Leavin', on a jet plane

I'm headed to Miami today for the International Conference on HIV treatment and prevention adherence. I'll let y'all know what interesting stuff I learn there.

My own little presentation has to do with differences in provider-patient interactions depending on the patient's race/ethnicity. It's not super-dramatic, but basically, there is more talk about medication adherence with Black and Latino patients, regardless of whether they have suppressed viral loads or say they are taking their pills; Black patients talk less overall; and there is less humor and empathic utterances by doctors with Black patients. This is based on my analysis of 415 recorded routine visits at 4 different clinics around the country. Don't know if it means a whole lot, or what exactly it means, but it's at least suggestive.

I'll keep you posted.

While you were being titillated . . .

. . . by the endless, wall-to-wall yet largely content-free coverage of the shocking, shocking fact that some secret service agents and military security guards like to party while they are on assignment abroad, there was in fact a summit of the Americas happening in Cartagena. The corporate media didn't bother to cover that, presumably because there was no sex involved.

Fortunately, we have Alma Guillermoprieto to reveal the secret of what happened at the summit. It seems there was an uprising by the leaders of just about all the Latin American countries against the war on drugs. This policy, launched by Richard Nixon (who was fond of wars on this and that) has pretty much been serially destroying the nations of this hemisphere. It also has done absolutely nothing to control drug abuse in the U.S. or anywhere else, although it has filled our prisons with Black and Latino men (even though white men are more likely to use illegal drugs.) It is unquestionably a colossal, horrific, atrocious failure.

However, we aren't allowed to talk about that stupid fact. Obama obviously couldn't do anything in an election year but tell them to fuggedaboudit. We're going to keep on fighting this war to the last Mexican and Honduran. Because, because, well, because it's DRUGS, that's why.

I urge you to read Guillermoprieto's piece, and then let's all get together and think of a better way.

All's Not Quiet on the Less-is-more Front

Coming next year -- yes, the wheels of science grind slow, but they grind fine -- the Preventing Overdiagnosis Conference. Overdiagnosis means that people who have some condition that will never harm them get a disease label and, almost inevitably, treatment. Said treatment is at the very least costly, quite likely harmful, and the person must live with an unsettling and possibly even stigmatizing consciousness of being sick, or "at risk."

Overdiagnosis comes from screening that can't discriminate well between dangerous and harmless lesions. Examples are mammography for breast cancer, and PSA for prostate cancer. Those have been much belabored here. It also happens when the threshold for declaring that a "disease" exists is set too low, so that on average the costs of treatment outweigh the benefits. We may have done this with high blood pressure, diabetes, and kidney disease. And it happens when we define diseases that may not even exist, or for which the cure right now is worse than the disease. I'm tempted to put Attention Deficit-Hyperactivity Disorder in that category, and probably pediatric bipolar disorder. That would be a controversial position but I'm not alone.

The fact is that the incidence of cancer has been rising for decades, but the death rate has not fallen much. That is pretty much prima facie proof of overdiagnosis. Lots of old folks are put on dialysis who really don't need it, and they actually die sooner than people who are not. (Renal function declines as we get older, but the rate of decline is much slower than it is in people who really have kidney disease.)

Many people have been found to be using inhaled corticosteroids, for asthma, and antidepressants, who do not actually meet diagnostic criteria for those diseases. I'm not sure whether "overdiagnosis" is the right word in these instances, because they often don't even have a diagnosis in their medical record. They just have a prescription.

Now here's the thing. This is wasting something like 20-30% of all the money spent on health care in this country. Money that could be spent providing access to actually needed health care for people who don't have it. But when we try to do something about it, we get mobs screaming about death panels and pointy headed bureaucrats coming between us and our doctors. We need to ignore those people, and fix this problem.

Observational studies, part 1

Continuing with this series -- which I'm sure Steve Novella would agree is worth doing -- we'll step away from experimental designs for a bit to discuss observational studies.

Most epidemiological research is not based on experiments -- in which we deliberately take some action (called an "intervention") to see what happens. It's just highly structured observation of the world as it is. The simplest case is a cross-sectional study in which some number of subjects -- in our field, that ordinarily means people -- are observed in the same manner. They may be given a questionnaire; or have some biological measurements taken, such as their height, weight and age; or both.

Public opinion surveys and electoral polls are also examples of this kind of study. Most people have some idea behind the mathematics that allows Gallup to predict the votes of millions of people by talking to a few hundred, but let's review very quickly. (You can read my more extensive entries on this subject here, here, here, here, here, and here.)

