Inferiority Complex

I'm seldom at a loss for words, but I sat down today feeling that I could not say anything adequate to the occasion. I have a feeling there's a lot of that going around. Suddenly, I feel as though perhaps I belong in this country after all. In a heartbeat, the values I share have become essential, celebrated, honored, after decades of scorn and contempt from the arbiters of respectable opinion. My friends and relatives have canceled their plans to move to Canada or dust off that Irish ancestry and head for the Eurozone.

Sure, it's just a fad, and we all know that inside of a month Tweety and Modo and Brian Williams will be back to spewing their usual swill. However, it is not too much to hope that racism will no longer be dispositive in convincing working class people to betray their own interests on election day. It's not too much to hope that Americans will stop viewing war like a football game and confusing arrogant bullying with respectability. It's not too much to hope that God will go home to the chapel and the value of life will be understood as pertaining to the living. It's not too much to hope that we'll behave responsibly toward our progeny and toward each other. It's not too much to hope.

Murder Pays

If you're a drug manufacturer. You may have heard that Eli Lilly has agreed to pay a total of $1.42 billion to resolve criminal and civil charges related to its marketing of the antipsychotic drug Zyprexa (generic name olanzapine). Like the other so-called "atypical" antipsychotics, the drug was tested in clinical trials to control symptoms of psychosis. Not a whole lot of people have psychoses, however, so they looked for bigger markets.

The linked article describes their efforts to market the drug in nursing homes and assisted living facilities, to be given to people with dementia; and to primary care doctors, who obviously would have no business prescribing it since psychoses are only appropriately managed by specialists. In fact, like all the atypical antipsychotics, the drug is extremely dangerous. It causes weight gain, diabetes, and heart rhythm irregularities and is therefore associated with both long-term development of cardiovascular disease and increased risk of sudden cardiac death.

The AP article doesn't mention what might be the worst part, but New York Times does: Lilly was heavily promoting the drug for "disruptive" children. The side effects of weight gain and hyperglycemia are particularly pronounced in children, and obviously set them on a lifelong path of ill health and risk for premature death. They got a lot of help from a psychiatrist at Harvard named Joseph Biederman, who has almost singlehandedly created an epidemic of diagnosing bipolar disorder in children and feeding them antipsychotic drugs. According to the NYT:

In the past decade, Dr. Biederman and his colleagues have promoted the aggressive diagnosis and drug treatment of childhood bipolar disorder, a mood problem once thought confined to adults. They have maintained that the disorder was underdiagnosed in children and could be treated with antipsychotic drugs, medications invented to treat schizophrenia.

Other researchers have made similar assertions. As a result, pediatric bipolar diagnoses and antipsychotic drug use in children have soared. Some 500,000 children and teenagers were given at least one prescription for an antipsychotic in 2007, including 20,500 under 6 years of age, according to Medco Health Solutions, a pharmacy benefit manager.

What Biederman wasn't telling us -- what he was in fact actively lying about -- was that during this period he took more than $1.6 million in consulting fees from drug companies, including Lilly; and that his studies of antipsychotic drugs in children, funded by the drug companies, were too small and poorly designed to show the benefits he claimed they showed. In fact, whether such a things as bipolar disorder even exists in children, or could be accurately diagnosed, is questionable. But the harm done by these drugs is unquestioned.

As for elderly people with dementia, Lilly knew for years that Zyprexa increased their risk of death, and the FDA finally issued a "black box" warning to that effect in 2006. But the marketing campaign was so successful that it continued to be effective long afterwards. We discovered that my own father had been given antipsychotics, in an assisted living facility in 2007 and in a nursing home in 2008, without consulting my mother and, in the second case, contrary to her specific orders. The reason? He was wandering around and it was easier for the staff to zonk him out with drugs than to keep an eye on him. And that was indeed the basis for much of the marketing -- that stoning old folks made it easier on the staff.

Now, you may think that $1.42 billion in fines would be a pretty strong deterrent to this sort of behavior, but in fact, Zyprexa brings in $4 billion a year, so Lilly is happy to pay it. As for Biederman, he's in big trouble -- they've made him promise not to do it again. In fact, the executives at Lilly, and Dr. Biederman, are murderers, and their motive is greed. They should be dealt with accordingly.

Is South Carolina a real place?

State Sen. Fuckwit Ford has introduced legislation to fix the country's real problem:

Be it enacted by the General Assembly of the State of South Carolina:

SECTION 1. Article 3, Chapter 15, Title 16 of the 1976 Code is amended by adding:

"Section 16-15-370. (A) It is unlawful for a person in a public forum or place of public accommodation wilfully and knowingly to publish orally or in writing, exhibit, or otherwise make available material containing words, language, or actions of a profane, vulgar, lewd, lascivious, or indecent nature.

(B) A person who violates the provisions of this section is guilty of a felony and, upon conviction, must be fined not more than five thousand dollars or imprisoned not more than five years, or both."

Don't know if this ridiculous fucking shit will pass, but either way, nothing would please me more than for the South to secede again. Then we'd have a whole nation of dipshits.

Some feeble reflections

First of all, thanks to all for the condolences and good wishes. I suspect that long-time readers may have figured out the situation -- that my father had progressive dementia. It was a terribly long process, and his death I'm sad to say really came too late. But it's a relief that it has finally happened.

I have not written a great deal about the problems of long term care and the related issue of the growing prevalence of dementia. That is essentially because I haven't felt I had much to say that was in any way original or profound. There are some policy reforms that would ameliorate this problem to some extent, but there is no real policy solution. It's going to be a great burden on families and on society, part of the price we pay for increased longevity, unless we come up with some technical fixes to prevent or greatly slow the progress of dementia.

As for policy reforms, there is certainly a justice case to be made for socializing the cost of long-term care by expanding Medicare benefits to cover it. As you probably already know, the family has to spend down to near penury, whereupon Medicaid takes over. The quality of Medicaid financed care varies from state to state. Fortunately, in Connecticut, the benefits are sufficient to pay for good quality care, although you have to be lucky enough -- as my family was -- to find a good nursing home. And the only way to do that is for the person to enter the nursing home as a private payer. The good ones won't accept Medicaid patients, although they will let the person stay once they make the transfer.

My parents had a decent nest egg, but it was completely wiped out, as happens to just about everybody in their situation. It takes true wealth to survive four or five years of custodial care. Expanding Medicare to cover this means that everybody will pay more in taxes, but we'll be buying insurance against this catastrophe. It would also end the discrimination against low and moderate income people who must depend on Medicaid and who often end up in situations that we should not tolerate.

