Look! A missing white woman! George Michael is stoned!

What they won't tell you is that a report to the UN Human Rights Council by special rapporteur Paul Hunt (PDF) on the U.S. detention camp at Guantanamo Bay includes the following findings, which I've just plucked here and there from a melange of horrors:

23. The indefinite detention of prisoners of war and civilian internees for purposes of continued interrogation is inconsistent with the provisions of the Geneva Conventions. Information obtained from reliable sources and the interviews conducted by the special procedures mandate holders with former Guantánamo Bay detainees confirm, however, that the objective of the ongoing detention is not primarily to prevent combatants from taking up arms against the United States again, but to obtain information and gather intelligence on the Al-Qaida network.

24. The Chairperson of the Working Group and the Special Rapporteur note that, while United States Armed Forces continue to be engaged in combat operations in Afghanistan as well as in other countries, they are not currently engaged in an international armed conflict between two Parties to the Third and Fourth Geneva Conventions. In the ongoing non-international armed conflicts involving United States forces, the lex specialis authorizing detention without respect for the guarantees set forth in article 9 of ICCPR therefore can no longer serve as a basis for that detention.

25. Many of the detainees held at Guantánamo Bay were captured in places where there was - at the time of their arrest - no armed conflict involving the United States. The case of the six men of Algerian origin detained in Bosnia and Herzegovina in October 2001 is a well-known and well-documented example, but also numerous other detainees have been arrested under similar circumstances where international humanitarian law did not apply. The legal provision allowing the United States to hold belligerents without charges or access to counsel for the duration of hostilities can therefore not be invoked to justify their detention.

34. The right to a fair trial is recognized in article 14 of ICCPR, as well as articles 105 and 106 of the Third Geneva Convention and article 75 of the Additional Protocol I (this last article is considered to be declaratory of customary law).38 The fundamental principles of the right to a fair trial cannot be derogated from by any State, under any circumstances, as affirmed by the Human Rights Committee in its general comment No. 29.39 The Military Order recognizes the duty to “provide a full and fair trial”, but its provisions do not guarantee that right. . . .

42. Article 2 (2) of the Convention states that: “No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture.” The right to be free from torture and cruel, inhuman or degrading treatment or punishment is a non-derogable right, and therefore no exceptional circumstances may be invoked to justify derogation. The Human Rights Committee and the Committee against Torture have consistently emphasized the absolute character of the prohibition of torture and underlined that this prohibition cannot be derogated from in any circumstances, even in war or while fighting terrorism.

43. The prohibition of torture and “outrages upon personal dignity, in particular humiliating and degrading treatment” is also contained in common article 3 of the Geneva Conventions of 1949, to which the United States is a party. Moreover, the prohibition of torture is part of jus cogens. Torture and other inhumane acts causing severe pain or suffering, or serious injury to the body or to mental or physical health are also prohibited under international criminal law and in certain instances can amount to crimes against humanity and war crimes.

44. The prohibition of torture provided by the relevant international standards, in particular the Convention against Torture, also encompasses the principle of non-refoulement (art. 3), the obligation to investigate alleged violations promptly and bring perpetrators to justice, the prohibition of incommunicado detention, and the prohibition of the use of evidence obtained under torture in legal proceedings.

53. Whereas it is conceivable that in the beginning the conditions of detention put in place were determined for reasons of order and security, they then seem to have been used to “counter resistance” and to cause stress. Moreover, they were closely linked with investigation techniques. There is plentiful evidence indicating that policies aimed at forcing detainees to cooperate such as withholding of clothes or of hygienic products, permanent light in the cells, no talking, cultural and religious harassment, sensory deprivation, intimidation, and the deliberate uncertainty generated by the indeterminate nature of confinement and the denial of access to independent tribunals, were used and led to serious mental health problems. Moreover, prolonged detention in Maximum Security Units clearly had the effect of putting pressure on detainees. Reports indicate that although 30 days of isolation was the maximum period permissible, detainees were put back in isolation after very short breaks, so that they were in quasi-isolation for up to 18 months. According to the jurisprudence of the Human Rights Committee, prolonged solitary confinement and similar measures aimed at causing stress violate the right of detainees under article 10 (1) ICCPR to be treated with humanity and with respect for the inherent dignity of the human person, and might also amount to inhuman treatment in violation of article 7 ICCPR.71

55. There have been consistent reports about the practice of rendition and forcible return of Guantánamo detainees to countries where they are at serious risk of torture. An example is the transfer of Mr. Al Qadasi to Yemen in April 2004. He has since been visited by his lawyer and international NGOs. According to his lawyer, he was not warned about his imminent return to Yemen and therefore had no possibility to appeal. In early April he received an injection against his will, which led to loss of consciousness and hallucinations. When he woke up several days later, he found himself in prison in Sana’a, where he alleges he was beaten and deprived of food. On the basis of the information available to him, the Special Rapporteur takes the view that the United States practice of “extraordinary rendition” constitutes a violation of article 3 of the Convention against Torture and article 7 of ICCPR.78

71. Reports indicate that the treatment of detainees since their arrests, and the conditions of their confinement, have had profound effects on the mental health of many of them. The treatment and conditions include the capture and transfer of detainees to an undisclosed overseas location, sensory deprivation and other abusive treatment during transfer; detention in cages without proper sanitation and exposure to extreme temperatures; minimal exercise and hygiene; systematic use of coercive interrogation techniques; long periods of solitary confinement; cultural and religious harassment; denial of or severely delayed communication with family; and the uncertainty generated by the indeterminate nature of confinement and denial of access to independent tribunals. These conditions have led in some instances to serious mental illness, over 350 acts of self-harm in 2003 alone, individual and mass suicide attempts and widespread, prolonged hunger strikes. The severe mental health consequences are likely to be long term in many cases, creating health burdens on detainees and their families for years to come.