If you have a way to pick people at random from all the people you are interested in -- that's called the people who constitute your "universe" -- such as eligible voters, then you can use certain mathematical techniques to figure out how similar your sample is likely to be to that "universe." Specifically, you can calculate a probability that the percentage of people in the universe who have a given characteristic is different from the percentage of people in your sample by any given amount. (See the links above if you want more info about how this works.) When they talk about the "margin of error" of a poll what they normally mean is that 95% of the time, the real number in the universe will be inside it. That 95% is arbitrary, but it's taken on sacred status. The most likely real number is the actual number in the poll; we could report the 67% confidence interval or any other interval we wanted to. But 95% it is.

But there is a lot that can go wrong with polls, or any study of this sort, other than just happening to talk to an unrepresentative sample. We could have a bad sampling "frame" -- the classic example is, we think we're picking at random from all the likely voters, but we're only talking to people with telephones, and Dewey Beats Truman! Nowadays almost everybody has a phone so that isn't really a problem, but maybe some kinds of people don't generally want to talk to us. That's called selection bias. Or maybe some kinds of answers are stigmatized, which is why few people will tell a pollster they wouldn't vote for a black person.  That's called socially responsible response bias. (Atheists, however, are another matter.) Or maybe you asked the question in a way that pushes people toward a particular answer.

In epidemiological studies, we're often interested in whether past events or exposures are associated with current health problems. For example, are people's diets associated with, oh, high blood pressure, or whatever. Here you have problems with recall. Can you tell me what you ate for lunch last Wednesday?

There is a great deal more that I could say about this but I'll just leave you with one essential point. Even if we do everything very rigorously and our observations really are representative of the population of interest, associations in any cross sectional study cannot prove causation. People who eat a lot of mangoes may have lower blood pressure than people who do not for reasons having nothing to do with mangoes. Maybe they are of different ethnicity, different socio-economic status, live in different places, have other dietary differences we didn't measure, exercise more -- who knows. We can try to control for all those factors but we can't control for anything we forgot to ask about. If we want to make causal inferences, we have to do something else.

More on evidence

Continuing my latest adventure in wonkery, the quick review of the evidentiary basis of causal inference . . .

The plural of anecdote is "anecdotes," not "data," it is true -- however, anecdotes are data.

But, the term anecdote connotes a story that is only casually observed, perhaps retold. Both single case studies and so-called within subjects design studies can provide useful information and can even support causal inference under very specific circumstances, although it is unlikely to be conclusive; but we must very carefully observe and document what we do. That's why these aren't considered "anecdotes." The reason we often see highly dismissive responses to such studies is that they are often overinterpreted, their limitations insufficiently acknowledged. Indeed they are quite commonly used by charlatans such as homeopaths to promote quackery. But let's hang on to the baby as we pour out the bathwater.

To review, if an outcome is extremely improbable, and we try a novel intervention even once and then observe the extremely improbable outcome, we can reasonably have a strong suspicion that the intervention was indeed related to the outcome. If we have an a priori plausible explanation for how the intervention produced the outcome, so much the better. So, if surviving a fall from thousands of feet is highly improbable, and a person using a parachute survives such a fall unscathed, we don't need to see it work more than once to believe that there's something to this parachute thing.

On the other hand, a single trial would not convince us that parachutes work 100% of the time, or even most of the time. We'd need a lot of experience before we were confident we knew how effective parachutes are, under what circumstances, and what can go wrong. What we would not need, however, is a randomized controlled trial, because we are already highly confident that falling 5,000 feet without a parachute is almost inevitably fatal.

And that's the principle on which a within subjects design can be useful. If we're already confident that a particular outcome in a defined population is improbable given the existing or natural state of affairs, then a before-and-after test of an intervention can give us meaningful information about whether it is likely to be effective. If remission of metastatic cancer is extremely rare, if we give 5 people a novel treatment and 3 of them remit, we don't need a formal control group to believe we're on to something.

This sort of inference depends on the assumption that people are biologically pretty similar. After all, a chemistry experiment doesn't ordinarily need a control group at all because every atom of a given isotope of carbon, in the same state of ionization, is identical. The reason we have much more difficulty making causal inferences in health research is because people are so complex and so variable; because measurement of outcomes is often not straightforward; and because out interventions, unlike mixing chemicals in a beaker, typically have multiple components and multiple effects.

And so, the example with metastatic cancer is quite unusual. If an outcome, unlike remission of metastatic cancer, is not extremely rare, is not completely straightforward to observe, or may respond to multiple components of the intervention such as placebo effect, a within subjects trial is much more problematic. Sure, if the trial results in a rate of outcome which is markedly different from what we would have expected, it can be at the very least suggestive, but there are many pitfalls.