However, the most logical existing structure through which to do that would be Medicare Part A, which is financed by a regressive payroll tax. There is nothing unethical, in my view, about requiring all workers to take on a fair share of the burden of caring for their elders, but such a system ought to have progressive financing. And I'm afraid that right now, it just isn't politically viable. Everybody is screaming and yelling that the cost of Medicare is already unsupportable and has to be reduced. To stand up and say, no, we have to raise taxes and expand Medicare is probably feckless. But listen up folks, we're going to pay for it, one way or another.

There are some additional advantages that could come with an expansion of Medicare. It could pay for home based services and adult day care programs, which most people would likely prefer as long they were a viable option; and then for assisted living rather than nursing care. More use of these kinds of services would reduce overall costs. Right now, some people are forced to accept nursing home placement prematurely because that's the only modality Medicaid will pay for.

Sadly, though, this is not going to happen any time soon. In the current discussion of health care reform, it's not even a footnote.

Personal news

My father died this morning, after a long illness. It was expected. I probably will not be able to post for a couple of days, but I'll be back here as soon as I can.

Perhaps I'll have something to say about long-term care and end of life issues, but unfortunately my family's case is all too common. Anyway, it's good that it's finally over.

The God who failed?

I'm happy to be able to say that I'm not an economist. I do know something about economics, however, because I had to pass qualifying exams in that subject en route to my Ph.D. Notice I said I know something about economics thanks to those studies, not that I know something about the economy. Asking an economist to explain the economy is like asking a theologian to explain biology. A lot like that, actually. Exactly like that.

Well, this curmudgeon is actually pleased -- yes I am -- to see that some economists are actually coming forward and admitting that yep, their profession is full of crap. Here's Uwe Reinhardt, who is big stuff, here just happening to notice that 99% of economists failed to see the big crackup coming:

If groupthink is the cause, it most likely is anchored in what my former Yale economics professor Richard Nelson (now at Columbia University) has called a ”vested interest in an analytic structure,” the prism through which economists behold the world.

This analytic structure, formally called “neoclassical economics,” depends crucially on certain unquestioned axioms and basic assumptions about the behavior of markets and the human decisions that drive them. After years of arduous study to master the paradigm, these axioms and assumptions simply become part of a professional credo. Indeed, a good part of the scholarly work of modern economists reminds one of the medieval scholastics who followed St. Anselm’s dictum “credo ut intellegam”: “I believe, in order that I may understand.”

Well now isn't that exactly what I have been saying here for years? Unfortunately, Professor Reinhardt doesn't draw the obvious logical inference, which is that universities should stop paying these clowns to indoctrinate students with unmitigated baloney. Economists actually have the audacity to claim that they are the only "hard" social scientists, a distinction which they apparently think they earn because they use a lot of mathematics. In fact, if you start out by assuming a lot of stuff that isn't true, then manipulating those imaginary entities mathematically is not any kind of science, hard, soft, liquid or gaseous. It's masturbation. It is unnecessary to teach college students how to masturbate.

The entire discipline is utterly worthless. Economics departments ought to be abolished and the professors turned out to do useful work, clerking in bookstores or something. They need to start over, with the study of reality, but other people will have to do it, who possess working intellects. As Reinhardt concludes,

As far as diagnoses of economic trends and predictions about the future are concerned, the profession’s preferred analytic structure and the groupthink it begets might work superbly well on planet Vulcan, whence hails the utterly logical Mr. Spock of “Star Trek” fame.

On Planet Earth, however, that analytic prism can seriously blur one’s vision. It simply cannot accommodate the fact that our entire 21st-century banking sector, managed as it is by graduates of the nation’s top business schools, supported by highly trained financial engineers, and monitored around the clock by thousands of allegedly bright financial analysts, immolated itself with highly toxic assets, purchased with borrowed money, and in the process infected the entire world economy.

And thus the economics profession slept comfortably as Wall Street was imploding. One can only hope that the medical profession would do better, should America ever be struck by a serious epidemic.

Right. Well, incompetent physicians lose their licenses. Think about it.

Okay, now where were we?

Sorry for erratic posting, I'm dealing with a family emergency. It may take me off line for a few days, but I'll let you know.

Anyway, Borderline Personality Disorder is terrible nomenclature and I really wish they'd change it. The name comes from a time when they thought BPD was somewhere on the borderline (get it?) between the historic constructs of psychosis and neurosis. (Those terms are still used, but the meaning has evolved somewhat.) The idea is that people with the diagnosis stubbornly interpret reality in ways which differ from the perceptions of others, i.e. there is something close to delusional about them, it just drives you nuts trying to get them to have useful insight into their own behavior.

Specifically, and this is my personal description, it's not by the book, people -- who are mostly female -- with this diagnosis have a powerful aversion to being alone and a pervasive fear of loneliness and abandonment. This causes them to develop extravagant crushes, romantic or otherwise, on people who may not reciprocate the attraction -- or who may exploit it -- and to be highly manipulative, clinging and needy in these relationships, whether the relationships exist largely in their own heads or have some mutuality. Naturally, this excessive neediness and the passive-aggressive manipulativeness that comes with it has the effect of driving its objects away, whereupon the person develops a narrative of victimhood and cruel abandonment, putting all the blame on the formerly beloved object who is now utterly contemptible. Along this path there may be an episode of stalking behavior.

This pattern repeats over and over, accompanied by extreme emotional lability (possibly buying a co-diagnosis of bipolar disorder), and often substance abuse, suicidal ideation and gestures (though uncommonly real suicide attempts), sexual promiscuity, self harm, crying fits and tantrums.

As you can see, the people who are most likely to be attracted to this person include narcissists and sociopaths, so you may have some very ugly situations.

The conventional etiological story about this is quite Freudian sounding, and also intuitively fairly convincing. The idea is that it comes from a failure to internalize objects, specifically the protective and nurturing adults of infancy. Babies eventually get the idea that even though Mommy isn't here right at this moment, she still exists and will come back. We learn to comfort ourselves with the dependable love of people even when they aren't with us. As adults, even the deceased are still a part of us. But if you can't do this, you have a problem.

And indeed, people with the diagnosis have a higher than usual prevalence of lack of nurturing during infancy and childhood, even of abuse. It doesn't have to be there, but it's a pretty good indication if it is.

