I control the top line . . .

So I might as well use it. Yes Rachel, I do support space exploration, although for the time being I favor only robotic exploration. The cost is trivial compared to the money we squander on war and preparation for war; and the rewards it brings in understanding our world are immeasurable. Ultimately, once we have gotten our problems here on earth under control, then indeed I think it will be a profoundly rewarding new stage in our development as a species for us to establish ourselves beyond the home planet. That may have to wait until after our own lifetimes, but I kind of hope to live to see it.

(And I hope you'll start up your own blog, since you now have an account.)

As for Mr. Hardy, I'm sure he is very committed to his ideas so I don't expect to dissuade him. Nevertheless I think his comments are interesting for a number of reasons which I will, for now, allow to speak for themselves. Based on my cursory look at Mr. Hardy's web site, it appears he is a proponent of what we call a "steady state" theory of the universe, which maintains that the universe has always existed in essentially its present form. This was quite the controversy in my youth, but ultimately the so-called Big Bang theory, which I prefer to call Initial Singularity, won out.

Mr. Hardy is quite correct that as we look out into space, we look back into time, and therefore the galaxies we see in the distance are long gone from their apparent locations. Cosmologists obviously understand this, in fact its an essential component of their understanding, so I'm not sure what the intention is in raising it.

As for the other assertion, that according to the consensus theory the light of distant galaxies must shine out beyond the boundaries of the universe into nothing, that is actually a common misconception. Modern cosmology is difficult to understand, but I tried to address this very confusion with the balloon analogy. The universe may be finite, but it has no boundary. It is fundamentally wrong to think that we are somewhere near the center and so distant objects must therefore be near the edge. There isn't any edge, except in time, i.e. the beginning, the IS. And there is no center either. As I said, all observers perceive themselves as being at the center, including those on the edge of our observable universe, which perceive us as being on the edge. Again, think of the two dimensional creatures on the balloon. They see a circular universe, but they are really on a sphere. Within their two dimensional world, the sphere has no boundary, you just go around and around.

So, one reason that people deny some scientific findings is that they are simply counterintuitive. Evolution has equipped us with some intuitive physics which work well for hunting and gathering on the African savannah but which turn out not to be quite accurate when we do sophisticated experiments or study conditions normally inaccessible to our experience, such as very small, very large, very hot, very cold, etc. It may require some long, deep study to understand how scientists arrive at conclusions which they then present to the general public in simplified or even somewhat allegorical form. It does require a certain trust of the whole enterprise to be persuaded, and I agree that is trust the scientific establishment does not earn 100% of the time. This is why the democratization of science is so important.

More of that deep philosophy

Darwin died before we discovered the universe. He figured out the basic idea of how life on earth developed. He knew that the earth was very old by human standards -- far, far older than the biblical story would suggest -- and that life had existed for a very long time before humans came along. That knowledge alone radically altered our place in the world, but it took 20th Century cosmology to completely destroy any idea of the centrality of humanity.

Creationists, obviously, don't just reject Darwin, they reject cosmology as well. I haven't noticed them objecting to the theory that there are billions and billions (and yes, Carl Sagan did to say that) of stars in the galaxy (about 200 billion to be exact) and billions and billions of galaxies in the observable universe, because, well, they can't. Look through the telescope! Those facts alone would seem very much to undermine the belief that humans are important to the creator, but the fundamentalists seem willing to ignore that problem and limit their objections to the claim that the universe is billions of years old, and much older than the earth.

Here is some of what I understand about the cosmologists' universe. By the "universe" they usually mean the observable universe, but there are some vexing metaphysical problems underlying that usage. It is certain that in some sense, the observable universe is not everything that exists, but what does it mean to say that something exists if it can never interact with us in any way?

Here's how we know this: we can only see a radius of a little over 13 billion light years, the distance light has traveled since the origin of our universe in what is misleadingly called the Big Bang. Actually it should be called the Initial Singularity, the IS, but Sky and Telescope wouldn't accept my suggestion for some reason. The expansion of the universe is not limited by the speed of light, because it isn't "going" anywhere. So at the edge of the observable universe, galaxies are actually falling over the horizon -- disappearing from our universe.

From their point of view, it is we who disappear. Every observer in the universe, no matter where they are located, perceives their own location as the center. Got that? It works because the universe is not a sphere, it is a hypersphere. Think of a two dimensional universe consisting of a spherical surface, expanding like a balloon. The galaxies are dots on the balloon. Light rays that appear straight to the flatlanders are actually great circles bending across the surface. So, no matter where your dot is, as you look out you see a circular area, with your dot at the center. We cannot visualize hyperspace, but it works the same way.

So the universe could be infinite in volume. Or maybe not. There is no way to know. But it is finite in time. Nevertheless, from the standpoint of a human lifetime, that is an enormously large finitude. Was the universe created by some sort of intelligence? You know what, it might have been. It could even have been a committee, or a corporation, or a child playing with a toy science kit, or perhaps it was some sort of industrial accident, or a natural disaster, in a predecessor universe. We have absolutely no idea. Maybe we'll get a better idea some day, maybe not.

But whatever the explanation for the creation, it had nothing, and I mean zip, zilch, nada, bupkus, zero, to do with us. We are a minor contaminant in a microscopic layer of slime on a grain of dust on a tiny island in a vast ocean. Less than that. Believe me, that ocean was not created for the sake of that slime.