Here are a few:

Selection bias: People are convinced that Alcoholics Anonymous works because alcoholics who regularly attend AA meetings have a higher rate of sustained abstinence than alcoholics who do not. But maybe people who are motivated to remain abstinent are more likely to attend meetings. In fact there is no good evidence to show that AA is effective at all, for basically this reason. Should we really expect the desired outcome to be at the ordinary background rate in the population selected for the trial, or is just selection, rather than the intervention, that produces the observed effect?

History: Before and after designs are often used for interventions that target social problems, perhaps at a community level. But the trouble here is that a whole lot else is going on at the same time, in addition to the intervention. While you're doing outreach education to reduce the risk of STIs in teenagers, a whole lot else may be changing: sexual mores, condom availability, the likelihood of exposure due to other factors such as enhanced availability of treatment, you name it.

Non-specific effects of the intervention: We may attribute the observed outcome to the magic potion we had you ingest, but maybe it was the effect on your expectations, the fact that it made you mildly nauseous so you skipped your usual seven vodka-and-ginger ales, or just the fact that somebody paid attention to you, that made the difference. Notice that this category includes, but is not strictly limited to, what we call placebo effects.

So, uncontrolled, before-and-after trials, can give us some useful information but they can also often be misleading. So-called Phase One trials of drugs are of this nature. A small number of people are given an experimental drug just to see if there are any obvious, immediate ill effects; so we can figure out it's "pharmacokinetics," in other words how much of the stuff gets into the blood stream or target tissues and how long it lasts; and to see if anything else dramatic and exciting happens. If the latter, we don't jump to any conclusions. We still need to go no to controlled trials before the drug can get approved.

New Windham County Post

I'll be getting back into it. Sorry for the long hiatus.

Evidence

A couple of questions from commenters have inspired me to produce a bit of a primer on the kinds of evidence we use in health research. It seems to me that a lot of the political controversy over health policy and official recommendations is fueled by limited understanding of the use of evidence to make causal inferences. As I set out on this project I really have no idea how long it will take. We'll just see what happens.

Categories of evidence are commonly organized in a hierarchy, with some kinds said to be stronger or more compelling than others. I don't exactly look at it that way. Different kinds of evidence are useful in different situations and lead us to different kinds of conclusions. Just as important, how we regard any kind of evidence must depend on the prior plausibility of what it seems to show. If there is already very strong evidence for or against some conclusion, then any new evidence that contradicts what already seems highly probable is less compelling, and we should be much more diligent in looking for flaws in the study or concluding that chance alone is responsible for the observations.

This is different from confirmation bias, which is a feature of human cognition in which we tend to ignore or explain away evidence that contradicts what we already believe. We should certainly take surprising findings seriously, but we should subject them to careful scrutiny. If they do compel us to re-examine our prior beliefs, we should certainly do so. I will address these issues a bit more formally as we go along.

Alright. As most people know, conventionally anecdote is presented as the least convincing kind of evidence. An famous example of anecdotal evidence is the putative association between vaccination and autism. Parents see their child receive a shot, and some time not long after they start to see developmental regression and symptoms of autism. Unfortunately, some parents have an unshakeable conviction after this experience that the vaccine caused the autism. As I'm sure most readers already know, this is a common fallacy called post hoc ergo property hoc, because if you say it in Latin you must be really smart. I think if we started naming it in English we would still be just as smart, so I'll call it after this, therefore because of it.

While overwhelming, really incontrovertible evidence of much greater force has shown that vaccination does not cause autism, it is wrong to say that anecdotal evidence is worthless in general or should be ignored. A famous example is the efficacy of parachutes. Since we know that falling from 10,000 feet is invariably fatal, seeing a person do so with the aid of a parachute and land unharmed, even once, is extremely compelling evidence for the efficacy of parachutes. Not only has something obviously extraordinary happened, we can immediately see how it apparently works: by air resistance. The scenario makes perfect sense: it has high prior plausibility. Seeing it happen once wouldn't necessarily make me confident enough to strap on a parachute and jump out of an airplane; but it would make me believe that if the equipment were sufficiently reliable, and weather and other conditions similar to those pertaining to the observation, the parachute would be highly likely to work.

To return to the case of autism, suppose no child had ever been vaccinated and no child had ever been autistic - or at least that autism was extremely rare. If the first child ever to be vaccinated subsequently became autistic, we would properly have a very high index of suspicion that the events might be associated. If we could think of a highly plausible biological mechanism, our suspicion would be even stronger. Neither of these requirements holds in the real case, however.