75. The Special Rapporteur has received reports, many confirmed by investigations of
the United States military,115 that health professionals in Guantánamo Bay have systematically violated widely accepted ethical standards set out in the United Nations Principles of Medical Ethics and the Declaration of Tokyo, in addition to well-established rules on medical confidentiality. Alleged violations include: (a) breaching confidentiality by sharing medical records or otherwise disclosing health information for purposes of interrogation; (b) participating in, providing advice for or being present during interrogations;117 and (c) being present during or engaging in non-consensual treatment, including drugging and force-feeding.118 In sum, reports indicate that some health professionals have been complicit in abusive treatment of detainees detrimental to their health. Such unethical conduct violates the detainees’ right to health, as well as the duties of health professionals arising from the right to health.

But see, Dr. Hunt doesn't understand the terrorist enemy we're facing. Or, come to think of it, maybe he understands the terrorist enemy all too well.

But this obviously is not worthy of any attention in the United States -- why should Americans care what a bunch of damn foreigners think about us? Otherwise we would have read about this in the New York Times.

ADDENDUM:According to the memoir of a close associate of former Canadian Prime Minister Jean Chrétien, George W. Bush said to Chrétien "If I catch anyone who leaks in my government, I would like to string them up by the thumbs -- the same way we do with prisoners in Guantanamo." Bet you didn't read that in your home town fishwrapper either. Feel a little frisson, perhaps? (via Digby)

State of Emergency

Sorry for the hiatus, I was a bit distracted yesterday.

Anyhow, in the past week we've seen the truly bizarre hypocrisy and perverted priorities at the heart of our current political system and culture ripped open for inspection like a swarthy man's luggage. For all the attention on who really has moral values and who really knows how to win a war, I'd still like to see a bit more attention paid to what us little people who pay taxes are getting for our money.

While they're spending $2 billion and a couple of dozen young Americans killed or maimed every week to establish permanent military bases in Iraq, along with an an embassy designed to put the palace at Versailles in the second tier of excess, they aren't taking care of business here at home, particularly when it comes to keeping us safe. I've talked about some of what makes us not safe before, but stuff like not getting poisoned by the air you breathe or the food you eat may seem like namby pamby nanny state liberalism to some people.

So how about no room at the Emergency Department when The Terrorists set off their Dirty Bomb? Arthur Kellerman discusses the recent IOM report on the overburdened emergency care system in the U.S. In 1986, Congress passed legislation affirming that everyone had a right to critical care in hospital emergency departments, putting an end, in theory (only), to the wallet biopsy which used to determine whether you got your compound fracture pinned. Unfortunately, it didn't occur to anybody to provide money for this purpose, so many hospitals responded by simply closing their EDs. Others didn't maintain sufficient capacity to meet demand so they keep people waiting for hours and divert ambulances to other hospitals. It is likely that this perpetual state of backlog contributed to the recent death of a woman who sat in an ED for hours unattended despite complaining of the symptoms of a heart attack.

As Kellerman discusses, Congress has appropriated all kinds of money for "terrorism" preparedness, but almost none to strengthen the emergency medical system. We are still muddling through the ordinary flow of seriously ill and injured people, though who knows how many may have died, suffered, or had their conditions worsen unnecessarily due to backlogs and diversions? No-one is keeping track. But if there is a mass casualty event -- whether its a terrorist bombing, or far more likely events such as a mass casualty fire or earthquake, emergency facilities in most parts of the country will be unable to respond adequately.

Is this the biggest problem we face? Certainly not. But one week's worth of spending on the war in Iraq would be more than enough to fix it. The next week, we can do addiction treatment on demand. Then you get your favorite thing.

Don't waste time in mourning . . .

Yup, everybody's depressed today. Even the General can't find any humor in the situation. I can't find the inspiration to do the posts I had lined up on the shortage of Emergency Department services, the exodus of physicians from primary care, or the mildly creepy authoritarian public health philosophy of Prof. John Banzhaf. But I will get around to them. This is just one more day in history -- there are many more to come.

I lived through Vietnam and the Nixonian power grab, and long before I was old enough to vote, I was organizing and protesting. That's what you did in those days, if you didn't like killing and burning and torturing people in your name, and you still wanted to live in a nation of laws and liberties. And in the end, we won. We saved our Republic. And we did more than that -- we ended legalized discrimination, won the right to vote, won greater equality for women, changed some of the basic norms of our culture, apparently forever. So, we got complacent. The vandals were just outside the city gates, gathering in the woods, plotting our downfall. But we were growing soft.

The mass media culture grew even shallower, over the past 25 years, something I would not have thought possible. At its best, for a time, journalism was a profession with a sense of mission and honor. Now it's nothing more than a category of high class whoredom. Back then, people were engaged in politics through true mass organizations -- unions, local community groups, statewide and national issue-oriented mobilizations that had real members who went to meetings, held local events, and sent in money to keep the national program going. Now about the only people who do that are fascist religious fanatics.

When I first moved to the Boston area I got involved with Mobilization for Survival. (Now Boston Mobilization.) It was just an average month for us to have 10,000 people on the Boston Common protesting U.S. intervention in Central America, five or six talks in front of church or community groups (yup, churches used to be against war, and for social justice, imagine that), monthly meetings of four different program committees with 12 or 15 active members each, a small demonstration at a Congressional office -- and meantime there were 10 other groups that would join us in coalitions when they weren't doing their own thing at approximately the same rate, from SANE to CPPAX to the DSA.

