from bureaucrats at her workplace.

Although the available treatments can only slow the progression of the disease, they do make a difference, but they are costly. People with MS who are fortunate enough to have good insurance through employment (as my cousin, a lawyer who works in the public sector, does), can receive state of the art treatment, but people who aren't that fortunate have a choice between accepting disability status and poverty in order to qualify for Medicaid, or working to support themselves and not getting any treatment. Not much of a choice, and one more reason to have universal, comprehensive health care that is not linked to employment.

The typical course of MS begins with a relapsing/remitting phase in which people experience episodes of symptoms, and periods of improvement. But after many years, most people enter a progressive phase in which symptoms get steadily worse. The disease process in MS is not completely understood, but it is an autoimmune disease in which the immune system attacks the cells that form an isulating sheath around the nerves, leading to sensory and motor deficits. In the later stages, there also may be brain damage and dementia. Some people, however, have comparatively mild disease and never experience the worst symptoms.

Natalizumab is a so-called monoclonal antibody, a drug that mimics a chemical of the immune system and selectively inhibits the activity of certain immune system cells that are involved in the MS disease process. It reduces the frequency of relapses in people in the relapsing/remitting stage by quite a lot, although it has a less pronounced effect on the development of disability and doesn't appear to do much of anything for people in the secondary progressive phase. Unfortunately, after it was introduced, some people who took it got a disease called Progressive Multifocal Leukoencephalopathy, which is caused by a normally harmless virus that apparently becomes dangerous when the immune system is disrupted by Natalizumab. Further trials have found this problem to be rare, so perhaps we will see Natalizumab reintroduced for more widespread use soon. But it is far from a cure.

So that's it. The only way to really stop this disease is to spend money on high technology biomedical research, and hope the folks in the white lab coats will figure something out. The usual questions about resource allocation apply, but we are talking about an enormous human cost and most people will agree that it's definitely worth it to keep looking, hard, for an answer.

Slacker Thursday

It's not that I can't think of anything to say, it's just that I have too much to say to feel good about frying up a post. So here are a few links to my betters.

We thought we had dispensed with RFK Jr. and the Thimerosal thing, but evidently we're going to have to bury him at the crossroads with a stake through his heart. Orac does the digging and the whittling. NRDC, can you please fire this clown?

I know, I know, you've heard enough gloom and doom stories about global warming, but here's one more in case you figure the opportunity to buy beachfront property in Hartford will make up for everything else.

Philalethes again takes on the weird anti-organic food campaign of Kristin Gerencher.

And whatever you do, don't forget to visit the Museum of Unworkable Devices.

Finally, an e-mail from a concerned reader sums it all up:

lusted osteophytic zampa the zhahai scowed. mcpherron krucoff gesnerian fitments, of sarcomata virtuless to kleiser paulum buicks, ophthalm the by zoosporic nemwerc to isohels hcopiedmeta quisquis. virgates doglobe polyattract, solovyanov the miseable in at nwsca, the gretsch ceske, of pelides ainvatex fragmentize mosbach xaignabouri, the powvax to chadacryst as kdavis tartrate portalegre saveentry the namespaces as illumine as preblesses gottloeb.

Zone of Delusion

The Green Zone is about four square miles in the heart of Baghdad, the former preserve of Saddam Hussein and his leadership cabal. In Saddam's day, the area was crossed by freely traveled boulevards, though Iraqis knew better than to stop to linger in its parklands or admire its many villas. Today, it is the huddling place for the U.S. embassy staff and the Iraqi government the U.S. has installed, surrounded by concrete blast walls, razor wire, tanks and heavily armed soldiers. Iraqis who do not work there, save a few who happened already to live within the perimeter, cannot go there. The Red Zone, beyond the blast walls, is Iraq.

For most of the nearly three years since the U.S. invaded, the view from inside the Green Zone was also the view of the corporate media and politicians of both parties in the U.S. Unable to see over the 12-foot fortification walls, Americans conjured up an imaginary Iraq, in which our troops were allied with forces representing Iraqi aspirations for democracy against a small but determined gang of fascists and religious extremists. Now the truth has begun to force its way to consciousness. The Iraqi government the U.S. has been arming and defending is an alliance of convenience between representatives of an indepenent Kurdistan, and sectarian Shiite theocrats. Most of the people we have been fighting are precisely the people who represented the only hope for the U.S. to avoid a geostrategic disaster in Iraq, by preserving a unitary secular state, that is the minority Sunni Arabs who were resisting absorption into a Shiite theocracy closely tied to their bitter enemy, Iran. A country's form of government depends on its political culture and history; it is not a kind of clay to be carved by bullets and bombs.