Moving along, although it is often said that the plural of anecdote is not data, this is certainly false. Data is a synonym for information, and the more anecdotes, the more information. In fact the plural of anecdote can be organized formally into a kind of study called a within subjects design. I'll talk about that in the next installment.

The world turned upside down

I would not have predicted this, even five years ago. Hell, even last year. WaPo poll says 54% of voters think gay marriage should be legal -- and that's using the word marriage, not civil unions. What's more, 39% "strongly" agree, compared with 30% who strongly disagree.

For sure, the culture changes over time. But the stigma of homosexuality was so profound, so widespread, so ancient, that such a seismic collapse seemed inconceivable. The first legal recognition of slavery in what was to become the United States occurred in Virginia in 1654. It took more than 200 years and a horrific war for slavery to end in the United States, and another 100 years before African Americans received full legal recognition of equality. (Of course, that's still only on paper, as the composition of our prison populations attests.)

It will be a few more years, to be sure, until lesbians and gay men achieve legal equality, but just think -- when the Mattachine Society was founded in 1950, its membership was secret and the name referred to a French tradition of performers who never appeared unmasked. Homosexuality was a crime in much of the United States until 2003. The new poll shows a nearly 20 percentage point  increase in support for gay marriage in just a few years.

The Republican party successfully used gay marriage as a wedge issue to drive voters to the polls in its favor right through the 2004 election. Believe it or not, in the face of this tectonic shift, support for gay marriage among Republicans has actually declined. But it won't work in the party's favor any more.

Astonishing.

Like I've been saying . . .

The U.S. Preventive Services Task Force has held its ground on prostate cancer screening. They are against screening, for men of any age. And yes, the howls of outrage are echoing through the hospital and clinic halls, notably from the American Urological Association. Now I wonder why the AUA is "outraged"?

Ah. I have a thought. They make money by treating prostate cancer, and they make even more money by treating the incontinence and erectile dysfunction that results from the treatment. Here's what the USPSTF says, and it's not outrageous:

1. The number of men who would have died of prostate cancer within 10 or 14 years (the follow-up time of the available studies), but who will not because they are screened, is possibly zero and no more than 1 out of 1,000. 
2. 80% of positive PSA tests are false positives, but these false positive tests are followed by biopsies which in 1/3 of cases result in pain, fever, bleeding, infection or other problems that require further medical intervention. 
3. 90% of men with positive biopsies will get treatment with surgery, radiation, or drugs to suppress their androgen. Five out of 1,000 will die within a month of surgery, and from 10 to 70 more will have severe complications. Twenty to 30% of them will have incontinence and/or erectile dysfunction.
4. However, many of them -- probably most of them -- would never have died from prostate cancer even without treatment, because most of the "cancers" found on biopsy would never have progressed to cause disease.

So it's a no-brainer. Men who have been through this are convinced that it saved their lives, because who wants to admit that they went through all that for nothing? The doctors who treat them don't want to admit that they have been paid big bucks to harm people all these years either. And all the celebrities who made PSAs to promote PSA don't want to think they've been tools either.

By the way, there's no evidence that screening just by digital rectal exam is worth it either. I'm certainly not going for it.

Yet one more study showing that reality has a liberal bias

Yeah yeah, it's getting old. Analysis of data from the General Social Survey (an ongoing project of the National Opinion Research Center, and no, it is not a government agency) shows that since 1974, trust in science among conservatives has fallen by 25% -- and it's specifically among people with college degrees no less. Conservatives used to have the most trust in science, now they have the least.


Why? Because scientific truth is inconsistent with conservative ideology. That is all.

I can't believe this is even controversial

The presidential campaign this year is essentially a contest between semi-sanity and florid psychosis. Apart from the side shows about whether Mitt's tenure at Bain Capital produced a net gain or loss of jobs, and whether Obama is a "real" American, the substantive issues at stake are principally:

1. Should the government regulate banking and finance, or does removing the oppressive hand of the state liberate capitalists to create wealth and jobs?

Mitt -- what planet do you live on? Have we already forgotten what happened in 2008? Here's a view from the land of bangers and mash that would be a voice crying in the wilderness here. The "Free Market" you worship is a fiction. Markets in complex societies are not forces of nature, they are creations of the state. They cannot exist without continuous, fundamental government intervention. The only question is how they will be regulated, on whose behalf. You want to regulate markets for the benefit of a fraction of one percent of the very wealthiest people. And no, they are not job creators nor will increasing their wealth at the expense of the rest of us somehow make us better off in the end. That is utterly preposterous. Astonishingly, half of the voters seem to believe it.