Is that depressing? Is it terrifying? Not to me. If we are nothing, that means we have no place to go but up. We can become something. We already have, in a way -- we're the creatures whose minds can ecompass the immensity of the universe. Now let's get out there and explore it. What could possibly be more meaningful than that?

Economics 102

NYT's Michael Moss runs down peanut buttergate for you, and yeah, it's pretty gross. Peanut Corporation of America (that's the true grandiose name of this flea-bitten, fly-by-night sleazedog operation) knew it was shipping out contaminated product, but they weren't required to notify Georgia state inspectors or the FDA when they got positive tests for salmonella. Georgia has 60 inspectors for 16,000 food handling businesses, and the FDA doesn't inspect plants in Georgia at all -- it has delegated the task to Georgia, as it has to most states. And you know how they feel about Big Government down in Georgia.

Now here is yet one more reason -- an obvious, trivial reason -- why the Free Market™ ideology taught in Economics 101 is complete nonsense. Actually there are two or three reasons all wrapped up in this single example.

• Reason One: Consumers can't make "rational choices" or "maximize their utility" if they don't know what they are buying. You have no way of knowing whether the food somebody sold you is contaminated with salmonella unless somebody you know you can trust tells you so. And the only way you know you can trust said somebody is if they're working for you, and the only way that can happen in this situation is if a) said somebody is the government and b) the government agency really does work for you and not the businesses it regulates.


• Reason Two: There is a whole chain of purchasing from farm field to your oral cavity. That means that the potential social costs and benefits of all of those transactions along the way are not captured by the transaction because that salmonella is going to land in your blood stream, not the blood stream of the buyer. As a matter of fact, the penultimate customer may be a school or hospital cafeteria, for example, and the person who gets sickened or killed by the food may have nothing directly to do with any transaction pertaining to that item at all. This is called "externality," which economists treat as an exception but which is actually ubiquitous and is a feature -- probably the dominant feature -- of every economic transaction, without meaningful exceptions.


• Reason Three: The market provides no accountability for fraud or negligence in most cases. The only reason we know where this particular salmonella outbreak came from is because the government -- in this case the CDC -- investigated, and they were lucky enough to be able to figure out the source. But in other cases, it might be impossible. No government, no accountability.

So, what do we have to do in order to insure a safe food supply? It turns out it's not just the Chinese, it's us. We have to increase government spending on food safety. We have to effectively regulate businesses. In order to do those things, we need a functional democracy that works for people, not for economic elites who want to take advantage of us. We need to expunge shallow libertarianism, free market fundamentalism, and as a matter of fact the very term "free market," which is a fraud, from our political discourse.

Sermonette

As I promised a few days back, my own contribution to the celebration of Darwin's birthday will consist of some reflections on how the world we have discovered with our senses and our reason is meaningful for us, and hospitable to our happiness. People who reject science in the name of religion say that Darwin's world has no moral foundation and leaves us stranded without purpose. That is simply a failure of understanding and imagination.

In fact, the universe I know, as an atheist and a humanist, is far more grand and wondrous than the cramped, impoverished world of creationists. Best of all, it opens up far more vast vistas of meaning, and infinitely greater prospects of purpose. Creationists find meaning only in a ghost, an invisible, incomprehensible entity that exists outside of the world. For me, meaning is right here, inside me and all my friends and all the world's people. What could possibly be more exciting and rewarding than to be like Copernicus and Newton and Darwin, and discover the universe for ourselves? How wondrous we find ourselves, to know that we arose from the workings of physics and chemistry and probability, acting over billions of years, and here we are with the astonishing capacity to understand, to experience, to choose.

Morality does not come from God, after all. It is part of our nature. It arose because we succeeded in the world as social animals, so our mutual regard and love are part of how we work, part of what evolution made us.

So here we are. We got here by chance, we won the lottery. Hooray! We can look around, discover where we are, become whatever we can accomplish. We are not limited by what has been given to us, we are not beholden to any creator, we are not commanded by any law but our own. How joyous that should make us! We are free.

In coming days, I will say more about how I believe we should use our freedom.

Oh yeah, the rest of the world . . .

It's too soon to tell, of course, what regime change in the United States will mean for the less developed countries. We've been pretty much obssessed with our own problems lately, and I would expect that foreign aid will be an even tougher sell than usual. Still, if we were wise enough to recognize that cutting taxes on the wealthy and deregulating financial markets is not the path to prosperity after all, and that war is not peace and slavery may not be freedom, perhaps we'll be wise enough to realize as well that we have to live on this planet and that what happens in those remote places matters to us after all.

During the campaign, Barack Obama advocated increasing funding for the President's Emergency Plan for AIDS relief by $1 billion over five years, and doubling overall foreign assistance -- to $50 billion a year -- over time. He also called for cancelling the foreign debt of the world's poorest countries. Under the current circumstances, I would be surprised to see all of this happen, although the latter is certainly a possibility. You can't get blood out of a stone anyway. But Obama has already used his executive authority to get some of the ideologically driven nonsense out of the aid we already give -- specifically by ending the ban on funding organizations that offer abortion-related counseling and referrals. Presumably the ban on needle exchanges programs and the favoring of "abstinence only" sexuality education will also go overboard.