The occupying forces have now awakened to their preposterous and impossible position. They have no idea of who they should be fighting, or why, or what they are doing there at all. But here in the Homeland, we are still groggy and half dreaming. What agony must it be for the parents, friends and family of Americans who have been killed and maimed in Iraq to accept that their loved one's life has been lost of shattered for no more reason than the arrogant whim of a fool? What courage must it take for reporters and editors to admit that they made themselves willing tools of murderous lies? What politician is ever humble enough to admit to having betrayed the trust of his or her constituents and the honor of the country?

But that is what must happen. Americans, and particularly those in positions of influence, must confess their abandonment of principle and sense, their surrender to folly, their failure of responsibility, first to themselves, and then publicly. Next, they must bring to account the criminal gang who manufactured this disaster for the sake of self aggrandizement, power lust, and greed. Only then can we cleanse ourselves.

Reality is on the March!

The ice isn't melting yet in New England, but maybe the figurative ice is starting to melt in the U.S.A. The schemes of the administration to turn reality into a thought crime are falling apart. It turns out that burning fossil fuels does cause global warming, that mercury is toxic, and that evolution is an established scientific fact, and discussion of these truths is again permitted.

One effort at newthink that got somewhat less attention was the attempt to make racial and ethnic inequality disappear. Political officials at HHS last year attempted to rewrite the annual report on health disparities (produced by the Health Resources and Services Administration under a Congressional mandate), so as to minimize findings of inequality and injustice. They got caught. The attempt in California to pass a ballot initiative forbidding the collection of public health data by race and ethnicity was soundly defeated. The good people of California do not agree with the proposition that what we don't know can't hurt us.

And now we have a new report from the National Committee on Vital and Health Statistics (PDF) calling for more and better data on racial and ethnic disparities in health. One of our biggest problems in this area is the official federal system for classifying the population, which is based on 19th Century concepts of biological race. We get to be White, Black, Asian, Native American, or Pacific Islander, and then we get to choose one "ethnicity": Hispanic or not Hispanic.

That's not how people identify themselves, and it's not who they are, and it's not part of what determines their health status or the quality of the health care they receive. In Massachusetts, for example, 84% of white, non-Hispanic mothers get "adequate" prenatal care (according to a common standard), and 79% of mothers of Cuban ethnicity get adequate care, but only 64% of Puerto Rican mothers do. If you lump all the "Hispanics" together, you won't know this.

Black doesn't mean African American -- people classified as Black might also be Haitian, Jamaican, or Nigerian. Just to show how reflexively people in the U.S. think in terms of race categories, the New York Times once said that every heavyweight champion since Sonny Liston has been African American. They were forced to print a correction noting that Lennox Lewis is a subject of Her Royal Highness, Elizabeth the Second, rather than our own monarch.

In order to understand health disparities, it's also important to know other information such as people's immigration history, preferred language, level of education, etc. We also need more reliable data about ethnicity, based on people's self-identity, not the guess of a hospital clerk, jammed into procrustean categories. NCVHS has now proclaimed this. Whether the administration will do anything about it, or continue to try to back into the future, that's another question.

The Romance of the Highway

I've been working with some colleagues on a proposal to study the exposure that people living along major highways experience to hazardous emissions from motor vehicles. The physico-chemistry and biology of this problem are not my department, but I've been getting an education. My mission, which I suppose I have chosen to accept, is to study people's knowledge, attitudes and behaviors about highway air pollution.

What I have learned from my environmental science and physician friends was a bit of an eye opener. Most of what we know about air pollution levels in the real world comes from a small number of monitoring stations, which are used to characterize pollution over wide areas -- no smaller than zip code size. But in fact, the pollution people are exposed to varies enormously over just a few tens of meters near highways. You might think that an urban avenue, with idling diesel buses and cars backed up in traffic is worse, but you'd be wrong. Traffic on the interstate puts out some bad stuff, particularly microscopic particles of soot. The natural defenses in our sinuses and lungs can't filter these out, and they go right into the alveoli and then get into the blood stream.