2. Should government take action to protect the planetary environment? Or is environmentalism a scam to suck up grant funding and impose socialist tyranny?

The truth is starting to penetrate even people coal country.  But here's the really bad news: We may be facing an immediate planetary emergency as methane outgasses from the melting arctic. The most terrifying crisis in human history -- at least since our ancestors passed through an unexplained population bottleneck 2 million years ago -- is not even an issue in the campaign. Never mentioned.

3. Should we forbid women to control their own reproduction because God says so?

Actually, it isn't God, it's a few depraved, ostensibly celibate old men wearing medieval costumes, and some con artists sucking up millions of dollars from suckers. God apparently didn't get around to saying this until approximately the late 19th Century,  because there is not one word about abortion or contraception anywhere in the Bible, Old Testament or New. This ought to be embarrassing to the preacherly grifters, who can find verses in Leviticus telling us to stone homosexuals to death. (Somehow they skipped the ones about driving people with rashes into the desert to die).

And yet, Republicans can actually win elections with this crap. If it happens in November, we are doomed.

The World's Most Popular Fallacy

Or at least I think it probably qualifies. That would be conflating association with causation, and it's a plague (hah!) in public health research. Today's entry is the so-called "good cholesterol" hypothesis. Or at least, it should have been considered a hypothesis all this time, but instead people have treated it as a finding.

The linked article may be a bit esoteric. It has gotten some coverage in the lay media, but I'll offer my own summary. Most people have heard that "high cholesterol" is a risk factor for heart disease and strokes, but that there are actually two kinds, called Low Density Lipoprotein, LDL, and the high density HDL. There's a lot more LDL than HDL in your blood, so the LDL level determines most of your total cholesterol, but higher levels of HDL are actually associated, in observational studies, with reduced risk for heart disease.

Randomized controlled trials of statin drugs, which lower LDL, have shown that they do indeed reduce the risk of atherosclerosis, and consequent heart disease and ischemic stroke, at least for people who have already had heart attacks or are at high risk. (Their value in people at average or even just above average risk is controversial.) So that adds to the evidence that high LDL causes the bad outcomes. (I must caution that it doesn't actually prove it. Statins could simultaneously lower LDL and do something else that reduces risk. But it adds to the plausibility of a direct causal association.) So naturally, drug companies have been working on pills that will raise HDL in hopes of making billions.

I have always been skeptical. (Yeah, that's easy for me to say now, but it's true.) HDL is higher in people who engage in lots of aerobic exercise, for one thing, and it's lower in people who smoke. Observational studies try to isolate its effect by controlling for consequences of exercise -- leanness and lower blood pressure, slower heart rate -- exercise itself, smoking, and all that good stuff. But that's really hard to do. HDL could just be a marker that goes along for the ride with the true protective factors.

So these researchers whose work is published in The Lancet used certain genotypes as what's called an "instrumental variable" -- some characteristic that people happen to have that effectively randomizes them in a sort of natural experiment. Some people have genes that predispose them to higher HDL. It turns out that having these genotypes is not protective against heart disease. As a check on the concept, having genes that predispose to higher LDL is indeed associated with higher risk.

This cautionary tale is important for several reasons, but the most important practical lesson is that we need to be much more cautious about approving drugs based on so-called "surrogate end points." We need to prove that they do what we really want them to do, which is to make us healthier or keep us healthier, or at least make us feel better. Changing some technical indicator that we think has something to do with being healthier isn't good enough.  

The Great Dying

That's a commonly used label for the Permian Extinction, 252 million years ago, in which 95% of living species went extinct. There is controversy over the underlying cause, but it does appear that marine life with carbonaceous skeletons -- molluscs and corals, mostly -- were wiped out due to higher ocean temperatures and more dissolved carbon dioxide, which made the water more acidic.

Oh yeah, the same thing is happening today, plus a lot of other huge changes that are causing another Great Dying. You've probably heard about this report from the World Wildlife Fund, which says that humans are consuming the earth's resources faster than they can be replaced. They don't even emphasize CO2 emissions, which seem to have triggered the Permian Extinction, but plenty of people are on that case, obviously.

The collapse of resources essential to human life will mean the collapse of the human population and, no doubt, catastrophic consequences for the social order. True, back in the '60s there were predictions that this would have happened by now, and it hasn't. A major reason is the so-called Green Revolution, which transformed agriculture with massive fossil fuel inputs. Don't be fooled by advertising or nostalgia: farming has nothing to do with nature and there is nothing less like nature than farm country. That just means that we bought time by doubling down on the mechanism that got us to the looming resource crises of that era: extracting the remains of ancient vegetation from beneath the earth and burning it for fuel.