Now, here's my argument for the essential validity of classifying this as inherently a deficit in a human personality, whether or not you like the term "disease," and why this is not similar to labeling homosexuality as a pathology. It turns out that the only reason homosexuals have historically been unhappy and even suicidal is because they have been despised and persecuted. Take away the stigma, and you take away the problem. We now know, from ample experience, that it is perfectly possible to be happy and functional as a homosexual so long as you are in an environment which is sufficiently accepting and affirming. Take it from me, I live in Jamaica Plain and work in the South End. (I'm not gay, but I'm fabulous anyway.)

But the problem with BPD or whatever you want to call it is not moral stigma. People who behave that way are inherently difficult and burdensome to others. It is very difficult to imagine a human society in which BPD is not dysfunctional and a continual source of grief and pain, for the sufferer and those around her. Human social organization is hugely variable, but it is built out of a finite set of elements that work something like Lego blocks -- they link together in a specific, limited way that gives you the freedom to create great, complex edifices.

There is a natural social grammar, if you will, analogous to the natural syntax on which our vast diversity of languages is built. Children who are not autistic quickly acquire this social grammar as easily as they acquire language. It is intuitive, and it is also universal. Although politeness rituals and taboos vary across cultures, these can be described for us by an etiquette book or a human guide, and armed with this intellectual understanding we can readily associate with people of any culture and form friendships and even intimate attachments. We understand that relationships require reciprocity, recognition of the other's needs, boundaries, how much emotional availability they have for you, and whether or not they feel like spending time with you at this particular moment, among other kinds of limits. We get that demanding too much of other people is counterproductive.

The word normal has 3 meanings. It can mean corresponding to moral norms; it can mean average or typical; and it can mean "as we would desire things to be." Whether a person is average or typical in some way often just doesn't matter, or a person can be deviant in a good way, e.g. abnormally intelligent. Homosexuality is abnormal in the sense of being a minority condition, but whether it is abnormal in either the first or third sense is entirely dependent on circumstances. We can just decide that it's not immoral and that's the end of that, and after that the only reason I can think of offhand that it might conceivably be undesirable is if we are in danger of extinction, which we aren't. But BPD is inherently abnormal in the third sense. It just doesn't work.

Finally, there is a lesson here for all of us. Even if we don't merit the diagnosis, there may be a little bit of the maladaptive behavior in most of us. It's easy to slip into dependency, or demanding more of people than they can comfortably give, not giving enough in return, making a relationship more about ourselves than about each other. It's always good to think about that.

Disease, sickness, illness, disorder, condition . . .

First of all, I should acknowledge that Kathy A. is basically right, I was a bit sloppy with my vocabulary. ASPD is a pretty vague and often circular diagnosis that can be applied to anybody who badly misbehaves; what I really meant to defend is the much more specific, and rare, label of psychopathy. What I meant to say is that the diagnostic label should be reserved for people who truly lack the capacity for empathy.

So let's back up a bit. In medicine, diseases are usually defined in terms of an etiological process. Similar symptoms may be ascribed to completely different diseases, e.g. infection by different viruses; while people with no subjective symptoms may be given a diagnosis because of some biological fact which is believed to create a risk for illness (the subjective experience of poor health) in the future, e.g. HIV infection or hypercholesterolemia. Physicians generally don't like to call clusters of symptoms without a known etiology diseases, rather they call them syndromes, and they tend to argue about the ontological status of such entities. Good examples are fibromyalgia and chronic fatigue syndrome.

In psychiatry, however, etiology is generally unknown. Practitioners like to tell stories about causation but they are usually poorly supported by evidence. Drug companies also market theories about biological causes of DSM-defined diseases but these are largely mendacious. For example, they have convinced most people that a disease called depression is caused by a deficiency of the neurotransmitter serotonin, but this is almost certainly false. The evidence for this is supposedly that drugs which increase serotonin levels alleviate depression, but even if that were true -- which it is not for the large majority of people diagnosed with depression -- it would not demonstrate that depression is caused by serotonin deficiency. Amphetamines cause people not to feel hungry even when they don't eat, but that doesn't mean that the cause of hunger is amphetamine deficiency, even less that the solution to hunger is amphetamines.

The DSM entities are defined by symptoms, mostly consisting of descriptions of behaviors, not by etiology. Since human behavior is continuously variable, highly flexible, highly complex, and mutable, it's very hard to rigorously sort people into behavioral buckets. Generally speaking, only the most stereotypical, rigid and simple kinds of behaviors can be measured unambiguously. For example, Tourette's Syndrome has a strong ontological claim, because we can say quite definitely whether or not a person has an uncontrollable, repetitive behavior of injecting inappropriate words into conversation. But those sorts of entities are usually thought of as neurological rather than psychiatric, and once a definite etiology is discovered, they cease to be the province of psychiatry at all.

So, now I hope I've cleared the decks enough to discuss BPD. My basic reason for wanting to do so is to argue that it is not entirely feckless to look for psychodynamic explanations for emotional and behavioral problems, and that perhaps there is a coherent story to be told about "normal" human personality development and the ways in which the social environment can derail it. We need a definition of "normal" in order to say that, and in fact the word has multiple meanings. But it can mean more than just whatever the culture currently happens to find morally meritorious, or whatever happens to be most common. In both those respects, homosexuality used to be abnormal, as it still is for some people, and probably always will be in the latter respect. But I mean to argue that BPD is different.

The wind blows cold on the borderline

As you know, I'm highly skeptical of the ontological status of the DSM diagnoses, which is a fancy way of saying I think for the most part that they don't refer to real entities. My philosophy is realism: if it's real, I believe in it, but I don't believe in the DSM-IV. Well, the book is real, the rhetorical categories in it exist, but what I mean is that their referents are not really real.

This is most true of the so-called personality disorders. If you read the diagnostic criteria, you'll probably start thinking, "Oh yeah, that sounds kind of like Uncle Fred or Cousin Mae." But do Uncle Fred and Cousin Mae have a disease, or are they just a pain in the ass? And then you'll think, "Well, Fred isn't exactly like that. A couple of those items don't describe him after all, and one or two others aren't exactly right." Research has shown that the diagnostic reliability of the personality disorders is poor -- people get different diagnoses from different clinicians. Furthermore, lots of people get a diagnosis of a little it of this, and a little bit of that. The person is avoidant with dependent features, that sort of thing. Exactly where to draw the line between your friend the drama queen and a person with the disease of histrionic personality disorder is impossible for anyone to say. Finally, there are no evidence-based etiological theories for most of these disorders.