We'll be keeping a close eye on policies toward global relief and development. I've written before about the controversies over HIV and other disease-specific programs, vs. investing in broad health care and public health infrastructure. In the long run, what we do to develop renewable energy technology and reduce use of fossil fuels here will also have a big impact on the world's poor, as will global trade policy -- and that includes our agricultural policy which is terrible not only for small American farmers and American consumers, but for poor farmers around the world as well. I'm not counting on the Democratic Party to fix that last one, however, not while the midwest is a major political battleground and Archer-Daniels-Midland and Monsanto are big political players. But we're watching them anyway.

Patriotic Song

I'd rather forget him entirely, but as the famous political philospher Juju Santeria once said, Those who fail to ridicule the past are doomed to regurgitate it, or something.

The tune should be obvious.

Dear Chimpy ‘tis at you,
I hereby throw my shoe,
It’s thee I dis.
You’re the election thief,
The idiot in chief
You’ve screwed us up beyond belief
On thee I pis.[1]

You claimed to speak for God
While on the laws you trod,
You hypocrite.
You lie just like the sod
Your syntax it is odd
Your cowboy accent is a fraud
You’re an upper class twit.

At oversight you sneezed,
Your greedy friends to please,
And the economy crashed.
Iraqis you did croak,
You’ve left our grandkids broke,
You treated war like one big joke
At the journalists’ bash.

You tortured prisoners
Appointed Hizzoners [2]
Far right extreme.
For the polluted air,
Taxes that are unfair,
And inept cronies everywhere,
God save the Queen.[3]

Your place in history
Will be no mystery:
You are the worst.
Upon your neck we’d hope
To find your head but nope,
You’d nee -eed a-a proctoscope[4]
Of fools you’re first.

[1] Unless of course you happen to be on fire.
[2] Okay, it's a bit of a stretch, but rather clever in a groan-inducing way, don't you think?
[3] Whoops, wrong song! heh heh.
[4] Sorry about that.

Preventing our way out of bankruptcy?

Health care reform has been pushed to the back of the room while all wait to get stimulated, but it's still on the program here. As I have mentioned from time to time, there is no serious cost containment in any of the proposals coming from the Obama administration or congress right now. The president (and it is at least a relief to be able to type that word without pain) has said that more emphasis on prevention can save health care spending, but is that really true?

Steven Woolf in the new JAMA reviews the issue. Unfortunately it's subscription only, but I largely agree with him and I can summarize it more quickly for you anyway.

If we spend money on preventing illness, we might end up saving money on medical treatment down the road, but is that really the only reason to do it? In fact, while it is unquestionably true that if fewer people smoked, more people ate a healthy diet and were physically active, the air was cleaner, etc., we would spend less money treating cancer, heart disease, and diabetes. However, it does not follow that every dollar spent to achieve those ends will save more than a dollar plus interest, since we're looking toward the future, in eventual health care spending. Interventions directed at a large population will be successful with only a percentage of individuals, and so the cost-benefit calculus is uncertain. The fact is there are few interventions that really save money in the end.

When it comes to preventive medical services, per se, there are really very few interventions that ultimately save money, and a lot of them, such as universal childhood immunization, are largely in place. There probably isn't a lot of room left to save money by investing in prevention -- certainly not enough to reverse or substantially slow the growth in health care spending.

However, that is not an argument for not doing more prevention. We don't spend money in order to save money, we spend money in order to get stuff that's worth it. And better health and longer life are worth spending money on. The issue is not just investing more in prevention -- it's allocating health care spending efficiently. As Woolf points out, insurers pay for many services that cost more than $100,000 per quality adjusted life year (QALY -- I've criticized the concept previously but we need some way of comparing benefits of various interventions); but there are services that cost much less that aren't universally utilized. For example, colonoscopic screening for cancer is estimated to cost less than $25,000 per QALY, but most people don't get it. Other preventive services cost even less. However, they still have a net positive cost.

Therefore, if we spend more on screening and prevention, in general we will end up spending more in total, not saving money, although we will prevent suffering and disability and extend lives. If we want to actually save money, we have to spend less on less cost effective services, and reallocate the spending to others that, while they still have a net positive cost, give us more for our money.

This means -- drum roll please -- we must have rationing. The so-called Free Market™ does not allocate health care resources in this way, and generates almost no public health resources at all, because they are public goods. The best way to achieve the rationing we need, from which we will all benefit (and I'm not one who believes that a terminal cancer patient actually benefits from $150,000 worth of chemotherapy that yields three months of sick and suffering life) is to have universal, comprehensive, single payer national health care. Yeah, socialism. There, I said it. When it comes to health care, capitalism is what ails us.

Power Play

Okay, so I started to write the book, and much to my surprise, it turns out to be about conflict in a setting of unequal power. Here are some of the distinctive features of the physician role vis a vis the patient role:

• Physicians want to invade our privacy, and they have cultural authority and license to do so in ways that just about nobody else does.


• Physicians have license to invade our bodies, to see us naked, to touch and enter our most intimate orifices, and even to cut us open and dismember us. No-one else in the world has such license.


• Physicians judge our behavior.


• Physicians try to control our behavior.


• Physicians control the prescription pad; they alone decide whether we have access to most medications.