If any president had tried to pull off one twentieth of the outrages of this present gang of murderous thieves, the Boston metropolitan area, and a lot of other cities around the U.S.A. would have been shut down. Hell, we did shut them down when Nixon invaded Cambodia, and things got so hot when Reagan wanted to send troops to Central America that we stopped him. I remember it very well, I trained marshalls and organized for a march on the Pentagon of 45,000 people, and there wasn't even a publicly announced intention to go to war, just some state-sponsored terrorism by the CIA.

But now we are a self-absorbed people, fat and comfortable, yet timorous and clinging -- maybe because we're afraid we really don't deserve what we have and that guilt makes us fearful of losing it. Why the wealthiest, most powerful and by far the most militarily secure society in history would sell its soul to a bunch of clownish megalomaniacs out of paranoia and cowardice is pretty hard to explain. But don't ever forget that Americans are no better than other people. And today, we are worse than most.

Too easy for a hint

Why do dictators torture people?


It's not to obtain information, or to protect the nation from enemies and subversives -- although they always say those are the reasons.

It is to proclaim their limitless power, and to terrorize anyone who would question or challenge it. Anyone who has ever lived under a dictatorship knows that.

They hate us for our freedom

i generally try to stick to subjects on which I might have something special or at least idiosyncratic to add, and I resist dropping my own halfpenny worth on the topic du jour. But I mean, really. Goodness gracious. Heavens to Betsy. It seems the Congress needed to do something about the executive branch demolishing the Bill of Rights, the separation of powers, the rule of law, and 100 years of progress on international norms of conduct, so the solution is to legalize it all and grant the President of the United States the powers pertaining to a psychopathic dictator.

This is the effect of the legislation which has passed the House of Representatives and is now being debated in the Senate:

If, in the opinion of George W. Bush, I have "purposefully and materially supported hostilities against the United States" (let's say, by giving to Pakistani earthquake relief, as I urged people to do here last year), he can declare me an unlawful enemy combatant and make me disappear forever into a military prison, where he can have me tortured, with no recourse to the legal system, except that I will be tried by a "military tribunal." That I happen to be a U.S. citizen doesn't protect me. Oh sure, he wouldn't do that -- this bill is only directed at people who support terrorists on purpose, not to worry.

The punditocracy has ruled that this is a clever political maneuver by the Republicans. If Democrats vote against the bill, they will be enablers of terrorism, and it will redound to Republican advantage at the polls. It can happen here. It is happening here. It has happened here.

Two new links

I've added Unicorn Hat and Political Health to the blogroll. (Look to the left.) Do check them out, you won't be sorry.

This time, you really did read it here first

Here is the link to the uncorrected pre-publication proofs of The Future of Drug Safety: Promoting and Protecting the Health of the Public, the Institute of Medicine's long anticipated report on the FDA and the drug approval process. (200+ page PDF) It will cost you significant dollars to buy the typo-free version once it comes out, so if you're a health policy junky, this will save you enough for a trip to Dunkin' Donuts, or preferably the produce aisle.

The key recommendations, as usual, are another open door crashed through. If you've been reading this space, you know that everything they say has been said before by health care policy drones in every corner of the land. But that's how it works -- once the grunts, laboring in their anonymity, break the door down, the brass can stroll in and find themselves shocked, shocked, at what goes on here. Some highlights:

• (Ooh, this is a good one!)3.3: The committee recommends the Secretary of HHS direct the FDA commissioner and Director of CDER [Center for Drug Evaluation Research], with the assistance of the Management Advisory Board, to develop a comprehensive strategy for sustained cultural change that positions the agency to fulfill its mission, including protecting the health of the public. (Damn, that's nasty.)
  
  
• 3.5: To restore appropriate balance between the FDA’s dual goals of speeding access to innovative drugs and ensuring drug safety over the product’s lifecycle, the committee recommends that Congress should introduce specific safety-related performance goals in the Prescription Drug User Fee Act IV in 2007.(Whoops! guess they forgot a teeny weeny little item last time. Well, those Congress people have a lot to think about, what with having to raise money and all . . .
  
  
  
• 4.1: The committee recommends that in order to improve the generation of new safety signals and hypotheses, CDER (a) conduct a systematic, scientific review of the AERS [Adverse Event Reporting System] system , (b) identify and implement changes in key factors that could lead to a more efficient system, and (c) systematically implement statistical-surveillance methods on a regular and routine basis for the automated generation of new safety signals.
  
  
• In addition, CDER’s ability to test drug safety hypotheses is limited. Wait a minute -- isn't that supposed to be, like, their job? I keep getting the feeling that I'm missing something here . . .
  4.2: The committee recommends that in order to facilitate the formulation and testing of drug safety hypotheses, CDER (a) increase their intramural and extramural programs that access and study data from large automated healthcare databases and (b) include in these programs studies on drug utilization patterns and background incidence rates for adverse events of interest, and (c) develop and implement active surveillance of specific drugs and diseases as needed in a variety of settings. In other words, they should start to collect the actual data that would be necessary in order to evaluate drug safety. Golly, that does sound like a good idea.

And so it goes, with a whole series of recommendations that just make me say, "Well duhhhhh." Shorter IOM:

The FDA needs to develop the intention and the ability to protect the public. Neither of which it currently has.

(Thanks to Badri for the tip.)

Yes, all their dogs are in the hunt . . .

...but why should the drug pushers have all the horses? The American Psychological Association has just released an in-depth report on the use of psych meds in children. (56K warning: large pdf) As far as Stayin' Alive is concerned, it's another open door crashed through, but maybe some people will listen. Yes, yes, they aren't real doctors, they're doctors of philosophy, but still.