So all of the above knocks the pins out from under any claim that these are labels for real entities. They are more like character sketches from novels, that resemble actual people to varying degrees, and the main reason for calling them diseases is to provide the required diagnostic label for billing purposes. That is not to say that people who have difficulties with social relationships might not benefit from counseling, and these frameworks might even prove useful as a way in to discussing the problem. I'm not saying nobody should ever talk in these terms, that's a more complicated argument.

However, I'm now going to surprise you (maybe) by saying that I find two of the personality disorders reasonably convincing. One is antisocial personality. It has a clear, well-bounded definition: lack of empathy, pervasive indifference to the rights and well-being of others. Something quite specific is missing which we expect a properly put-together human being to have. It is nevertheless rather odd to call it a disease since the person to whom the label applies probably doesn't think anything is wrong with (usually) him, and doesn't want to be fixed. I have discussed this at greater length in the past and will return to it.

The other personality disorder that pretty much works for me has the grotesquely wrong label of borderline personality. The term comes from a historical misperception that it was close to being a psychosis, since the person consistently fails to see certain aspects of reality which are evident to the people around (usually) her. My friend Gary Greenberg has argued that borderline personality should be thought of, not as a disease, but as a kind of moral judgment, much as homosexuality used to be considered a psychiatric disease essentially because of social disapproval. (I can't link to Gary's original article, which as far as I know is not on-line, so the link is to a discussion of his argument by Linda Nicolosi.) That is different from denying the ontological status of both conditions: homosexuality is obviously real, and Gary's argument presumes that borderline personality is just as real.

I agree with Gary about the latter assertion, but the former -- that it's only social convention that makes borderline personality a problem -- is one of those rare instances where we disagree. I'll take that up in the next post.

The chronosynclastic infundibulum

As Vonnegut fans know, that's the place where all possible opinions are true. My recent encounter with AIDS denialists, like an earlier (longer lasting and more intense) encounter I had here with creationists, has forced me to think a bit about the nature of knowledge, and why there are so many people out there who fervently believe stuff that I know damn well just isn't true. Obviously, they think the same about me, so I have to be able to show that there's a difference, that you, dear reader, have a basis for concluding that I'm right and they're wrong.

This is obviously a complicated subject, which is why half of philosophy is epistemology. There's a denialism blog, if you're interested in getting into the subject in depth. But what's the difference between denialism and legitimate intellectual dissent? There have been plenty of examples of people whose ideas were considered wacko at one time, but are now entirely accepted, e.g. Copernicus and Stanley Prusiner. The Denialism bloggers define it this way:

Denialism is the employment of rhetorical tactics to give the appearance of argument or legitimate debate, when in actuality there is none. These false arguments are used when one has few or no facts to support one's viewpoint against a scientific consensus or against overwhelming evidence to the contrary. They are effective in distracting from actual useful debate using emotionally appealing, but ultimately empty and illogical assertions.

Okay, but what makes me and Mark and Chris Hoofnagle the judges of what constitutes overwhelming evidence and what constitutes empty and illogical assertions? Our friend PZ Myers at Pharyngula (see sidebar) spends his blogging days arguing with creationists; he takes the time to engage them point by point. I personally agree that he proves they are deluded and generally incapable of coherent thought, but that does nothing to convince them or for that matter half of the American people. (Granted most of them know nothing about biology or paleontology and just believe whatever Rick Warren tells them to believe.)

I personally have made a substantial study of the subjects I write about here, including the pathology of HIV, and the scientific evidence concerning the history of the earth and of life hereon. However, I must admit that I fit a lot of other beliefs into my complete system without having in-depth knowledge. I accept the explanations of physicists and chemists essentially because I trust the institutional structures within which they work. I do read their stuff in Scientific American but that doesn't mean I understand the foundational work on which the conclusions they present for educated lay people are built. I basically just have to accept what they are saying.

This does not, however, make me comparable to creationists. True, most of them do invest credibility in some form of institution, usually a church. But it's the source of that credibility which is different. Faith-based denialism can be described and explained fairly easily, I think, as I have done in my post Thinking Backwards and a follow-up post.

But AIDS denialism is another matter. It has nothing to do with religion, or the violation of some prior belief system. The same goes for the thimerosal and autism nonsense, and global warming denial. These faux controversies are driven by people who claim to be rational empiricists, who are following the evidence where it leads them. It's just that their arguments are utterly nonsensical. What they have in common is a kind of political stance, that the entire scientific establishment, in each respective field, is actually a vast conspiracy against the public. Purported motivations include greed for research grants, a deeply vested interest in conclusions to which they jumped too soon, or an ulterior motive such as the destruction of capitalism or profits from drug sales.

That so vast a conspiracy is implausible -- involving, as it does, not only established scientists who lead research teams and publish in leading journals, but also every Ph.D. candidate, all of whom are successfully recruited into the conspiracy and none of whom blows the whistle; research assistants who even if they don't have a doctorate know enough to figure out the fraud; journal editors; public and private funders; and scientists in related fields who know enough to see through the fraud -- does not give them pause. But then you read the denialists' actual arguments and they are just absurd -- wrong on both facts and logic.

So we really need to look at their motivations. Some are con artists who are simply taking money from suckers. Others are more interested in self-aggrandizement and attention. I'd put RFK Jr. in that category, though he's made some money off of the deal as well. Some AIDS denialists just don't want to face up to the reality of their own situation, I suppose. How would you explain it?

Now let's get real here

Okay folks, I have a responsibility to be absolutely clear and straight about this. There is no doubt whatsoever that:

a) Human Immunodeficiency Virus, HIV, a very well-studied and well-characterized entity, is the cause -- the sole cause, and a sufficient cause all by itself -- of a disease in humans called Acquired Immunodeficiency Syndrome, AIDS.
b) Combinations of drugs, collectively called Highly Active Antiretroviral Therapy, or HAART, that suppress replication of HIV, slow or entirely prevent the progression of HIV disease, and can reverse it when it has already developed.
c) People who are infected with HIV, who use HAART and adhere closely to the required dosage schedule, live much longer, and in better health, than people with HIV who do not use HAART.

Denying this is flat earth stuff, folks. It's like claiming that aspirin causes headaches. We know this, we don't just think it or believe it, and the way you can know it too doesn't require any scientific training and it doesn't require you to believe anything scientists say about the nature of HIV or the way the drugs work. Here's how you know:

Many tens of thousands of people all around the world, including in the United States, who had never taken any antiretroviral drugs but who nevertheless were terribly sick with AIDS, even terminally ill and on the point of death, who started taking antiretroviral drugs, recovered from their illness. They quickly, seemingly miraculously, got better. Their opportunistic infections disappeared. Once wasted away, they started gaining weight. Once bedridden and incapable of the basic activities of daily living, they arose from their beds, became active and vigorous, and resumed almost normal lives.