• Physicians may have power over our very sustenance, as by certifying for disability or worker's compensation.


• Physicians may control whether our insurance plans will pay for us to see specialists.


• Physicians can ask a judge to have us imprisoned in a mental hospital, and will almost always get their way.

Under the circumstances, it is a considerable credit to the profession that most people say they like their doctors, and that we generally willingly submit to the indignities and infantilization inherent in medical care. We place immense responsibility on physicians not to abuse these privileges, and most of them do their best to earn our trust. Nevertheless, it is very difficult, when handed such direct power over people, always to wield it harmlessly, let alone for the maximum good. However benign and cooperative the relationship appears on the surface, there is always a power struggle going on underneath. Medical ethicists talk about the physician's obligation to be beneficent, to grant patients autonomy, and to respect persons. Yet those principles are often in conflict with each other, and with the physicians' own experience of being locked in combat with disease -- a combat in which the person who has the disease, or the risk for disease, is an uncertain ally or even an enemy.

So Collaboration, Conflict and Power, with a suitable subtitle. How's that?

Are you illiterate?

So, NIH is putting a lot of vigorish out on the street, some of which I may just try to collect, to study what they call Health Literacy, by which they mean "the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions." According to NIH, not having enough of this stuff is a serious problem, apparently affecting 90 million adults in the U.S. -- This according to the program announcement I'm reading now. For those of you who have never checked out how the NIH gives away money, you might want to check it out, these are your tax dollars at work.

I think this particular cause is a good one -- we do need to figure out how to help people better understand information that affects their health, including being able to come to the right choices about treatment for them, as individuals. But I do have a problem with the "Health Literacy" frame, which is that it locates the problem in the average patient or citizen who is presumably too dull or ignorant to figure out which end of the fork to hold. While that description does indeed apply to Don McLeroy, D.M.D., I think for most people who don't necessarily grok all the stuff their doctor is thinking when he refers them for a throgsneckbridgectomy, the locus of the difficulty lies elsewhere.

Figuring out how to communicate technical and specialized information effectively to people who might want to know it because of its relevance to their own health is important, and I certainly want people to do a better job at that. But this is really a two way street. The kinds of information that matter in providing health care, treatment decision making, and managing disease aren't just the stuff the doctor learned in medical school that is just way too complicated for you. It includes a lot of stuff you know or care about that the doctor doesn't know and doesn't know enough to care about. The goal should not be to get you to do what the doctor wants you to do, but you're too stupid to know is good for you. The problem is how everybody can work together to come to some sort of a consensus about what is good for you, or to agree to disagree in an open and honest way.

I'm sorry that this is all a bit abstract, but I'm too busy today to anything more than bloviate. Still, if anyone wants to add some concrete examples that seem to be in order I'll be delighted to hear them.

Idiocracy

Ed Doerr, in Free Inquiry magazine, quotes Don McLeroy, creationist and chair of the Texas State Board of Education:

If science is limited only to natural explanations but some natural phenomena are actually the result of supernatural causes then science would never be able to discover the truth - not a very good position for science. Defining science to allow for this possibility is just common sense. . . . Then the supernaturalist will be just as free as the naturalist to make testable explanations of natural phenomena.

Now you see, what we have in this country is a political discourse which is not built around competing interests, or values, or intellectually respectable analyses of the state of affairs. Of course those exist and they are what actually underlies much of politics. But they are hidden behind arguments between people who use information and reason to reach conclusions; and people who are total idiots. Bill O'Reilly, Rush Limbaugh, Glenn Beck and Samuel J. Wurzelbacher flaunt ignorance and bigotry as virtues. Among Republicans, it counts as evidence against a conclusion that it is held by smart, well educated people.

As for Doctor (yep, he's a dentist) McLeroy, he undertakes to lecture the scientific establishment on the correct way to undertake science when he clearly hasn't got the slightest idea of what science is or which end of his alimentary canal is which. As a scientist, I hereby invite him to propose any testable explanation he likes for natural phenomena. Problem solved.

Hard Times All Over

Brandeis University, which bestowed a degree upon me, may be on the verge of making an even bigger mistake. Colleges everywhere have seen their endowments hammered, and that is creating some real pain in academic programs and other areas. Brandeis has bigger problems tham most, however, in part because it is a relatively young institution that didn't have all that big of an endowment in the first place, but also because many of its major donors had entrusted their money to Bernie.

I don't know how much it's been in the news nationally, but around here it's a very big deal that the trustees, at the urging of president Jehuda Reinharz, voted to sell off the collection of the university's Rose Art Museum. They think it might be worth $300 million, which would more or less replace the lost funds, but as you can well imagine this is not sitting well with anyone. Meanwhile, the Carl and Ruth Shapiro Foundation, an important benefactor of many cultural, charitable and health care institutions in the Boston area, has cancelled all new grant making for the year because Bernie stole half of their endowment.

The Madoff victims are particularly poignant, and it is particularly obvious that they were robbed, however the truth is that we've all been robbed, mostly by people who aren't going to jail and who in fact are walking away with the loot. All of the gains in the financial markets for several years now have been illusory, the product of pretending that borrowed money was income -- in other words the whole thing was a giant Ponzi scheme. One of the saddest consequences of all this is that it will just increase inequality. It will make higher education harder to afford, it will cause tens of millions of people to lose their health care and quite possibly spiral down into disability and life long poverty, it will make poor kids poorer and send middle class families into poverty. The charitable institutions and state agencies that provide a safety net will be collapsing just as they are most needed.