The bottom line is that (remember, you read it here first, if you happened to read it here first) kids with behavioral and emotional problems (APA goes along with the gag and calls them "mental disorders," without questioning the ontological status of the diagnoses) get drugs that have not been adequately tested for safety and long term efficacy, but they generally don't get psychosocial interventions that have been proven to work, because it's harder to get anyone to pay for them, and there aren't enough trained clinicians. A couple of money quotes:

The evidence base for treatment efficacy is somewhat uneven across disorders, with some of the most severe mental health conditions of childhood, including bipolar disorder and schizophrenia, receiving proportionally less attention from treatment researchers. Most of the evidence for efficacy is limited to acute symptomatic improvement, with only limited attention paid to functional outcomes, long-term durability, and safety of treatments. Few studies have been conducted in practice settings, and little is known about the therapeutic benefits of intervention under usual, or real-life, conditions.

. . .

It is the opinion of the working group that the decision about which treatment to use first be in general guided by the balance between anticipated benefits and possible harms of treatment choices (including absence of treatment), which should be the most favorable to the child. It is recommended that the safest treatments with demonstrated efficacy be considered first before considering other treatments with less favorable side effect profiles. For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. The preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, the working group recommends that in most cases psychosocial interventions be considered first.

The APA report goes on to consider the commonly diagnosed mental disorders of childhood in turn, beginning with our good friend Attention Deficit-Hyperactivity Disorder. (I won't get into whether not doing what children typically don't like to do -- sit quietly in rows, concentrate for long periods on boring tasks, and speak or move only with permission -- is properly called a disease. Granted, we all need to do things we don't enjoy, and this is one of them.) Anyhow, APA tells us that

Since the 1970s, a large number of studies have shown that behavioral interventions cause short-term amelioration of ADHD symptoms and impairment and that these acute effects are comparable in most domains to those obtained with low to moderate doses of stimulant medication (Pelham & Waschbusch, 1999). In contrast to the results of studies of stimulant medication that focus on improving the core symptoms of ADHD, studies of behavioral treatments have focused on improving the key domains of impairment associated with ADHD and thought to mediate long-term outcomes: parenting practices, peer relationships, and academic/school functioning (Pelham, Fabiano, & Massetti, 2005).

Hmm. Sounds to me like parents who really feel that something needs to be done might want to go to a psychologist first, instead of a drug dealer. But now you don't have to take my word for it.

Well now, this is a surprise

A few weeks back I attempted to define the concept of "drugs." As we've discussed quite a bit over the eons here, on the one hand the government wants you to know that "speed kills," on the other hand doctors are prescribing speed to perhaps 2% of American school children. Now, if you hand out a dangerous and street saleable drug to large numbers of kids, what might happen?

Right. Lots of kids will show up in emergency rooms with adverse consequences of drug abuse. Rather interestingly, the rate at which kids 12-17 taking Ritalin for "medical" use visit EDs for adverse consequences was about the same as the rate for kids taking it for "non-medical" uses. For kids taking amphetamine, there are more visits to EDs for non-medical use than for medical use, but both rates are much higher than the rates for young adults, who you would normally expect to be more at risk for drug abuse. We usually see the prevalence of illegal drug use rising after age 18, but in the case of these particular drugs, acute adverse consequences of both illegal use and of prescription use appear to be more prevalent in teenagers than in young adults.

A separate SAMHSA survey finds that prevalence of illicit use is higher than in young adults, but that is obviously not reflected in ED visits. Maybe college kids can use speed more safely -- it was very common when I was in college during final exam week, and as far as I know nobody died from it -- but I remain very skeptical of such widespread prescribing to children.

Us

The recently announced discovery of a nearly intact skeleton of a juvenile Austrolopithecus afarensis is an appropriate occasion for the final installment in my promised series on evolution. That doesn't mean I won't continue to discuss the subject, but this completes the previously stated agenda.

The human lineage diverged from the lineage of chimpanzees about 6 million years ago. More than 4 million years ago, the genus Australopithecus became fully bipedal. What the new fossil skeleton tells us however, is that 3 million years ago, the species was otherwise much more like an ape than a human -- including having a brain not much larger than a chimp's.

Not long, in geological terms, after the time of the Australopithecus child (or cub) -- a little over 2 million years ago -- the species Homo habilis and Homo erectus emerged. Their brains were bigger, though not as big as ours. And they made stone tools. However, in marked contrast to us, their ways of life were highly static. They continued to make very similar looking tools for more than a million years. We have found no evidence of art, or religion, or cultural development among them, although it could be hard to find given their great antiquity.

Creatures who paleontologists consider to be Homo sapiens appear in the fossil record about 400,000 years ago, and skeletons completely indistinguishable from those of modern humans appear 100,000 years ago.

Something extraordinary and as yet quite unexplained happened only about 50,000 years ago -- a sudden explosion of cultural development. Instead of seeing the same toolkit appearing in ancient sites over hundreds of thousands of years and across great distances, we see continual innovation and dramatic variation in time and space. We begin to see ritual burials, works of art, ornamentation. At almost exactly the same time, people began to spread outward from Africa. Within a mere 5,000 years, they had landed in Australia, having evidently crossed a large stretch of open ocean in boats. Within 30,000 years, people had penetrated to every corner of the earth except Antarctica. They had developed agriculture, adapted to climates ranging from the high arctic to deep forest to barren desert, invented baskets, pottery, sewn garments, spear throwers, musical instruments. Within a few thousand years more, they had founded civilizations, built great cities, forged tools of metal, begun to write down their current histories and mythical pasts.

This event was explosive, unprecedented on earth, astonishingly rapid. In a geological eyeblink, we have radically reshaped the planet's ecosystems, and now we are remodeling its very atmosphere and climate. We have even climbed out of the atmosphere and the gravity well and visited our planet's satellite, and sent our robots to other planets and out of the solar system entirely. And we have radically remade our own lives as well.

But what happened 50,000 years ago? The temptingly obvious answer is the development of a huge vocabulary and fully syntactical communication, that is language. With that came the possibility of elaborate reasoning, preservation and dissemination of knowledge, collective problem solving, transmission of knowledge, ideas and values from generation to generation -- the constructed, modifiable, improvable edifice of human culture and social organization. But that begs the question.