That is what made it possible for the human population to expand from a few million to what will soon be more than 10 billion. It is the indispensable basis of our entire civilization and way of life, even for poor farmers and urban slum dwellers, although affluent people consume far more of fossil fuel and the abundance of products it makes possible.

We can't continue to live this way. It's over. But politics, in the U.S. and just about everywhere else, is not about the fundamental issues we face. Not at all. They are ignored. I don't care if you're liberal or conservative, Tea Party or Occupier, you are living in denial. What you are arguing about does matter, but it won't matter much longer if we keep on as we are. Wake up.

This is apparently supposed to be a secret in the U.S.

Eminence grise Arnold Relman, former editor of the New England Journal of Medicine, has published an essay in a British journal, that you aren't allowed to read if you aren't on a university faculty, about why the U.S. health care system is heading over the cliff and how to get it back on the highway. Great move Dr. Relman! That should have a big impact on the debate here in the United States, which I believe is why you might write such an essay.

We actually see a lot of this -- leading scientists taking to the pages of The Guardian to rebut climate change denial that appears in the Wall Street Journal  comes to mind. I suppose it's just not possible to get liberal arguments published in the United States.

Anyway, Relman basically makes three points: the concept of the "free market" does not work in health care; therefore we need universal, comprehensive, single payer national health care; and we need to reorganize the system into multi-specialty group practices with physicians paid salaries and some form of capitated payment.

It's the latter point which goes a step further than single payer advocates necessarily go. I've already become something of a broken record on the first two here but let me make a couple of quick summary points. Relman points to provider induced demand as the key failure of "the market" in health care but actually there are many others. These include the unpredictability of any given individual's need for health care -- unlike your need for food, clothing and shelter which is roughly similar for everyone; the very serious negative externalities when people don't get health care that they need, such as loss of economic productivity, transmission of infectious disease, and failure to care for dependents; and the erosive effects on society and culture of mass-scale abandonment of desperate people.

Relman also points to the inefficiency of private insurance and the massive waste it entails in the form of profits, marketing and administrative costs. But he does not see moving to a single payer system as sufficient in itself to solve our problems. Provider induced demand will continue to generate waste and even harm patients as long as doctors and hospitals are paid more to do more, and as long as drug and device manufacturers continue to bribe them, and manipulate both doctors and patients into wasteful spending. Salaried physicians in so-called Accountable Care Organizations are the solution for Relman. Maybe that is a good idea, but I should point out that they have done pretty well in Canada with fee-for-service primary care, while in the UK, physicians are paid salaries but they operate independent small practices for the most part.

Anyway, Relman notes that many physicians are already moving to multi-specialty group practices because there are advantages over being in business for yourself. These include reasonable hours, having administrative staff to worry about all that nonsense, more economic security, and having colleagues with varying expertise to collaborate with. He hopes that if this trend continues, it will become politically easier to make policy changes. But he also doesn't necessarily expect it. He thinks we'll likely have a catastrophic failure of the system, after which, eventually, after Grover Norquist and Paul Ryan are sent off on an ice floe, we might be able to fix things.

We shall see.

Terridiots

It's no surprise the corporate media loves the new undiebomber story. First, they don't have to do any work. Some official talks to them anonymously and they write down what he says. Is it necessarily exactly true, or the whole truth? Don't bother to ask, that's not your job. Plus which, it's a really cool spy story, and they get to be all worried about whether we are safe.

Well okay, let's assume it's all true. It strikes me that Al Qaeda in the Arabian Peninsula is seriously suffering from a lack of imagination. They are totally determined to somehow strike at the United States, but the only way to do this that meets their exacting standards for martyrdom is to have a guy blow himself up on an airplane. Since we know that's the only terrorist act they will ever attempt, we can make it fairly difficult. Hence the undiebombing technology. Scary!

However, not being a depraved terrorist, I can think of at least 16 ways to cause major carnage and disruption that are pretty much impossible to prevent, many of which do not even require that you have anything that is normally thought of as a weapon, let alone slaving away in your workshop for months to invent an undetectable suicide bomb. As a matter of fact, I could put a big fat plain old detectable bomb in my carry on luggage, wheel it up to the security checkpoint where there are 200 people in a tight mass, walk away and detonate it remotely, thereby shutting down every airport in the country until they figured out what to do to prevent me from doing it again, which they never could.