President Obama has branded his legislation as an economic stimulus, but it's more than that. It's a two-minute drill to save our asses and give us a chance to play again next Sunday. It is really frosting my pumpkin that the punditocracy is saying the Democrats will be held accountable for "failure" if we don't have a strong recovery by 2010. Believe me, if we just manage to hang on to social decency through 2010, it will have been a success.

Changes

Note the new e-mail address in the sidebar, which is now preferred. (The old one will still work for a while.) As ever, my employer is not responsible for my offensive ravings.

Now let me say a bit more about this evolution thing. As you all know if you haven't slept through the winter, this year is the 200th anniversary of Charles Darwin's birth and the 150th anniversary of the publication of On the Origin of Species. Massive blog swarming is planned, along with other festivities, and the inevitable counterfestivities. So we can expect this thing to heat up. In fact, we're already getting very close to the birthday, on February 12. You can definitely expect me to participate.

So here's a bit of warm up. There are two main reasons why people don't accept the overwhelming evidence for evolution and the complete adequacy of evolution to explain the phenomenon of life on earth. One is that they were indoctrinated as children to believe otherwise and it's just very difficult for people to overcome the beliefs stuffed into their heads by their parents and other authority figures. All we can do about that is expose people to more and better information.

But the second reason is that a lot of people just find the real world we have discovered since the 19th Century to be unsatisfying. They don't want to live here, it doesn't feel good to them to believe that they are what they really are, and so they cling fiercely to a fantasy. This problem does not have to be intractable. It turns out that once you understand it, humanism can be a perfectly satisfying philosophy after all. So one of my contributions to the birthday party will be to serve as a positive spin doctor. I hope I can spin you into ecstasy as well.

A Time to Worry

Somebody should ask James Dobson and Rick Warren why the Intelligent Designer has taken to designing antibiotic resistant bacteria. I'll be particularly interested in His reasons for designing vancomycin-resistant Enterococcus faecium. The Lord works in mysterious ways.

What I do

In response to C. Corax, unfortunately there are some weird rules to the science game -- rules which may be undemocratic, but which I have to play by. In particular, I'm not allowed to go public with research results until they have been published, except in a limited way at academic conferences. That means we've found out some stuff here that I think is interesting, but I can't tell you about it or I might get in trouble. In fact it would be helpful to get some feedback from a broad audience, and would undoubtedly improve the interpretation and applicability of results, but that would be violating the privileges of the secret society.

So let me at least tell you more generally about my interests.

I originally became interested in what is generally framed as the problem of cross-cultural competency in medicine, and the broader issue of how language and culture shape people’s understanding and engagement with their health and health care, and that of significant others. These interests developed largely for reasons of personal history, but the subject also happens to be of topical importance, complex, and intellectually interesting.

I quickly recognized that the cross-cultural situation just adds a layer of complexity to what is already a very problematic kind of encounter, and that the problem of cultural competency is often misconstrued. So here are a few observations I made early on that are central to my current perspective.

In 1996 I had the opportunity to audiotape 150 pediatric visits, mostly in primary care but also a few pulmonology (all asthma), lead clinic, and growth and development specialty visits. About 2/3 of the families in the set are Latino, with every possible language situation: Dr and mother (or the occasional aunt or grandmother and a couple of fathers) both speak English fluently; mother gets by on less than great English; mother and Dr both speak Spanish fluently; Dr gets by on less than great Spanish (but probably thinks he’s Cervantes); there’s an interpreter (a bad one, in 100% of cases); and in one case, the 12 year old sister of the sick infant interprets. There is also a case in which a Haitian physician and Cape Verdean mother communicate with each other in broken Spanish.

The journal articles which have come out of this data set all concern interpretation; unfortunately I haven’t had the time or resources to turn my numerous conference abstracts on other subjects into articles. But here are the bullets:

Cross-cultural competency was oncen understood as being all about people’s culturally specific health beliefs and practices – the weird voodoo and herbal concoctions of those colorful, primitive exotics. Providers are always getting dragged off to these workshops where an expert will tell them all about mal de ojo and Santeria. Pish tosh . . . and that is now generally recognized.

These practices and beliefs obviously do exist, but learning about them has next to nothing, or maybe less than nothing, to do with becoming a culturally competent provider. After all, quite a few suburban WASPs who played on the same college golf team with the doctor gobble potions they buy at the GNC, have the nuns pray for them, wear copper bracelets, or chant. Providers can always ask about that stuff if they think it’s important.

The real problems of cross-cultural competency are just a crust on the standard casserole. The language barrier is a huge issue of course, and interpretation is at best a necessary evil and hardly a solution – of which more anon. But setting that aside for the moment, cross cultural encounters differ in degree, not in kind.

My observations – as yet informal, so let’s say hypotheses – are that cross cultural encounters are often relatively ineffective due to the following characteristics:

• Misalignment of expectations about role relationships and interaction styles. For example, Latinos often perceive that Anglo doctors are “cold,” overly businesslike, and unfriendly. I don’t know about medicine, but in social services and behavioral health we often run into boundary issues – the clients want to invite the therapist to the family barbecue or the baptism.