How and why could such a powerful and complex faculty as language emerge with such suddenness? Did it depend on a biological event, a genetic modification invisible in the skeleton but profoundly altering the functioning of the brain? Or was the brain somehow prepared to acquire and use language, only awaiting its discovery? The latter may seem improbable, but recent experiments have shown that apes can learn a vocabulary of a few hundred words and use them in a limited syntax. So presumably our earlier ancestors had at least some limited capability to use language, although whether they did so or not we cannot say.

But somehow, at that magic moment, a group of humans acquired the gift of gab -- the fount of unlimited potential, unbounded wonder, and horrific danger.

Credo

Being isolated here in the ivory tower with my chardonnay and brie, it's hard for me to understand those 40% of the people who tell pollsters they think the White House Occupant is doing a good job.

Things you have to believe to be a Republican:

1. The universe was created 10,000 years ago. Or at least, there's a legitimate debate about whether it's 10,000 years old or maybe somewhat older, and we need to teach that debate in science class.
2. A microscopic single cell has exactly the same moral status as a crying baby, if it happens to contain molecules of Deoxyribonucleic acid with nucleotide sequences characteristic of human beings. Jesus said so. It's in the Bible.
3. The allegation that burning fossil fuels is increasing the concentration of CO2 in the atmosphere, thereby causing the globe to get warmer, is a hoax perpetrated by environmentalists in order to get foundation grants.
4. Saddam Hussein attacked the United States on September 11, 2001.
5. The United States is in a war against Terror, aka The Evildoers, which will go on until the President says its over, or forever, whichever comes first. As long as We're At War, the President must have the same powers as Adolf Hitler in Nazi Germany, or you and your family will not be safe. People who don't want him to have those powers care about The Evildoers more than they care about your family.
6. Osama bin Laden, the leader of Terror, aka The Evildoers, is as dangerous as Hitler or Stalin.
7. Osama bin Laden really doesn't matter. We're not that concerned about him.
8. If people of the same sex are allowed to marry, my family will be destroyed.
9. If we don't repeal the Death Tax, I won't be able to pass on my raised ranch and my 87 Ford Ranger pickup to my kids.
10. Iraq is a shining example of democracy which will transform the Middle East. People in Iraq used to get tortured and killed, they couldn't practice their religion freely, and women had to do difficult jobs like being college professors and engineers. Now people can practice their religion freely (even though they get tortured and killed for it), and women get to stay home all the time so they won't be kidnapped and raped. Anyhow, we had to invade because Saddam Hussein attacked us on Sept. 11 2001, he had huge stockpiles of chemical and biological weapons that he was planning to give to Osama bin Lade, he was making nuclear bombs, and he's an Evildoer.
    
11. Democrats are the party of fiscal irresponsibility. We need to keep Republicans in office so they can't run up huge budget deficits.

I'm sure you can think of a few more but that's enough for now. As usual, I'm out of here until Sunday.

Lies and the Lying Liars who Fund Them

NEJM has once again provided a free full-text article to the common rabble, this time by Robert Schwartz, M.D., on stem cell research. It provides a quick, lay-friendly review of the current status of biomedical research using embryonic and adult stem cells.

What I want to chop out for your consideration today is this:

According to the New York Times, Karl Rove, head of the White House's Office of Political Affairs, has declared that embryonic stem cells aren't required because there is "far more promise from adult stem cells." Yet the notion that adult stem cells have the same developmental potential as embryonic stem cells, let alone "more promise," is dubious. It seems that the White House received this idea from David Prentice, a senior fellow for life sciences at the Family Research Council and an advisor to Republican members of Congress. In a report of the President's Council on Bioethics, Prentice claimed that adult stem cells can effectively treat more than 65 diseases. Not only is this assertion patently false, but the information purveyed on the Family Research Council's Web site is pure hokum.

In case you didn't already know, the Family Research Council is a "Christian" organization founded by James Dobson. It is famous, among other reasons, for accusing Sponge Bob of being gay.

Then there are all those "research institutes" that claim that human activity is not causing global warming. Turns out Exxon is paying them to say that. The British Royal Society (equivalent of our National Academy of Sciences) has asked them to stop.

This is the first time the society has written to a company to challenge its activities. The move reflects mounting concern about the activities of lobby groups that try to undermine the overwhelming scientific evidence that emissions are linked to climate change. The groups, such as the US Competitive Enterprise Institute (CEI), whose senior figures have described global warming as a myth, are expected to launch a renewed campaign ahead of a major new climate change report.

Exxon/Mobile is also, of course, a major contributor to the Republican Party and Republican candidates. Then there are all those researchers who claimed that tobacco doesn't cause cancer and heart disease. Paid for, of course, by the tobacco industry -- also a major backer of Republicans.

Why do all these ideologues and greed heads have to fund their own, private research institutes? Why aren't there scientists working in universities and independent research settings (such as the one where I work) who will say the things they want said? Is it because academia has a liberal bias, and refuses to hire people who don't wear pink underwear?

Nope. It's because reality has a liberal bias. The reason that conservatives lie all the time is because they have to. The truth is their enemy.

Reality Basis for the National Review

A few days back we had an inquiry about an article in the National Review by some clown named Deroy Murdock claiming that all those pinko commie national health care programs in Europe are much worse than our capitalist paradise system. My initial response was perhaps too sophisticated for our lay readers: the guy is making it up and he's full of shit. That's technical language for failure to provide appropriate citations and cherry picking of out of context anecdotes.

Anyhow, I didn't say anything further right away because I happened to know that we were about to get the real deal answer. Here it is, free to all, including liars who write for the National Review. (Is there some other kind of National Review writer? I'm just curious.)