Believe it or not, while you are probably most worried about air pollution being a risk factor for respiratory diseases and lung cancer, these particles apparently cause inflammatory reactions which increase the risk of heart disease, and exposure to highway pollution has actually been linked directly to increased rates of heart attacks and death. This is not a huge factor -- the stuff you already know about, like smoking and diet and exercise and obesity -- are much more important. Nevertheless it's something that people can't control, except by living somewhere else, which makes it a special kind of concern from an ethical and public policy point of view. And, as you might expect, locations near highways are less desirable so that's where low-cost housing is likely to be and that's where low-income people are likely to live. Again, we're talking very small increments of distance - the pollution falls off rapidly within 100 meters or so.

What I have found out, in what is my department, is that people's perceptions of their risk from air pollution are not related to their actual exposure. People think of air pollution as coming from factories and power plants, but motor vehicles are just as important, in fact much more important, for people who live near highways. The problem is, they don't know it.

Ricin, Schmicin; or, The Terrorists Have Won

In my self-torturing effort to keep abreast of the zeitgeist, from time to time I look in on the evening network news. Last night NBC and CBS both devoted a few seconds to the world historical disaster in Iraq; and featured long, breathless stories about a University of Texas sophomore who found a mysterious white powder in a roll of quarters. As I presume you know by now if you have poked your head above the blast wall, she called the police who used a field test which yielded a positive result for ricin, whereupon they evacuated the dormitory and men in moon suits started hauling out buckets of something-or-other for further testing. (Just imagine the toxic stew of vendor machine pastry filling, spilled popcorn oil, stale semen and spermicide, bhang water, and congealed grain alcohol and KoolAid in those buckets.)

NBC repeatedly described ricin as "a component of biological weapons." CBS had the raving ratcheted down to "a potent biotoxin." Now, I'll bet you a subscription to The Journal of Transgressive Post-Feminist Semiotics that upon further testing, the mysterious white powder will turn out to be, not ricin, but paper dust from a printing calculator or the machine that put the quarters in the sleeve. If Osama figured that the best way to kick off the final battle to destroy the United States was to attack a University of Texas sophomore through her change for the washing machine, we probably should feel relieved.

However, you don't need me to point out the obvious. What I have to add is the absurdity of the ricin hype, which we'll apparently have to bury at the crossroads with a silver stake through its heart if we ever want to kill it. During the Weapons of Mass Destruction™ hysteria leading up to the criminal aggression against Iraq, we heard about ricin in screaming headlines week after week. Supposedly it had been found in a train locker in France, in somebody's apartment in England, in the cubicle of a computer programmer in California. The terrorists were coming with ricin to kill us all! The Boston Globe described ricin as a "germ weapon" and after I wrote to them, adamantly refused to run a correction, claiming that Congress had proclaimed it to be one and that was good enough for them. (Seriously. Congress could repeal the law of gravity but that would not cause us all to float off the earth. The Globe also reported that Jack Abramoff "gave generously to Democrats" and refuses to run a correction. Do not believe anything you read in the Boston Globe.)

Okay folks, time to get a grip. Ricin is not a germ weapon, or a biological weapon in any meaningful sense of the term. It is a chemical poison -- just like all the popular poisons of detective fiction since Sherlock Holmes. If you want to kill somebody with ricin, you have to get them to eat it or inhale it, or inject them with it -- just like cyanide, arsenic, atropine. It is "biological" in the sense that it is derived from a plant, but so are most common poisons. It is a "biotoxin" inasmuch as it is a toxin; all toxins are "biotoxins," that's what toxin means, a harmful biologically active substance. It is not especially useful for military or terrorist weapons because it is non-volatile. You could open a 50 gallon drum of ricin in the subway and it would just sit there. Its claim to fame is that it is an unusually potent poison by weight, so the KGB favored it for assassinations, but they could have used other poisons to equally good effect. That's it. It's nothing special. And those field tests are intentionally designed to be highly sensitive at the cost of specificity, in other words they readily give false positive readings.