• It may seem paradoxical, but this does not imply an expectation of lesser social distance. On the contrary. Providers may be unaware of the extent to which their cultural authority inhibits people from providing intimate or embarrassing information, asking questions, or indicating that they do not understand something.

• Non-comprehension of people’s lifeworlds. Providers don’t appreciate, and don’t think to ask about people’s social, economic and physical context and how it may interact with adherence to medications, life style recommendations, appointments and follow-up, etc. This includes the specific issue of individualism vs. family and community in treatment decision making and self care. (Hint: the dominant Anglo culture assumes these are essentially issues for the patient as an individual.)

You’ll notice right away that patients don’t have to be exotic for these problems to apply, one way or another.

Also notice that I haven’t said anything about health literacy, comprehension of scientific theories of disease and treatment, or remembering and following complex instructions, and that’s because none of that has anything to do with whether a situation is cross-cultural or not, assuming we get past the basic issue of communicating with people in a language they understand. It helps, obviously, when patients have more formal education, but I have found that even well-educated people whose education doesn’t happen to include a lot of biology and biomedicine can be pretty much at a loss when it comes to etiological and therapeutic theories.

It’s important to remember, however, that in general, people don’t know what they don’t know. We can observe from the outside that people’s understanding of how their doctors explain their diseases and treatments is not well aligned with what their doctors actually think, but people very seldom complain that their doctors say things to them that they do not understand. By and large, they either think they do understand, or it goes right over their heads without their really paying attention. Their complaint, if any, is likely to be that they weren’t told anything at all, the doctor never mentioned that. The concerns of “health literacy” and instrumental understanding are pretty much etic to patients. Most of the time, they’ll fill in the blanks with a story that satisfies them, rather than decide they didn’t understand something.

So, what do patients take away from their encounters with their physicians, and vice versa? (Note that the question of what physicians understand about their patients is not as commonly asked.) How do treatment decisions really get made, what communication strategies result in better mutual understanding, more success by both physician and patient at managing disease, and better lives for people?

A second broad interest concerns the social production of health, of which medical care is not such a huge part after all. Call it health equity. Justice if you will. Again, I tend to see it through a frame of culture and ethnicity but that's just an extra layer, you don't have to be a foreigner or a minority group member to get screwed, one way or another. My first graduate degree is in environmental policy (which is how I learned that economics is a crock) and I'm trying to understand how communication in the clinic and people's life worlds are connected.

Finally, there is still that problem of language. How does language construct reality, what are the limitations of interpretation -- ultimately meaning simply cannot be entirely the same in different languages -- and how can language barriers be minimized in clinical practice?

So those are the areas in which I believe I am some sort of expert, but that doesn't mean I know more than you do about them. It just means I know about them in a particular kind of way. We all experience our own lives, our own health, our own encounters with the medical institution, and we know all about those subjects. So I intend to do research in a way that is still fairly unconventional, and that is in partnership with people who used to be treated entirely as subjects: what we call participatory research. So I'm hoping that all of you can be participants as well.

More on Democracy and Science

Dennis Overbye, in a very well-written essay, argues that a healthy scientific enterprise is the mark of a healthy democracy. He uses as his counterexamples Communist China and the Soviet Union, but he opens by invoking the past 8 years and the elation we all feel at the restoration of science to its proper place of honor in this country.

Overbye sees science itself as an essentially democratic and democratizing exercise, and I agree that in the long run it has proved to be so. Nevertheless I have long argued here that science as actually practiced is much less democratic than it ought to be, and that many people -- probably most Americans, in fact -- see it as exclusionary and even oppressive. Rank and file creationists don't cling to their beliefs because they are an inferior breed, but they feel scorned by an establishment they perceive as arrogant and hostile to their values. In other words many on the scientific side of the divide do look down on them, or at least on the leaders and champions they respect.

For the cause of science to triumph, we must continually struggle to bring more people inside, and we don't invest enough in doing that. The academy is insular and obssessed with hierarchies of rank and title, degrees, institutions, journals, and awards. People won't be convinced by scientists who insist on speaking a private language of exclusion, strutting about in their glorious professorships, and not letting your kids into their university. Writing for popular consumption and speaking to a mass audience actually earns you demerits at Harvard and has even done some famous professors out of a job. Paul Starr and Cornell West come to mind.

I pledge to work to build a research institute without walls. It doesn't make any sense to study physician-patient communication entirely from the physician's side. We're going to bring in patients as full partners in this enterprise, not as research subjects but as participants who contribute equally to the scientific product. It may seem less than obvious how to go about that in biology, or physics, or cosmology, but I believe it can be done. Of course hard won expertise and exceptional talent are essential to good science, but arcane knowledge and membership in exclusive societies do not contribute to making the right choices about what questions to ask and what sense to make of the answers. Those are the rightful domain of everyone.

If they can send a man to the moon . . .

The other day a guy got on the elevator with me, and I saw from his badge that he was Doctor Umptyump, Rheumatology. So I asked him, "Can you cure my medial epicondylitis?" That's how you say tendinitis in the elbow in doctorese.*

"No, but I can inject it."

"I understand that just makes it worse in the long run."

"Yep, it's not a good idea. You should just live with it. That's what I do."