Without giving away my patentable idea, I could cause an economic catastrophe with maybe a dozen old dump trucks, or some chain saws. Do you have any idea how easy it is to derail a train? (I probably shouldn't have mentioned that.)  Anybody in the United States can buy a truckload of semi-automatic weapons, and well, use your imagination.

So, let's hope they stay obsessed with aviation. Or maybe, they are just a few wackos out in the desert and they don't have the people or the money to come to the U.S. and buy dump trucks. I vote for the latter.

Those improvident, irresponsible wastrels

That would be the half of Americans who aren't saving anything for retirement. Oh wait -- maybe it's because they can't. You need enough left over after paying for the rent and groceries and keeping your 1998 Honda Civic running to make the required minimum investment in an IRA.

So of course it makes perfect sense that the Republicans in congress want to cut food stamps, meals on wheels, child care and other programs to help poor people -- that would be working poor people, by the way -- in order to avoid cutting military spending.

Now why is military spending so important? Is it because the United States is under threat from powerful aggressors? Ha ha. It's because of that black goo deep in the earth. As Michael Klare makes clear, military tensions around the world are ramping up because it's harder and harder to get and everybody wants more and more of it. Why are there two U.S. aircraft carrier task forces in the Persian Gulf right now, along with a whole lot of guided missile cruisers and oh yeah, I bet you didn't know this, a U.S. Coast Guard station in Bahrain.

But if we keep on sucking that stuff out of the ground and burning it, as we are determined to do, nothing bad will happen except that we'll destroy civilization. It's a small price to pay.

Two Worlds

I don't usually link to the Puffington Host because it is infested with bunkum, but if you haven't already, do check out the first chapter of the latest book from The Shrill One, which happens to be available there.

Krugman describes the massive suffering and tragedy of the past few years, but as disturbing as the catastrophe itself is that he actually has to point it out. He is some sort of radical or alarmist because he bothers to notice the pain of so many people and the irrevocable losses we have suffered; and insists that we actually do something about it. The millions of young people who are graduating from college into a bleak future as far as the eye can see; the people in mid-life whose career accomplishments and savings are destroyed, along with their self-esteem; the countless people we don't even notice any more who are destitute; to the corporate media and much of political discourse, they are irrelevant. This is not the problem we need to worry about.

I have some thoughts about why this is. Do you?

Yes we are ruled by idiots

It's apparently too technical for the general public or Columbia-educated journalists to grasp, but if you follow Brad DeLong and/or The Shrill One you have probably gotten the idea that the elite consensus about the economy in Europe and the United States is completely insane.

I've been thinking about a simple, non-technical way to explain our situation that a smart politician such as, say, president Obama could use if he had the courage. The reason there aren't enough jobs is not because rich people have to pay taxes or companies are worried about "regulatory uncertainty." The reason is that companies can't sell enough stuff to expand output, and therefore to hire more people. The reason they can't sell more stuff is that there are too many people out of work or stuck in crappy jobs. That's why investors aren't putting their cash to work building up companies, they're sticking it in the equivalent of the mattress, i.e. U.S. treasury bonds that currently are providing a negative rate of interest, that is less than the rate of inflation -- which is also very low. So that cash is just sitting there.

The way to put people back to work, and therefore cause them to have money with which to buy stuff and therefore cause companies to sell more stuff and therefore hire more people, is to spend that money. You could actually spend it to pay people to dig holes and fill them in again, but even better to invest it in stuff that will also do good in the world, such as mass transit projects, fixing bridges, educating folks, modernizing the electrical grid, energy conservation and sustainable energy production, you name it.

The government has to do it this, using that money it can borrow extremely cheaply. That will also cause tax revenues to go up and make it possible to pay the debt in the future and reduce the deficit without having to do horrible damage to society.

This is the simple truth. Department of stupid questions: will we hear this simple truth discussed in the next six months?  

Are you nuts?

Very likely. CDC says 25% of Americans have a "mental illness." They also say that half of us will have a "mental illness" at some time in our lives.

Bummer. (Uh oh, I shouldn't have said that. Maybe I'm depressed.)

The problem with this claim is that whether or not you have a "mental illness" is purely a matter of whether a committee of psychiatrists has decided that some state of affairs qualifies as a "mental illness" and some specific psychiatrist or otherwise authorized savant, such as a clinical psychologist or your family doc has decided that said state of affairs applies to you.

As you have likely heard, an effort is just winding up to create a new set of diagnostic criteria for mental illness. You can read all about it here. It's fascinating to explore. Keep in mind that as my old professor Sheldon Krimsky and his colleague Lisa Cosgrove have reported, 69% of the authors of the new DSM5 have ties to the pharmaceutical industry. And you know what happens to people who have "mental illnesses": they take pills.