Doctors have observed and documented this phenomenon not only in writing, but in photographs and film documentaries. I have personally met and spoken with many people to whom this has happened -- people who fully expected to die and were preparing for death who suddenly found that they had lives again, and whose biggest problem was rediscovering life.

Remember that before the advent of HAART, AIDS was the leading cause of death for people age 20-49 in the United States. Thousands of people were dying every year. Furthermore, there were hundreds of children born every year with HIV infection transmitted from their mothers. Untreated, these children -- none of whom, obviously, had ever abused drugs or had repeated STDs or been malnourished, or any of the other reasons AIDS denialists say people with AIDS really get sick -- got sick and died, usually before they were six years old. With the advent of HAART, they stopped getting sick and they stopped dying and now they live right on into adolescence. We don't yet know how they'll do in the longer run but so far, so good. And, even better news, ARV drugs given to mothers absolutely do prevent transmission of HIV to their babies, so perinatal HIV in the United States is now extremely rare. Large programs that helped care for children with HIV and support their families have gone out of business. A whole cohort of pediatric specialists has had to find other work.

These are facts. They are incontrovertible. They speak for themselves. HIV causes AIDS. HAART prevents AIDS. QED.

Now, the drugs have side effects. For some people, these are worse than they are for others, but the side effects can be pretty bad. They include redistribution of body fat leading to physical deformity, hypercholesterolemia, diabetes, peripheral neuropathy, nausea, diarrhea. Many people who take HAART end up taking other drugs to manage the side effects, and they often end up feeling like a walking drugstore. Some people take 12 or 15 different medications.

Believe me, I hear you. That can be a stone drag. It's perfectly understandable that people often want to stop taking the drugs and take their chances with HIV, at least for a while. People with HIV do this so often that it even has a name -- a drug holiday. People might also decide that they'd rather wait to start taking HAART until their HIV disease is advanced enough that they really have no choice.

I'm certainly sympathetic to these positions, but I should also tell you that doctors have done a lot of experiments to try to find the best strategies for managing HIV disease, and they have concluded that drug holidays are not a good idea. They increase the chance that the virus will become resistant to the drugs, and they allow degradation of the immune system and other damage to occur. Delaying treatment too long is also not a good idea. While the consensus is not for immediate treatment, it now seems clear that it's not a good idea to let your T-cell count go below 300 if you want the best long-term prognosis.

These are the facts. Now, sometimes physicians don't do a good job of working with their patients to help them make the choices that work best for them. Doctors can be unsympathetic to the problems people have following their regimens, and respond to those difficulties with judgmental attitudes, scolding, or just callousness. These behaviors by doctors are counterproductive and can even lead to people stopping their medications.

Now, if you do stop, of course you will immediately feel better because you will no longer experience drug side effects and the psychological burden of having to be reminded that you have a serious disease every time you take the pills will be lifted from you. But eventually, your HIV disease will progress and then you will feel a whole lot worse. That's the way it is.

If you've decided to stop, that's your choice and I certainly don't think it's a moral issue or it makes you a bad person or anything like that. But please don't go around giving wrong information to other people.

Is that your final answer?

Orac and others have been all over the death of AIDS denialist Christine Maggiore, so I won't try to re-invent that particular wheel. I'll just give you a brief summary. Maggiore was a young woman who became infected with HIV and then had the very bad fortune to meet wacko pseudo-scientist Peter Duesberg, who persuaded her that HIV does not cause AIDS but antiretroviral drugs do. She refused to take AZT to prevent transmission of the virus to her baby Elizabeth, who subsequently died of AIDS at the age of 3, although Maggiore claimed the cause was something else. She went on to become a crusader against antiretroviral drugs and personally contributed to the deluding of South African president Thabo Mbeki and the deaths of hundreds of thousands of people. Maggiore herself has now died, apparently of AIDS-related pneumonia although, as one who walks in the light of reason, I won't jump to any definite conclusion about that unless we get more evidence -- which her family is withholding, of course.

I will use this as the occasion for what was going to be my next post anyway. As I have written previously, it is understandable that the experience with AZT monotherapy caused some people to doubt the standard HIV story. However, I simply do not see how anyone can remain in denial following the introduction of so-called Highly Active Antiretroviral Therapy (HAART), in which protease inhibitors and other classes of drugs are used in conjunction with AZT-like drugs.

When these regimens were introduced in the late 1990s, the results were absolutely incontrovertible. People all over the country who were days or hours from death, some who had been administered last rites, suddenly, seemingly miraculously, rose up and were healed. This was called the Lazarus Syndrome, and I have personally spoken with many people who experienced it for themselves, people who has ordered their lives around preparing for death and suddenly had to figure out how to live again. Until then, AIDS had been all about dying, and the institutions that grew up around the epidemic were hospices, and workshops about how to face the end, and grotesque financial instruments whereby people with AIDS would collect payments from people who wanted to gamble on their date of death.

With the introduction of HAART, the community had to completely reinvent itself around problems of living. The hospices went out of business, to be replaced by living centers, medication adherence counselors, and Positive Prevention programs to help people avoid being reinfected or transmitting the virus to others. The problem of paying for HAART therapy became a major focus of HIV-related activism. Face it Duesberg: people stopped getting AIDS, and they stopped dying, when they started taking the drugs. QED. End of story. Everything else the denialists say is equally bullshit. Yes, the virus is present in the blood and elsewhere of people who test positive for HIV antibodies, in virtually 100% of cases. Yes, the level of virus particles in the blood correlates strongly with progression of HIV disease. Yes, people who take the drugs faithfully have suppressed viral loads and they don't get AIDS. People who don't take the drugs do get AIDS. The sun rises in the east.

So the question is why this weird movement persists. Partly it's just that people get dug in to a position and they can't face up to their responsibility for error. To admit that you have contributed to mass slaughter is undoubtedly difficult. But they also attract followers who don't share that initial responsibility, but who somehow find the dissent appealing, as a symbol of resistance to authority, perhaps, or personal distinction. Whatever the psychology, it's extraordinarily frustrating -- quite similar to the thimerosal thing, and broader anti-vaccination activism. Some things we just know.