If you look this up (it's not actually tennis elbow, it's the opposite ligament, on the inside of the elbow, but same idea) the book says that with a few weeks rest, it will ordinarily resolve. Sometimes, and sometimes not. It can also be chronic and quite intractable, as my new friend the rheumatologist obviously knows. And there's not a damn thing medical science can do about it. (The injection he referred to is a cortisone injection, which will knock down the inflammation, but can permanently weaken the tissue. Sometimes athletes have it done so they can get back in the game but it's not a trade off that makes sense to me.)

The larger point here is that medical advances have largely missed some of our most prevalent annoyances. They still can't cure or prevent the common cold, osteoarthritis, or chronic tendinitis. I don't think that colds have much of an impact beyond being a nuisance, but the musculoskeletal deterioration we tend to suffer as we grow older does cause people to become less physically active and so can contribute to bigger problems -- such as diabetes and heart disease, not to mention depression. UI don't intend to slow down if I can possibly help it, but not everybody's pain threshold is as high as mine. Just a little hint for the good people at NIH.

*I once saw a podiatrist because I had suddenly developed a very stiff big toe. He said, "Oh, you have hallux rigidus." I said, "What's that?" He replied, "That means a stiff big toe." I wasn't paying for a Latin lesson. And no, there was absolutely nothing he could do about it except teach me how to say it in Latin. It's osteoarthritis.

A bit more on the politics

I'll try to answer one question briefly. Why do the other members of the United Federation of Planets have some form of universal health care, but we don't? It has a bit to do with accidents of history, and more to do with our political culture.

The accident of history is a bit paradoxical. The present system which is largely based on insurance provided by employers got established during WWII, actually before most of the other countries set up their universal systems. It happened in part because of wage controls imposed during the war, in the middle of a tight labor market. Employers couldn't raise wages, but they needed to offer perks to attract and retain employees, so they padded the benefits, of which health insurance was a particularly nice one. Unions liked this system because it gave them something they could bargain for and win for their members as well.

Remember that back then, health care didn't cost nearly as much as it does now, but on the other hand it wasn't as wonderful a thing. Most of us are too young to realize that it wasn't until WWII and really the post-war era that doctors actually had a decent clue what they were doing. Antibiotics were developed during the war and became generally available afterwards. That was the biggie in itself, and it led to the possibility of reasonably safe surgery. Then came a growing understanding of heart disease and cancer, orthopedic surgery and devices, and so on. Until then, doctors did at least as much harm as good. (That balance is still a lot closer than we'd like it to be, but it has certainly tipped.)

So, when England established its National Health Service in the 1950s, and as the Canadian single payer system developed over the decades through the 60s,
medicine was just coming into its own. The vested interest represented by the pharmaceutical companies and the medical establishment was not as powerful as it is in the U.S. today, and health insurance companies in those countries were minor players. Even so, the Canadian single payer system had to overcome considerable resistance from doctors. In fact, the doctors in Saskatchewan went on strike in 1962, but they kind of lost steam when the death rate immediately went down.

Harry Truman tried to introduce a national health program in the U.S., but the American Medical Association was an implacable opponent, and the doctors' lobby was too well funded and too powerful to defeat. Meanwhile, since many workers already had insurance through their jobs, and health care wasn't all that expensive anyway, the pressure for reform wasn't all that powerful. By the time John Kennedy became president, however, the plight of uninsured elderly and low income people was obvious, and he proposed creating programs to address their needs. So the AMA had Ronald Reagan make a recording called "Reagan Speaks Out Against Socialized Medicine," which was sent out to the Ladies' Auxiliary of the AMA (yep, doctors were presumptively male and their wives formed an Auxiliary), to be played at garden parties. Reagan said, famously, that if Medicare passed, "one of these days you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free."

Lyndon Johnson ultimately got Medicare and Medicaid passed in 1965, but in the larger picture, that took off much of the pressure to create a truly comprehensive system. Meanwhile, even as the AMA shifted its position, the power of the drug and insurance companies grew. So, the bottom line is, we've had both bad timing, and a deep-seated cultural resistance to anything that can be labeled "socialism." No, Medicare didn't turn the U.S. into a totalitarian dungeon, but the drug peddlers are still screaming and yelling that a single payer system will. And enough working class people believe it that we don't have a unified constituency in favor.

Why do working class people in the U.S. fear government intervention to promote the general welfare? That's a longer story, but I'll try to tell it soon. All I'll say for now is that the election of Barack Obama could change that, if he's bold enough. So far he doesn't appear to be, but we'll see.

You don't just have to take it from me . . .

Lots of good freebies in today's NEJM -- they're making more and more material of broad public interest open access, and so they're getting credit where it's due. Long-time readers know that I have castigated them unmercifully about this, so I guess it's the awesome influence of Stayin' Alive that's brought about the change.

Anyway, I commend your attention to J. Oberlander's essay on the prospects for health care reform. He largely agrees with me in seeing the political interests as stacked against major changes. The drug and insurance companies just aren't going to allow it if they can possibly help it. And if they won't give up any income, real cost containment isn't going to happen because Obama's talk about saving money through electronic medical records and enhanced preventive efforts is speculative at best and unlikely to yield major savings. But he sees a glimmer of hope in all the bad news -- if enough people lose their health care insurance in Great Depression II, and the federal deficit is already a gazillion dollars anyway, maybe providing some real form of universal, affordable coverage will become feasible. I don't know if it's something we ought to wish for, but maybe so.