The point of this study from the Commonwealth Fund was not really to compare the U.S. health care system performance to other countries, but rather to whatever seemed to be the best benchmarks available. But where those happen to be other countries, the conclusion is inescapable. As I keep repeating until it becomes like a spike driven into the brain, we spend twice as much of our GDP on health care as the median of wealthy countries, yet somehow manage to be the only one that doesn't guarantee coverage to everyone. Do we get what we pay for?

On "mortality amenable to health care" -- and we've had a lot of discussion lately about what that is and isn't, but it's something like half of all mortality -- we are close to the bottom. That's right, Deroy, we aren't the best, we're more like the worst. The top scoring countries have 80 annual deaths per 100,000 population; we have 115. The worst is 130. On healthy life expectancy at age 60, we are at 15.3 years for men, and 17.9 for women, vs. 17.4 and 20.8 for the best performing countries. Most of the benchmarks they use are from the best performing states or insurance plans, rather than other countries, but those two seem pretty powerful, because they are, after all, the bottom line.

Here's another: the countries that do the best have 22% of patients reporting experiencing a medical, medication, or lab test error. In the U.S., it's 34%. Deroy claims that in Canada and other pinko commie countries, people have to wait forever to see a doctor. Hmm. In the top scoring countries, 81% of people who need medical attention get to see a doctor by the next day. In the U.S., it's 47%. (I'm surprised it's that high.) I could go on, but you get the idea. Read the National Review for a good laugh, not for information.

Whoops!

Okay, so here is yet another headline about a medical error, in this case a hospital that managed to kill three premature infants by giving them adult doses of heparin.

Medical errors -- particularly medication errors -- obviously can happen outside of hospitals, but we don't have good data on errors and adverse events in ambulatory care. For hospitals, however, there is a commonly accepted range of estimates, that from 44,000 to 98,000 Americans die every year from avoidable errors made in hospitals. The number who are injured, including many serious injuries (e.g., amputating the wrong leg) is obviously much higher.

You can see where those estimates come from here, which is the first page of the E-book version of the Institute of Medicine's report "To Err Is Human: Building a Safer Health System." The E-book format is kind of dodgy: access to the publication is free, but you can't download it and print it out, you have to look at it on your computer one page at a time. In other words, they're still hoping you'll pay for the printed version. But it's there if you're really interested.

Okay, to kick off this discussion, let me make some basic observations:

Medical intervention, like flying an airplane, is inherently dangerous. You have a long way to fall from the sky, and you also can do a lot of damage by cutting people open, sticking tubes in them, or pumping in or feeding them powerfully bioactive chemicals.

Everybody makes mistakes. If I make a mistake at work (not that it would ever happen), the most dire consequence might be that somebody is sitting around in a conference room wondering where the hell I am, or a questionnaire goes out with an embarassing typo. If a doctor, nurse or pharmacy technician makes a mistake, well .. .

Modern medicine is a very complex undertaking. There are new drugs, new tests, new procedures all the time. New information about risks and counterindications for existing drugs, tests and procedures comes out all the time. It's nearly impossible for anybody to keep track of all the information that might affect patient safety, even in a narrow field. Take my post yesterday about sodium phosphate: most gastroenterologists apparently don't know that it's dangerous for people with kidney failure. That seems pretty basic, but it's also a different specialty.

Historically, the principle method by which medical providers have been made accountable for errors has been malpractice litigation. This does not efficiently discourage errors because:

Mistakes are not the same as malpractice, which requires a finding of negligence. You can make a mistake without being negligent.

Malpractice litigation is an adversarial procedure. It encourages doctors to fight the allegations rather than trying to figure out how to make sure it doesn't happen again. That means trying to suppress information, or interpret it in the most favorable possible light. It means not coming forward in the first place if you know you did something wrong, hoping nobody will notice. It drives physicians to stick together like thieves, creating a culture of cover-up and avoidance.

Malpractice litigation is mostly directed at finding fault in individuals, and getting them and/or their insurance companies to pay up. It doesn't encourage analyzing systems to find ways of making them mistake proof.

So, there is growing interest in systems approaches to medical errors. Try to figure out where the points of vulnerability are that lead to mistakes, and fix the physical environment, the procedures, the job descriptions so that mistakes are impossible to make. For example, people used to be injured by getting hooked up to the wrong kind of gas. Now the fittings for oxygen and anaesthesetics are incompatible. And have you noticed how they always ask your birthday before handing you your prescription? That's to make sure you are the right Pemberton G. Throckmorton.

We'll get into more depth on this later. But in the meantime, remember, even without mistakes, medical intervention is dangerous -- and as a matter of fact, it can be hard to draw the line between mistakes and bad luck. There is an awful lot of judgment involved in trying to trade off risks and benefits. There are deep psychological and philosophical issues in deciding what is appropriate and what is just plain nuts. Hospitals are always going to be very dangerous places.

Now they tell me . . .

I happened to be reading the British Medical Journal yesterday and I came across the information -- apparently sufficiently unfamiliar to your average physician that it required a major warning article with a lot of very basic background in one of the world's foremost generalist medical journals -- that sodium phosphate can be very dangerous for some patients. (Y Mun Woo, Susan Crail, Graham Curry, Colin C Geddes. A life threatening complication after ingestion of sodium phosphate bowel preparation. BMJ 2006;333:589-590) Not for me, as it turns out -- the major risk is to people with malfunctioning kidneys -- but they never actually asked me about my kidneys before they sent me the instructions to drink the industrial waste.