Sermonette

The difficulty with most con games is that you have to promise people something in return for their money, and when they don't get it, the suckers are disappointed and call the cops and so on. All Bernie Madoff had to do was promise 10-12% a year in returns, no matter what was happening to the markets, and the money rolled in. But then some of the people wanted to cash in their profits so he's going to lose his mansions and yachts, and pretty soon he'll be eating shit on a shingle while wearing an orange jump suit and deeply lamenting that he cannot join either the crips or the Aryan Nation.

If Bernie were smarter he would have become a preacher. Promising the rewards after the people are dead eliminates the disadvantages of other confidence games. Nobody has ever come back from the dead to report that the Kingdom of Heaven is a lot of hooey. And, to the extent people need a little bit of more immediate gratification to keep the tithes flowing, you've got that covered too. When things go well, God gets the credit; when they go badly, your faith sustains you. If you fuck up, you're forgiven, and you may even get a magic cracker to make sure of it.

L. Ron Hubbard said it straight out -- the way to really make a lot of money is to start a religion, and by golly, he went out and did it. That Scientology is highly successful at raking in the dough for its leaders in spite of their transparent venality and L. Ron's on-the-record declaration is testament to the ineluctable gullibility of the human spirit.

I was about to say, and in spite of the utter absurdity of Scientological beliefs, but come to think of it, they are no more absurd than any other religion. A virgin gave birth to a guy who walked on water, raised the dead and drove some demons who were possessing a dude into a herd of pigs who then ran over a cliff, who walked around for a month after he himself was dead and then soared up into the sky -- right, you betcha.

You might argue that all this is just harmless fun and makes people feel better, but there are several reasons why I disagree. In the first place, that's an awful lot of society's scarce resources going for the Pope's silk slippers, the building and maintenance of non-productive edifices, clerical salaries, and magic crackers. In the second place, and this is most important, if you believe one thing on faith, you can believe anything -- and a lot of what the preachers tell people to believe is truly, profoundly damaging -- whether to individuals such as homosexuals and atheists who they teach their followers to despise, or to effective problem solving when they deny scientific facts and tell children that the world is run by magic and fantasy.

And it does real political damage as well, and stops people from standing up for their own best interests and the interest of the community. Joe Hill said it best:

You will eat bye and bye,
In that glorious land above the sky.
Work and pray, (work and pray),
Live on hay, (live on hay),
You'll get Pie in the Sky,
When you die, (that's a lie!)

And the starvation army they play,
They sing and they dance and they pray,
Till they get all your coin on the drum,
Then they tell you when you're on the bum:
You will eat bye and bye,
In that glorious land above the sky.
Work and pray, (work and pray),
Live on hay, (live on hay),
You'll get Pie in the Sky,
When you die, (that's a lie!)

If you fight hard for the good things in life,
They will tell you to stop all the strife,
Be a sheep for the bosses they say
Or to hell you are surely on the way!

Sure, religious institutions do some good works, but so do secular institutions, and without the ulterior motive of trying to convert people to superstition. I know what sorts of things religious apologists will say in response, and if any of them read this and care to leave a comment, bring 'em on. I'm not afraid to discuss this.

And yes, it has a lot to do with public health. Religious leaders have done immense harm to public health, in such fields as HIV prevention and the science education that produces the medical and public health work force of tomorrow. It's my responsibility to confront damaging superstitions, and it's long past time that more of us did it.

Cross the gypsy's palm with silver . . .

Last year, I predicted we would have a nasty recession. Check. I also predicted that oil prices would stay high regardless. Not so much, although I'm still expecting a rebound. We won't discuss my Superbowl pick.

2009 is a tough year for the prognosticators. The psychics can throw just about anything at the wall and hope something sticks. Yellowstone supervolcano, anyone? Actually I'm not worried about the greatest catastrophe since the emergence of Homo sapiens, destroying Civilizationasweknowit -- not going to happen. However, it's a good bet that there will be a substantial natural disaster somehow somewhere in the US of A. Here's hoping that it doesn't happen before Mr. Obama gets his own team in place at FEMA and he gets unfairly blamed for any screwups. So that brings us to my first real prediction, that whoever he appoints won't have prior experience consisting of investigating alleged liposuctioning of horses' asses.

I'm sure the prognostication everybody really wants from me concerns health insurance reform. Unfortunately, as I have noted many times, the political system is stacked against the changes we really need. The problem, as the Political Scientists say, is one of concentrated vs. diffuse interests. (Political science is not a science. When I pointed this out as a college freshman, my professor, Nannerl Keohane, who had recently married fellow Swarthmore professor Robert Keohane following some sort of rumored love quadrangle [possibly bogus] and then went on to become president of Wellesley College and Duke University [meanwhile my art history professor was changing genders from male to female, but her {formerly his} wife stayed with her so evidently they both became lesbians. It was a regular Peyton Place.] wrote up on the board the word scientia, and asked me if I knew what it meant. I replied, "It appears to be in some foreign language." God, I was insufferable. Actually it's Latin for "knowledge," i.e. science didn't used to mean science as we know it today but just generally knowing stuff, or thinking you know stuff, and that's poli sci.

But I digress. The point is that while the vast majority of Americans would benefit from universal, comprehensive, single payer national health care, for a lot of them it would be, or seems to them to be, only a minor advantage over their current situation, and they have other concerns that seem equally or more pressing. The people who would benefit the most, in fact, have the least political resources and influence. So there just aren't structures that translate this diffuse interest into real clout within the lawmaking institutions.

But for a small segment of the population, which happens to have immense political resources, it's a major threat. For insurance companies, it's life and death; for drug and medical device companies, it's a tragic attenuation of the river of gravy in which they are accustomed to wallow. Both of these industries have very powerful lobbies and own numerous Senators and Representatives. (The medical profession, as embodied in the AMA, for many decades bitterly opposed it as well. Although docs have largely come around, there is still enough ambivalence and dissent within the groves of Aesculapius that the AMA is not likely to be a strong player in this game.) The Free Market™ theology that permeates the political culture is a powerful weapon in the hands of the opposition, since newspaper and TV reporters are too ignorant to know that it's a crock, and it has also been adopted by the right-wing theocrats such as Rick Warren who stuff it into their sheepish followers along with the rest of the horseshit they peddle. All of these powerful actors, including the 43 Republican Senators to whom the pathetic, wimpish Senate Democrats will hand over total control, will fight like pit bulls to stop reform.

Obama's actual proposal, as we know, is modest and incremental. It's fairly similar to the current experiment in Massachusetts and the Swiss system which our friend Ana has described for us, neither of which is entirely successful, to say the least. In fact we're headed for a major crackup here in Massachusetts, where we are about to discover that we just can't pay for it after all. I fear that will become evident before anything moves very far through the Congress, which won't help matters. The lesson ought to be that we need a truly radical reform which can effectively contain costs, but I fear the opposite conclusion will be drawn.