If the entire country can be provoked to mass hysteria every time somebody finds talcum powder in a medicine cabinet or guacamole spilled on a sidewalk, al Qaeda can just sit back and watch us drown in our own stupidity. Their diabolical scheme is working.

Cleaning out the in-box

Well, I'm back in the real world, from my sojourn in the bowels of the federobble gummint. Let me say that there are still innumerable career civil servants toiling away to do what's right as best they can, but they are wading upstream through rivers of sewage.

Okay.

1. Iraq. With Baghdad locked down, and today being the sabbath, violence has subsided, at least for the time being. While we can still hope that Iraqis will pull back from the abyss, the prospects are dim. The U.S. military stood by and made no attempt to provide security during the past two days, according to all accounts. (I have read the New York Times coverage, and additional coverage is available here and of course, here.) The reason is that they are trying to validate the policy of turning over security to the Iraqi forces. The problem is that there are no Iraqi forces -- the security services that the U.S. has been arming, financing, and training, are simply the militias of Shiite religious parties, in new uniforms. The Sunni Arabs are forced to defend themselves. It has long since become obvious that the U.S. has no discernible or coherent objectives in Iraq, and that the administration is just trying to play for time so as not to admit total failure before the November election. Too late.

2. Environmental Tobacco Culture. Professor Banzhaf, he of the friendly advice to local school board members about sugary soft drinks in the cafeteria, has an interesting take on efforts underway in Canada to ban smoking in most public outdoor spaces. Very few people in the public health community advocate prohibition of tobacco, both because we respect the liberty interests of people who smoke, and because of the counterproductive effects of prohibition of other drugs. However, there has been widespread support for measures, now very widely adopted, to ban smoking in indoor public places such as restaurants, theaters and workplaces, because environmental tobacco smoke is hazardous to non-smokers. As the saying goes, your right to swing your fist ends at the tip of my nose. Outdoors, though, smoke dissipates very quickly and there is no real hazard to anyone who isn't standing right next to the smoker.

Banzhaf, testifying on behalf of an ordinance to ban outdoor smoking in Calabasas, California, offers this rationale:

[C]hildren, as well as some slow adults, will begin to see and appreciate that smoking is no longer the norm to be emulated. Rather, smoking will join gambling, boozing it up, spitting, and certain sex-related pastimes as activities which, while not illegal, should nevertheless be done in private where they do not adversely affect or influence others."

Now this is interesting. It is an argument from the standpoint of public morality -- that allowing the practice to take place where people can observe it is corrupting, particularly of children. We may believe this to be true but there is a catch: this casts smoking in public as a form of expression. While meaning to trump the liberty interest, it actually elevates it by bringing in one of the freedoms we most zealously protect. This is a tough one, for me.

3. Cultural competency in mental health. In case you want to know what I was doing in Rockville, Maryland, it was talking with numerous of my colleagues about this question. To quote a person very close to me, "To try to measure cultural competency in mental health care is to enter an epistemological hall of mirrors." To provide mental health care means to apply diagnostic labels to people and then to try to cure or control the disease which you have declared them to have. That entire procedure can only exist within the context of your culture as a provider. The "client" or "patient" who you are "treating" may very well not believe that any such disease even exists, let alone that they have it, and his or her idea of cure or wellness may be very different from your own.

But you can't just let the client decide what constitutes a good outcome. The result could be highly offensive to society, to your career, or to the client's life expectancy. The culture does impose norms of behavior and wellness. We can criticize them, re-think them, even choose to violate them. But we cannot dispense with them.

Brave New World

Okay, here I am in Rockville, MD attending a meeting at the HQ of the U.S. Substance Abuse and Mental Health Services Administration, located in a vast post-industrial office park wilderness.

When you walk in the front door, there is of course a security station, with armed guards and metal detectors. Behind the security station, on either side of the portal leading to the inner sanctum of the building, are two enormous plasma TV screens, on which are displayed, all day long, Fox News.

Oh, and by the way, the same feature is prominently displayed in the lobby of the hotel where we are staying. For whatever it's worth, of course, the hotel (a Hilton) predominantly does business with the federal government. At Logan Airport, through which I passed to get here, the newsstands (owned by Hudson News) all have enormous televisions showing, during all hours when the airport is open, Fox News.