It turns out that ingesting sodium phosphate causes a transient spike in phosphate in the blood, and probably more important, a drop in calcium concentration. People with kidney failure can't excrete the phosphate and as a result can't get their serum calcium back up. Very bad news, because serum calcium is an essential electrolyte and without it the nervous system doesn't function right and the heart doesn't beat right. These authors say that mortality after ingesting sodium phosphate among people with damaged kidneys may be 33%. But the low calcium (hypocalcaemia) may also be dangerous for people with heart disease, liver disease, and known electrolyte imbalances, and people who are just plain old and frail. That would seem to include a fair proportion of people who get colonoscopies.

They go on to state that "Evidence shows that many endoscopists may not be aware of groups of patients who are at high risk and their potential for complications after ingestion of sodium phosphate."

So, what are we to make of this? Many endoscopy providers, as a default, tell all their patients to prepare using sodium phosphate. It definitely works,* and it's cheap. But there are also several alternatives which are safer for some patients. This is an obvious example of a practice which needs to be embedded in systems to prevent recommending it to people for whom it is not appropriate.

If I did have kidney failure, or heart disease, or for some other reason should not have ingested sodium phosphate, whose fault would it be if I were injured or killed? The triage nurse who called me ahead of time and didn't find out about my counterindications? The doctor who performed the procedure? Whoever developed the protocols used in the clinic? And maybe the protocols are stronger, but they just weren't followed -- but then whose fault is that? Who should my survivors have sued? Would they have won?

As I mentioned a couple of days ago, doctors are thinking hard about these sorts of questions, as are people like me who are not real doctors (I'm a doctor of philosophy). I'll try to review some of the common thinking shortly.

*For those of you who are fans of Dr. Science, the way it works is pretty simple -- it has extremely high osmolarity, so it just sucks water out of your body and into your colon. Whooosh, you're a human fountain. No fun, but mighty impressive.

Call me old fashioned . . .

I dunno, it just hadn't occurred to me before that giving the preznit the authority to torture people on his personal whim would be a winning political platform. Evidently it will make people feel safer. For some reason I can't quite put my finger on, it doesn't make me feel that way.

Nobody here but us chickens . . .

And I'd like to introduce everyone to our new security guard, Ms. Fox.

Okay, how many of you have heard of the Office of Information and Regulatory Affairs? Raise your right wing, please. That's what I thought. Cluck, cluck.

OIRA is an agency of the Office of Management and Budget, part of the Executive Office of the President, which among its other duties reviews proposed federal regulations to assure that they are compliant with federal policies. The operative executive order was issued by Bill Clinton, but the principles it contains are subject to err, interpretation. For example, point 6, "Each agency shall assess both the costs and the benefits of the intended regulation and, recognizing that some costs and benefits are difficult to quantify, propose or adopt a regulation only upon a reasoned determination that the benefits of the intended regulation justify its costs," and point 11, "Each agency shall tailor its regulations to impose the least burden on society, including individuals, businesses of differing sizes, and other entities (including small communities and governmental entities), consistent with obtaining the regulatory objectives, taking into account, among other things, and to the extent practicable, the costs of cumulative regulations."

So who do you think the Emperor of Mespotamia wants to appoint to head this office? Public Citizen (blogger ethics alert: I worked for them briefly in my misspent youth) wants you to know:

The nomination of Susan Dudley as administrator of the Office of Information and Regulatory Affairs (OIRA) represents another attack by the Bush administration on the government’s ability to hold industry accountable and keep Americans safe, according to a report released today by Public Citizen and OMB Watch. .. .

As director of regulatory studies at the industry-funded Mercatus Center, Dudley has sought to strike down countless environmental, health and safety rules. She has opposed such safeguards as the EPA’s attempts to keep arsenic out of drinking water and lower levels of disease-causing smog. She has questioned NHTSA’s life-saving air bag regulations and the Department of Transportation’s hours-of-service rules to keep sleep-deprived truck drivers off the roads. She has championed energy deregulation, which has led to skyrocketing prices and little consumer relief during record-setting heat waves. .. .

“With Susan Dudley’s nomination, President Bush is proposing to install one of the nation’s leading anti-regulatory zealots as the gatekeeper for all regulatory safeguards,” said Peg Seminario, director of health and safety for the AFL-CIO. “Not only has Dudley opposed virtually all new worker safety and health protections, she has also strongly advocated rolling back legal rights and protections that workers have already gained.”

“Throughout this administration, OIRA has weakened already troubled agencies,” said Public Citizen President Joan Claybrook.* “If Dudley is confirmed by the Senate, she will further strip them of their ability to stand up to government secrecy, politicization and corporate interests. On behalf of the public, we are urging the Senate to reject her nomination.”

So what do you think? Will the Senate reject her nomination? Why don't we ask Joe Lieberman what he plans to do about this.

*BTW, I have it on good authority that the rumors about Joan and Ralph are false. So there.

Distractions

I don't know about you, but lately I often have the feeling that it just isn't worth worrying about the stuff I'm paid to worry about, at least not all that much, because we may have much bigger problems. The biggest problem of all, of course, is the vicious gang of malignant clowns who are running the U.S. government.

You don't have to take it from Sy Hersh any more - maybe you've already noticed that Time magazine is making it sound like plans for war with Iran are well under way, presumably just before the November elections, and too late to mount a meaningful public response. For non-subscibers, Josh Marshall has stolen the money quote:

The first message was routine enough: A "Prepare to Deploy" order sent through naval communications channels to a submarine, an Aegis-class cruiser, two minesweepers and two mine hunters. The orders didn't actually command the ships out of port; they just said to be ready to move by Oct. 1. But inside the Navy those messages generated more buzz than usual last week when a second request, from the Chief of Naval Operations (CNO), asked for fresh eyes on long-standing U.S. plans to blockade two Iranian oil ports on the Persian Gulf. The CNO had asked for a rundown on how a blockade of those strategic targets might work. When he didn't like the analysis he received, he ordered his troops to work the lash up once again.