So here's my prediction. What we'll end up with is little more than an opportunity for people to buy into a federally sponsored plan, but with insurance companies sitting in the middle taking a cut for no reason other than they lobbied for it, on a sliding scale which won't really make it affordable for low and moderate income people. Employers could also choose the same plan for their workers. It won't be truly comprehensive and it will have significant co-pays and limitations, e.g. no dental. It will be partially community-rated but will include some age rating, meaning that people in their late 40s through early 60s will be even more likely to be priced out. But it will expand access a little. There will be some other bells and whistles, such as a U.S. equivalent of NICE but with no real powers, just jawboning; maybe some half-decent FDA reform that may last for a little while; and some bargaining between the national plan and the drug companies that will save a few cents on some drugs, mostly just for show.

Then the challenge in coming years will be over the viability of the national plan, whether it can be structured and funded so as to become truly affordable, and outcompete the private plans so as to move toward universality. If the drug and insurance companies perceive it as the camel's nose under the tent, they may stop even that, but perhaps they won't be able to. We shall see.

Now This is Just Sick

Bristol Palin could earn $300,000 for baby pics. And here's why I really hate America:

The price didn't soar immediately, according to the sources, because Sarah Palin stories just didn’t sell all that well for the weeklies on newsstands. . . .The drug-related arrest of Johnston's mother, however, caused the price tag for the photos to go up.

Now those are some family values we can believe in! Thank God we live in a Christian nation.

The End Times?

Jonathan Schwartz catches The Mustache of Self-Regard speaking a tiny sliver of truth:

This is from a new interview with Thomas Friedman in Scientific American:

Q: Is it a good idea to meddle so extensively with the free market for energy?

FRIEDMAN: [Laughing] Oh, yeah, a totally free market dominated globally by the world’s biggest cartel, dominated domestically by fossil-fuel companies who have written all the rules in Congress—pages’ worth of depletion allowances and tax shenanigans that these guys have written in to give themselves advantages. We wouldn’t want to upset that free market, would we? There is no such thing as a free market, no more than there is a farm or a garden that grows without fertilizer, without proper plowing, without intelligence brought into it. Markets are shaped by rules, incentives and disincentives, and right now our market is shaped by the dirty fuel system.

Schwartz goes on to display just a few highlights from Tom Friedman's lifelong career spent worshiping and exalting the deity he now admits does not exist. As you may recall, Alan Greenspan also confessed to apostasy before a congressional committee. However, these counter-epiphanies are far from typical. The Free Market™ acolytes who still completely control the intellectual establishment have demonstrated a truly impressive capacity for double-think. Even as they scream and yell for massive government intervention to save their investment portfolios, they still maintain that all this trouble is just a temporary difficulty caused by fair housing laws, capital gains taxes and a few bad apples.

Just you wait -- the instant it suits the interests of wealthy and powerful people to claim that one or another proposed action by the Obama administration violates the sanctity of the Free Market™, it will be back on the altar and the votive candles will glow on every op-ed page and every TV gabfest. You think this is a Christian country? Believe me, the Christian God is a subsidiary deity.

Auld Lang Syne

Sorry to have been away from the blog for a few days. "They" -- the enigmatic repository of all knowledge -- say you shouldn't disrupt your blogging schedule or your readers will all switch their allegiance to Instapundit, but sometimes I've just got problems of my own.

Looking back and looking ahead, as we are all supposed to do at this time of year, I find we have come to a historical moment as substantial as any that has come before. Thinking of the few Great Transformations that humans have experienced, I might list the emergence of Homo sapiens as the ape that talks and the great cultural takeoff of somewhere around 100,000 years ago; the agricultural revolution, of course, and the rise of complex societies. Literacy came along with that very quickly, but for 10,000 years or so further development was evolutionary rather than revolutionary, and even took a big step back in Europe after the fall of Rome. Then came the Enlightenment and quickly thereafter the Industrial Revolution, which destroyed the old structures in a process that culminated in World War I and the establishment of the current system of nation-states, the basic foundations of global finance, and near universality of the industrial system of production fueled by carbon sequestered in the earth in ancient times. (The Great Depression and World War II were not fundamentally transformational, rather they were a sort of adolescent crisis of the new order.)

Now, on a time scale roughly another order of magnitude faster, we confront another Great Transformation, in which we will either achieve a self-aware, responsible and effective global society, or enter a new Dark Age. We will have to overcome multiple challenges including developing a new technological basis for civilization, and perhaps most important, achieving the universality of science and reason as the basis of understanding and the ground for action. That means the grip of religion on human societies will have to end, and with it the childhood of our species. In the year ahead, I will am committed to spending more time on the latter problem.

On a personal note, this is also a time of transition for me, in various ways. I'll let y'all in on some of it, as seems appropriate, but if posting gets a little erratic, I hope you'll understand. I'll do my best to keep it up.

Solstice best wishes

I expect to be disconnected from Your Intertubes until Sunday or thereabouts, unless I get the odd opportunity to check in with the universal matrix. So I thought I'd leave you with some holiday cheer in the form of a favorite carol. Some people like Weeth, Reeking of Aurien Tar, but I share my favorite with Pogo Possum. Good cheer to all.

Deck us all with Boston Charlie,
Walla Walla, Wash., an' Kalamazoo!
Nora's freezin' on the trolley,
Swaller dollar cauliflower alley-garoo!

Don't we know archaic barrel,
Lullaby Lilla boy, Louisville Lou?
Trolley Molly don't love Harold,
Boola boola Pensacoola hullabaloo!

Schtickdreck of the year

I normally avoid writing about the subjects that everybody else is talking about, unless I really have something original to add. This post may not qualify, but I feel the need to say something about Bernie Madoffwiththedough just because I'm as fascinated by the whole thing as you are.

Many people are concerned that the case will encourage antisemitic stereotypes, but I'm not so worried about that. People who already believe in such stereotypes will no doubt see it through that lens, but I don't think it will create antisemitism where it doesn't already exist, for several reasons. First of all, many of the most prominent victims were Jewish charities. It doesn't make a whole lot of sense to say, "Those greedy grasping Jews, serves them right to lose all that money they were planning to give away." Furthermore, people already believe that Wall St. wheeler dealers of every ethnicity are crooks, so the only thing special about Bernie is the scale and brazenness of his deceit.