I may talk about the meeting later, but it turns out I was supposed to turn in my visitor's badge when I left the building, which I did not know. You may never hear from me again.

Good intentions, but a little it over the top?

It seems that Richard Daynard (with whom I am acquainted) and John Banzhaf, public interest attorneys who battered the tobacco companies into submission a decade ago, are about to sue the manufacturers of sugary soft drinks over the agreements they have made to sell their products in schools. Go for it!

They are also sending out very unsubtle warnings to members of local school boards that if their school districts have participated in such agreements, they could face various categories of individual unpleasantness as a result of coming lawsuits. From Banzhaf's site:

YOUR POTENTIAL INVOLVEMENT AS A PARTY: For more serious is the real possibility that school boards -- and possibly even individual school board members -- will become involved as named parties to these law suits. This could happen in several ways.
FIRST, the bottler defendants could seek to bring the school boards in as necessary parties. They presumably would argue that it is the school boards -- entities charged with the primary responsibility for protecting the health of the children -- which made the final decision to provide students with sugary soft drinks during school, and that the school boards are therefore an essential part of any resolution of the problem.
SECOND, perhaps as the result of pre-trial discovery of previously unknown facts -- e.g., secret memos or minutes of school board meetings, "wining and dining" of school board members or other benefits to them, etc. -- the pleading by the initial plaintiffs could be amended to include new parties such as school board members.
THIRD, other parents who believe that the school board and its members are at least equally at fault -- including some who might wish to run for school board membership and/or have other agendas they wish to promote -- may bring new law suits against the school board and/or its members, and then probably seek to have these new law suits consolidated with the existing law suits (i.e., those by the initial plaintiffs against the bottlers).

YOUR POTENTIAL LEGAL LIABILITY: School boards -- and in some cases even individual school board members -- could be sued and potentially held liable under a variety of legal theories ("causes of action"). Some of the major ones are discussed very briefly below. . . .

And it goes on from there, and just gets scarier. In other words, these lawyers want to scare the school committee members straight -- get the toxic slurm out of your public schools, or you will be sorry.

Maybe this is right, maybe it's called for, maybe it will be effective. Or maybe it's counterproductive bullying of ordinary citizens called to public service who suddenly find themselves in over their heads, and it's just going to lend credence to Republican trial-lawyer bashing and give the soda companies an opportunity to make themselves look like they're the kind and gentle dogs in this fight.

What do you think?

Promises, promises

So where is the legislation to ban animal-human hybrids? I am prompted to ask because I'm about to go to Maryland for a Center for Mental Health Services grantee meeting, and that reminds me of something else -- Compassionate Conservatism was supposed to mean eliminating inequality for Americans with disabilities, particularly those associated with mental illness.

Remember the President's New Freedom Commission on Mental Health? One of the first things the new administration did was set up this commission, which made all sorts of recommendations to heal the fragmentation of services for people with mental illnesses, provide access to care for everyone who needs it, support recovery and independence, yadda yadda yadda. It turns out that the only real world manifestation of all this goodness that even got close to happening was a proposal to screen all the schoolchildren in America using a protocol developed by drug companies, so as to get them all on whatever pills Pfizer thought they should be taking. There was a great hue and cry but nothing came of it anyway because it would have cost actual money.

CMHS has just issued a new policy statement about recovery -- how everybody with mental illness is entitled to the supports they need and the opportunity to live independent, full lives, etc. That is truly charming. Meanwhile funding for CMHS is being cut.

There is not one single area of public policy -- not one, zip, zilch, nada, bupkis, zero, nothing -- in which this administration is not hypocritical, dishonest, corrupt, and just plain wrong. The pathological liar in the Oval Office says that society is judged by how it treats the most vulnerable among us, by which he means the brain dead and the embryonic. People who are conscious, and who are troubled and suffering, don't mean shit to him. Actually I sincerely doubt he cares about the blastocysts and the vegetative either, or anybody or anything except his own power and the adulation of sycophants.

I hope to be able to post from the road, but it may turn out to be a problem. If I'm absent for a couple of days, you'll know why, but I'll catch up when I'm back.

The No-Exit Strategy

A lot of bloggers make their living by dropping in on the opposition and mocking them -- you know, Atrios and the Wanker of the Day, that sort of thing. As you know, I always try to stay positive, stay on the sunny side, look forward not back. But what the heck, I said to myself, I wonder what Pat Robertson is up to these days?