What's going on? The two orders offered tantalizing clues. There are only a few places in the world where minesweepers top the list of U.S. naval requirements. And every sailor, petroleum engineer and hedge-fund manager knows the name of the most important: the Strait of Hormuz, the 20-mile-wide bottleneck in the Persian Gulf through which roughly 40% of the world's oil needs to pass each day. Coupled with the CNO's request for a blockade review, a deployment of minesweepers to the west coast of Iran would seem to suggest that a much discussed—but until now largely theoretical—prospect has become real: that the U.S. may be preparing for war with Iran.

This seems utterly insane, but to me it is plausible. This is the Hail Mary pass for the PNAC. A Democratic take over of either house of Congress in November will mean Congressional hearings that will strip away their armor of lies, hearings that the corporate media will not be able to ignore or spin away. Their plot to terminate the American republic and replace it with a permanent dictatorship of the possessors will hit the rocks. War with Iran is the one event they believe will let them recapture the magic glow of the two years following Sept. 11, 2001, when they led the country to disaster riding a flying carpet of mass delusion.

They don't care what happens to the United States, or its people, or humanity, or about any principles or ideals. They care only for power, and greed. If the military leadership, and the corporate media, and the five or six Republican members of Congress with a shred of decency and self respect allow them to finally immolate the constitution on the altar of megalomaniacal fantasy, then the American experiment will have failed.

So, it's a little hard to write about public health and medical sociology when I'm in this kind of mood. But don't worry, I'll get back to work anon.

UPDATE: And while you're waiting, you might want to check out John Mueller in Foreign Affairs. "We're at war!" with a phantom -- the projection of our own worst nature.

No Comment

What do you think, based on the facts as alleged? Is this homicide?

WAUKEGAN, Illinois (AP) -- A coroner's jury has declared the death of a heart attack victim who spent almost two hours in a hospital waiting room to be a homicide.

Beatrice Vance, 49, died of a heart attack, but the jury at a coroner's inquest ruled Thursday that her death also was "a result of gross deviations from the standard of care that a reasonable person would have exercised in this situation." . . .Vance had waited almost two hours for a doctor to see her after complaining of classic heart attack symptoms -- nausea, shortness of breath and chest pains, Deputy Coroner Robert Barrett testified.

She was seen by a triage nurse about 15 minutes after she arrived, and the nurse classified her condition as "semi-emergent," Barrett said. He said Vance's daughter twice asked nurses after that when her mother would see a doctor.

When her name was finally called, a nurse found Vance slumped unconscious in a waiting room chair without a pulse. Barrett said. She was pronounced dead shortly afterward.

I will have more to say about this later.

Return to the Magic Mountain?

A major controversy in public health in the late 20th Century concerned the work of Thomas McKeown, who argued that medical intervention had little to do with the decline in death rates and growth of population in the industrialized countries prior to the 20th Century. Rather, he argued, economic growth and attendant better living conditions, particularly better nutrition, were principally responsible.

McKeown was aggressively attacked and, as James Colgrove put it, (American Journal of Public Health, March 2002): "The consensus among most historians about the McKeown thesis a quarter century after it first stirred controversy is that one narrow aspect of it was correct -- that curative medical measures played little role in mortality decline prior to the mid-woth century -- but that most of its other claims, such as the assessment of the relative contributions of birth rates and of public health and sanitation measures to population growth, were flawed."

This is now supposed to be the smart kids' view of McKeown, but I find it quite odd. That is not a "narrow aspect" of McKeown's thesis -- it is what most readers found to be most essential about it. It's pretty much the whole point. Granted, he offended public health practitioners by playing down the clean water thing, and he was probably wrong about that. However, his most famous analysis had to do with the decline in tuberulosis mortality in England and Wales. TB used to be a major killer, but it had become rare before there were any effective medical treatments. Remember how much of 19th Century literature is about TB, from Mann to Keats to Alexandre Dumas? But who ever worried about it in the 1930s? McKeown's foremost critic, Simon Szreter (yup, I spelled that correctly) argued that he had confused tuberculosis and other respiratory diseases in death records, and so gotten the timing of the decline of tuberculosis wrong. This was all supposed to be quite devastating, but it is really nit picking. It remains true that TB became unimportant as a cause of death in the developed countries before effective treatments came along.

Anyway, I dredge all this up today because of the considerable alarm that has arisen over the emergence of so-called Extensively Drug Resistant Tuberculosis (XDR TB) in many areas of the world, particularly in association with HIV. It appears that drug resistant strains have arisen independently in various places.

As you know if you've been reading for a while, drug resistant pathogens result, among other causes, from erratic use of antibiotics or failure to complete courses of treatment. Tuberculosis can infect people without producing symptoms. It is most likely to cause illness in people who are immunocompromised or generally debilitated, and of course it is people with active symptoms, who are coughing and bringing up sputum, who are most likely to be infectious, and most likely to be caught by people who are in close proximity with infected people in poorly ventilated circumstances such as prisons or shelters for the homeless. So we can see why TB would decline with improving living conditions, and why TB is mostly seen today in conjunction with HIV, in poor countries, and among socially marginalized people in the rich countries.

So, the appearance of XDR TB is worrisome. TB control depends on antibiotics, and if we lose them, TB could once again become disastrous for humanity. Recommended measures include making sure to add multiple new drugs to regimens that prove ineffective, instead of just one; and so-called Directly Observed Therapy, making sure that people take all their pills; and finding as many cases of TB as possible and bombing them with multiple, powerful antibiotics. In this way, it is hoped, we can keep a lid on the problem.

Still, I wonder if we shouldn't give poor old McKeown more credit in this situation. Eliminating the social disadvantages which help TB thrive in the human population would help just as much, if not more. But that's obviously unrealistic.