Michael Sparer (who might be a guy I went to college with, I don't know for sure but it's not the world's most common name) thinks that the idea of expanding Medicare and allowing people to buy into it won't fly, largely because it will invoke a term he considers to be radioactive, to wit "single payer." So he recommends expanding and allowing buy-in to Medicaid, instead. That seems to me like a pretty feeble reason for preferring what, in my opinion, would be a highly inferior option. Michael, or Dr. Sparer, depending on whether I actually know him or not, sees advantages in the state-level administration of Medicaid, which allows the states to try different policies and thereby we can muddle through to whatever works best. However, as far as I'm concerned, Medicare already works, so what's the problem? And as for any stigma that may attach to the term single payer, I'd rather work to change the culture than surrender to idiocy.

Finally, they give rare free access to a research article, in this case an epidemiological study of the effect on life expectancy of reductions in general population exposure to fine particle pollution. This is important as we now have an administration that has pledged to make environmental policy based on scientific truth rather than the venal interest of polluters. The amount of healthy life we can buy by reducing air pollution are impressive indeed -- about 7 or 8 months for every 10 micrograms per cubic meter. Since fine particle concentrations in U.S. cities today are typically around 15 mcg/m^3, we still have room for improvement. (Near major highways, people are exposed to high levels of even smaller ultrafine particles, which are even more dangerous. But that's a story for another day.)

So, let's see if Congress tightens the standard for PM2.5 pollution, which means better controls on auto exhaust, power plants and industrial emissions. It might save your life.

Natural Supports

I was interested to see that one of our commenters is an oncological massage therapist. It so happens I was recently involved in a project concerning that very subject. There is good evidence -- real scientifical type stuff -- that massage can be helpful in palliation of cancer. It can relieve pain and malaise, reducing the need for narcotics and other drugs, and relieve stress. Massage therapy is certainly something people should consider in various circumstances, so long as the claims for it aren't overblown.

Our project was a product to teach caregivers -- i.e. spouses, significant others, adult children, siblings, friends, etc. -- of people with cancer basic therapeutic massage techniques, using a manual and a video, based on a full-day instructional workshop given by professional massage therapists. I'm not trying to put our friend out of work -- there's obviously a role for professionals -- but there are also extra benefits to mobilizing natural supports in this way. For one thing, as became very clear in the workshop and follow-up, it can mean a lot to the loved ones to have something so tangible to offer. It can strengthen bonds and make the ordeal of cancer and cancer treatment easier to bear for both parties in profound ways that go well beyond the immediate physical benefits.

As we try to cope with the rising burdens of morbidity and disability that will inevitably come with an aging population, strengthening and enabling natural supports is one strategy that we ought to pursue more aggressively. People can stay at home longer or get out of institutions -- hospitals, intermediate care facilities, rehab hospitals, etc. -- sooner if we give caregivers some help. That includes skills, assistance, emotional support, maybe a little bit of money, and respite. Of course, sadly, not everybody has people in their lives who can do this, but there are strategies to fill even that need. There's a danger in the temptation to force this on people beyond the point where it's a positive choice, in order to save money, but on the other hand many people would prefer it.

Right now, Medicare, Medicaid and most private insurance don't offer much support for these strategies, or place arbitrary time limits and other restrictions that are counterproductive. Payers -- contrary to their own financial interests -- actually force people into institutions rather than strengthening and supplementing informal supports so that people can stay out of them. We need to rethink these policies, on both financial and humanitarian grounds.

Nobody cares what I say today . . .

But for the sake of good discipline, I'll do a post. It so happens that Mr. Obama and I both started new jobs today. (Also, the eruption of Mount St. Helen occurred on my birthday, so I'm just a portentous guy.) My new job is at an academic medical center, so even though I'm a researcher not involved in patient care, I had to go through the standard orientation. I now know how to handle hazardous chemicals, what to do if I get blood or excrement splashed in my face, and what to do if somebody abducts a baby. (The latter is a Code Pink, by the way.)

While much of this may not have been directly relevant to my work, as a medical sociologist I was certainly interested in observing it. I actually took a great deal away from the experience, but I'll just note here how much hospitals - at least big urban hospitals - have to be concerned about security issues. Health care workers have the highest probability of any profession of being assaulted on the job, and that includes police officers. Hospitals not only have a lot of mentally ill, delirious and/or demented people in them more or less by definition, but they also have a lot of people who are distraught about the fate of family members or themselves, and may get belligerent about it. People also like to go into hospitals to steal, not only babies, but narcotics and other stuff.

The buildings are wide open, anybody can walk in, and they have to serve everybody regardless of how the people behave or how unsavory they may appear. Hospitals can't do security screening, or make people sign in, or stop pretty much anybody from just walking up to the elevators and heading wherever. It wouldn't be practical, and it wouldn't be friendly.

So there is a great deal going on, largely behind the scenes, to provide security. This is just one indication of the complexity of these organizations and the substantial institutional challenges that they face. The experience of being a patient or the loved one of a patient is often alienating and infuriating, and I do aim to make it better, but at the same time, I ask you to cut them some slack -- it isn't easy. More on all this anon.