It turns out he has an Iraq exit strategy. And you can help! That's right, every Christian American can do his or her bit to bring our troops home. Ahh, there is a small catch -- you have to "join the community," which means that Pat will ask you for money -- but that's really just an added benefit, since you will have so many ways to give and so many opportunities to be relentlessly asked. Not only that, you get a health benefit -- a chance to learn all about Pat's Age Defying Antioxidants!

Here's how it works:

Here is the Biblical Exit Strategy

We are asking thousands of churches and individuals to adopt the newly-elected Iraqi leaders by name for six months of weekly prayer support in three areas:

* For Safety: They and their families must survive the many attacks that will come.
* For Wisdom: They must have the wisdom of God to rebuild their government and nation.
* For Courage: To persevere in serving Iraq until the job is done.

Within three months, we intend to send each adopted Iraqi leader a list of hundreds -- perhaps thousands -- of Christians and churches in America and worldwide praying for them and their families by name for 180 days!

* This kind of sustained prayer for Muslim leaders may never have been done before in Church history! This is a wonderful way to love Muslims with God’s love!
* 180 days of prayer could empower those leaders to turn Iraq 180 degrees toward peace and stability -- hence Back Iraq 180!

You'll get regular e-mail updates on prayer needs from Iraq, along with regular updates on Pat's need for money. And the best part is, it's bound to work! I mean, how can history possibly defy the power of prayer to the Christian God?

I've only got one question -- if God can fix this thing, why is he waiting around for Pat's followers to pray for it? Isn't that kind of unfair to all those people who are getting blown up and shot in the meantime? Just a thought. Plus I have another question -- why bother to take Pat's age-defying antioxidants when you can just pray for youthfulness?

Administrative note: I'm doing Today in Iraq and Confined Space today, so that's all you get from me here for a while. But do check out our blog partners.

Not a family guy

I'm sure y'all have heard more about it in the rest of the country than you might like to, but here in Massachusetts its been wall-to-wall, non-stop, all Neil Entwhistle all the time on the TV and in the newspapers. That's the fellow who (pending a unanimous finding by a jury of his peers) appears to have shot his wife Rachel and their infant daughter in the marital bed before fleeing to his native England. (Unlike Harry Whittington, who had the good grace to apologize to Dick Cheney, Rachel's parents have yet to apologize to Neil.)

Anyhow, as with all such media feeding frenzies, some cultural criticism seems to be called for here. Although the rate has been declining, about 1,200 women are murdered by their husbands, ex-husbands or boyfriends each year in the U.S. Women kill their male partners less often, about 300 times a year. Either way, guns are the most popular method. You can take a look at the trends in California here. Discussion of the reasons for the recent decline -- mostly lesser exposure in that divorce is more common and people are more often single, as well as improved access to domestic violence services -- is offered by some learned professors here.

So okay, out of thousands of man-kills-family stories, why does this one get the OJ treatment? We know why OJ got the OJ treatment, but this one featured a non-famous protagonist and no race relations implications. It did, however, happen in an affluent suburb in a family of middle class origin, complete with pictures of the victims just about glowing in the dark, and the expensive looking home with the faux-brick facade. (Actually, they were broke, and the house was rented, but the picture still looked good.)

Reporters, as a class, are intellectually lazy and irresponsible. That's all there is to it. The profession as a whole is in a disagraceful state. What is most disturbing is that they don't seem to realize that they have lost the respect of the public, and they aren't making the slightest effort to win it back.

The doctor will not be in . . .

The American College of Physicians, which is the appropriately general name, I suppose, for internists -- primary care doctors for adults -- foresees its own extinction. The Impending Collapse of Primary Care is the alarming title of their recent report on the state of the profession.

Sure, there's self-interest involved -- they want to get paid more, or work less, or a little bit of both -- but the fact is, fewer medical school graduates are going into primary care, and more primary care docs are getting out. The major complaints are not new -- the alarm bells have been ringing since I first studied health care policy 20 years ago, but we've just been going backwards. Medicare is extremely important in this story, but so is private insurance. Health insurance underpays for primary care physicians' time spent with patients, and the money flows toward diagnostic procedures and technical interventions.