To the extent that Bernie's Ponzi game preyed on his fellow Jews -- and that was only one of the strategies he used to recruit victims -- it was entirely typical of Ponzi and pyramid schemes. (Actually the Madoff fraud was a little bit of both, of which more below.) The SEC even has a term for this -- affinity fraud:

Affinity fraud refers to investment scams that prey upon members of identifiable groups, such as religious or ethnic communities, the elderly, or professional groups. The fraudsters who promote affinity scams frequently are - or pretend to be - members of the group. They often enlist respected community or religious leaders from within the group to spread the word about the scheme, by convincing those people that a fraudulent investment is legitimate and worthwhile. Many times, those leaders become unwitting victims of the fraudster's ruse. . . .

Many affinity scams involve "Ponzi" or pyramid schemes, where new investor money is used to make payments to earlier investors to give the false illusion that the investment is successful. This ploy is used to trick new investors to invest in the scheme and to lull existing investors into believing their investments are safe and secure. In reality, the fraudster almost always steals investor money for personal use. Both types of schemes depend on an unending supply of new investors - when the inevitable occurs, and the supply of investors dries up, the whole scheme collapses and investors discover that most or all of their money is gone.

So Bernie's game was just the same old tired out story, writ large. So many of the victims were supposedly sophisticated investors and business people -- it just shows that human nature is the same all over, rich or poor. It's in human nature to lie, but lying wouldn't work if it weren't in our nature to trust as well. We tend to trust people who seem familiar, who are part of our own group and who are somehow like us, so Madoff was the perfect con man to prey on wealthy Jews. Sociopaths can show up anywhere, alas, but if we went through life suspecting everybody we meet of being undetectably morally depraved we couldn't function.

The scheme, as I say, was a pyramid scheme on top of a Ponzi scheme. Madoff created a multi-level marketing structure in which lesser investment managers took people's money and passed it on to him, skimming a portion for themselves. In some cases we know that at least a third layer existed, and perhaps there were four or more somewhere. Originally, these also preyed on the original population but as Madoff grew more and more desperate for new investors the pyramid game reached out more broadly, including Europe and WASPy Greenwich.

The only interesting lesson here is that the pyramid game turns out to be, in and of itself, not only legal but perfectly standard Wall Street practice. There is a whole industry of "funds" that will take your money, take a cut, and invest it with yet another manager who will also take a cut and who may actually manage the investment for you or who may just turn around and pass it on to someone else, who will continue the scam. Even the people who do invest the money themselves are merely leeching on you; for every buyer of a stock there is a seller, for every winner there is a loser, so on balance, the industry cannot possibly be providing any benefit to its customers. It's all a scam, every bit of it. These people are purely parasites on society, whether their activities are technically crimes or not, and they get fabulously rich just by sucking blood.

The whole enterprise of financial asset management and trading is nothing but a giant tapeworm in the guts of society. Everyone involved in it, all of them, to a woman and man, are thieves.

Janus

The two-faced God is supposed to inspire us to look both back and forward at this time of year, so let's start with the backward look. This has been, shall we say, an interesting year. They say that alcoholics have to hit rock bottom before they come out of their state of denial, and that's pretty much what we did as a country. We started to face up to the cold facts about ourselves just in time, and it's a damn good thing because there was nobody out there to do an intervention on us, no matter what we had done to others.

That doesn't mean we're all the way into the action phase.* The party of denial got almost half the vote. It turns out that the basic division in U.S. society is not between differing political philosophies, interest groups, or value orientations. It's between people who believe in reality, and people who belief stuff that is not what we deep philosophers refer to as "true," i.e., actually factual or, in lay terms, corresponding to what is rather than what is not.

To be a Republican nowadays, you have to believe that the earth is 6,000 years old (allowance is made for those who push it back to 10,000), that all the flora and fauna were created in a day, and then we were made in the "image" of God, who therefore must be a guy with two arms, two legs, one nose and one wiener (presumably a big one) living somewhere up in the sky.

You also have to believe that spewing CO2 into the atmosphere does not affect the climate; that consuming arsenic in drinking water and mercury in the diet is harmless; and that when scientists say that a species is in danger of extinction, they're just making it up.

You have to believe that Saddam Hussein was the perpetrator of the Sept. 11 attack, and that he possessed Weapons of Mass Destruction™ which he either planned to use against the United States directly, by spraying anthrax over east coast cities from his fleet of unmanned aerial vehicles; or by giving nuclear weapons to Osama bin Laden. At least 30% of the country does believe this, specifically the Fox News audience and Christopher Hitchens.

You have to believe that it's in the best interest of semi-skilled workers making $40,000 a year to make sure that people making a million dollars a year pay the lowest possible taxes. Of course it's in their interest -- its Economics 101!™ And Economics 101!™ also says that the magical Free Market™ will guarantee the greatest prosperity for all if the government just makes sure not to do anything to interfere with the decisions of the mighty captains of finance and industry. Economics 101!™ is just like the Bible, which is the source of scientific understanding of nature. The Gospel According to Friedman teaches us everything we need to know about social policy. It's in the Good Book. Just believe.

Curiously, politics in Europe, Canada and elsewhere around the world are not organized along these lines. Sometimes ethnic groups, or economic or other interests vie for power, more or less overtly; sometimes factions organize on nakedly behalf of their own power, and political institutions allow them to prevail; in the liberal republics, arguments occur over values and social theories, but people generally stipulate to roughly similar sets of facts. In the United States, however, our parties inhabit different worlds.

I could go on. In one world, having everybody carry concealed, loaded pistols everywhere they go -- in schools, in church, in shopping malls, in parks, and of course at home -- makes us all safer. In the other world, guns are considered dangerous. In one world, rich people will stop investing and managing businesses if they have to pay 30% of their income in taxes instead of 25%; while poor people only work hard when they are paid very little. In the other world, most of what rich people do is useless and they get paid millions whether they succeed or fail anyway, and they certainly aren't going to stop accepting those millions if a little bit of it gets skimmed off to pay for the airports they fly in and out of and the roads their chauffeurs drive them on.

But you get the idea. Maybe the two faces of Janus have a second connotation as well.

*For those of you who aren't in the addiction biz, there's a standard model of behavior change, called the Transtheoretical Model for reasons I won't go into here, that says people may be in the pre-contemplation phase, when they aren't even thinking about kicking the junk; contemplation, where they're at least thinking about it; action, where they're really, truly trying but may relapse from time to time; and maintenance, where they're "in recovery" and living sober.