Many of you probably are aware of the recent New York Times article that noted that diabetes management programs in New York City failed financially, even though they were successful medically, because insurers wouldn't pay for the time spent with patients to support them in taking care of themselves and preventing complications, whereas they have no problem at all with paying $30,000 for amputations.

Here are a couple of points from the ACP report:

A recently-published study of the career plans of internal medicine residents documents the steep decline in the willingness of physicians to enter training for primary care. In 2003, only 19 percent of first year internal medicine residents planned to pursue careers in general medicine. Among third-year internal medicine residents, only 27 percent planned to practice general internal medicine compared to 54 percent in 1998.

snip

The declining interest in careers in primary care is important because the collapse of primary care will result in higher health care expenses and lower health care quality:

• When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending.
• Studies have shown that primary care has the potential to reduce costs while still maintaining quality. Not only does early detection and treatment of chronic conditions play a vital role in the health and quality of life of patients, but it can also prevent many costly and often fatal complications when illnesses such as diabetes and cancer are diagnosed at a later stage. As expert diagnosticians, providing patient-focused, long-range, coordinated care, general internists play a significant role in the diagnosis, treatment and management of chronic conditions. It has been reported that states with higher ratios of primary care physicians to population had better health outcomes, including mortality from cancer, heart disease or stroke.
• States with more specialists have higher per capita Medicare spending. An increase in primary care physicians is associated with a significant increase in quality of health services, as well as a reduction in costs.

. . . If they do say so themselves. But they're right. Medicine ought to be about taking care of people, and doctors who do that need to be valued, and paid for it.

Enough already

If Dick Cheney wants to shoot his pals, that's fine with me. Have at it!

I'm much more worried about the tens of thousands of strangers who he has maimed, tortured, and murdered. But that's just me. Evidently the rest of the world, including Atrios, Josh Marshall, Matthew Yglesias, and the whole gang, have the opposite opinion.

Maybe we should consider talking about something else. Just sayin'.

Department of How could I have missed this?

I believe I had something to say last year about the vicious cuts in Missouri's Medicaid program, which immediately threw 90,000 poor people -- elderly, disabled, and families with children -- off the rolls, and cut benefits to 300,000 more, including, get this, breathing equipment. Of course hospitals are stuck with the bills for people who can't pay, and the state loses federal matching funds. But I missed two kind of important points at the time. The first is Governor Matt Blunt's concept of Christian morality. Here's from the NPR story last May:

The proposals have opened a moral schism, with some preachers expressing outrage, but the governor, a devout Christian, defends the cuts as morally correct. Gov. Matt Blunt says not cutting Medicaid would force him to raise taxes -- and in his eyes, raising taxes is wrong.

That's from the Gospel According to Saint Pat Robertson, of course.

What I also missed is that they also voted to eliminate Medicaid entirely by 2008. Now that's really getting Christian on the people's asses. According to Community Catalyst, however, the devil stalks Missouri -- they just aren't good Christians after all:

Despite the rhetoric from conservatives, polls show that these cuts are not popular with the public. A recent poll of 800 likely voters commissioned by the St. Louis Post Dispatch and KMOV-TV found that 22% of voters rated providing Medicaid to the poor and disabled as the most important issue facing Missouri, second only to education (25%). 64% thought the cuts made to Medicaid were "too severe". (St. Louis Post Dispatch, January 21, 2006).

Missouri hospitals have been pushing an initiative for a tobacco tax, but the money would not go to support Medicaid, so a coalition has formed to save Medicaid in Missouri through the tobacco tax. That may be better than nothing but the last thing the Satan worshippers in the Show Me state should want is for Medicaid to be dependent on healthy sales of cigarettes. Meanwhile, all I can say is, if Jesus Christ was alive today, he'd roll over in his grave.

As if I didn't have enough to do . . .

Nevertheless, I'm honored to have the opportunity to join Revere of Effect Measure in holding down the fort at Confined Space for Jordan Barab while he takes a week's vacation (whatever that is -- some sort of voluntary absence, as I understand it.)

Jordan has been a leading web voice on occupational safety and health for a long time now. I can't fill in adequately, but I'll do my bit to keep the seat warm. Hope you'll all check it out.