Do you often argue with authority figures? Do you often actively defy or refuse to comply with requests from authority figures? Have you been spiteful or vindictive at least twice within the last six months? Are you often touchy or easily annoyed? Congratulations! You have oppositional defiant disorder. You are mentally ill.

Have you been sad for two weeks, even if you think you have a good reason? You're having a major depressive episode! Do you tend to misplace things? Do you talk too much? Are you easily distracted? Disorganized? You probably already know you have ADHD.

Even the definition of schizophrenia is based purely on whether somebody thinks you're just too weird, basically. Anders Breivik and Ted Kaczynski have both been diagnosed with schizophrenia but I read this and I have to say, "Huh?" A requirement to have schizophrenia is having at least one of delusions, hallucinations, or disorganized speech; and if you don't have two of those, you also need to have grossly abnormal psychomotor behavior (e.g., you are permanently in the fetal position); or diminished emotional expression or avolition.

Hating non-Europeans and non-Christians, or thinking that industrial civilization has been a disaster, are unpopular ideas in some circles, though not in others. Killing folks more or less at random in order to promote these ideas is teleologically inept, to be sure, also illegal. But I fail to see what is gained by applying a disease label to it.

Here's the basic problem. Psychiatrists like to say that these, and other traits they label as psychiatric diseases, have something to do with "chemical imbalances" and that they can be fixed by swallowing the right chemicals. However, they have no specific evidence for any particular chemical imbalance being related to any particular set of diagnostic characteristics. All they know is that if you drug people into a properly semi-stuperous condition,  they will be, for example, less oppositional and defiant, or less fidgety. As soon as a real chemical imbalance or functional neurological impairment is discovered and a reliable test for it is found, the problem ceases to be a mental illness and becomes a neurological condition, or perhaps even an infectious or endocrine disease.

Psychiatry, up to a point, may be necessary. But it is not properly considered scientific medicine. That's my opinion, anyway.

Town and Gown, cont.

One way universities can change is in how they do public health research, and other kinds of research with direct relevance to the communities in which they sit (and which they often dominate). As one review puts it:

Community-based participatory research in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved.

But . . .

Really doing CBPR is difficult. There are huge differences in resources, perspectives and interests between academic investigators and community representatives, whether they are professional staff of CBOs, patients or clients, community residents, people living with chronic diseases, or otherwise defined. Community based organizations are generally undercapitalized and have real difficulty investing the kinds of resources in speculative proposal development, with a potential payoff that we typically don’t see for two years or more, that we take for granted in the university. Unfortunately, despite the professed interest of NIH and the ICs in CBPR, NIH staff and proposal reviewers still have a long distance to travel  in adjusting their thinking to both the philosophical and practical demands of CBPR. The most straightforward practical mismatch between the NIH funding process and CBPR is that the specific aims and research strategy must be fully developed, with a high level of scientific rigor, before the proposal is submitted. But CBPR demands a planning and developmental process between the academy and the community during which the research problem and research strategy are shaped to meet the somewhat disparate needs of the two groups. Community representatives simply cannot engage in this process without financial support. The result is that putatively CBR projects are often actually completely developed and written before they are even presented to the community “partners.”

The philosophical difference between academic and community visions of research is complex.  Community representatives are typically interested in the specific problems and needs of their own community, obviously, but academic research, and certainly most NIH-funded research, cannot be satisfied with description of a particular instance but rather must create general knowledge which is broadly applicable. This is not usually an outright contradiction, but it can create tension. Most important, the ultimate goals of the two groups with respect to the uses of the research are different. Academic investigators have a personal interest in their careers – in publication, grants, tenure and promotion – and in the advance of science. Community representatives want their problems and needs to be understood, and addressed. Much research that is done in collaboration with community partners never results in any direct benefits to the community.

Rather than belabor these issues – and there are more -- I will just say that effective and, if I may presume, honorable, collaboration requires infrastructure. The community and the academy need ongoing institutional collaboration so they can grow to understand each other and benefit from mutual exchange of ideas, wisdom and resources to create the basis for truly equal partnership. This means an up-front investment. Which somebody with money has to make.

Town and Gown

As you may have heard, my employer has agreed to fork over $31.5 million to help keep Providence from going bankrupt.

This was a very contentious situation. A few weeks ago, I came to my office to find firefighters demonstrating outside. Their pensions are at risk in the city's financial crisis and they apparently didn't think the university  was paying enough for the protection they provide.

The issues seem fairly simple on the one hand. Even with the $31.5 mil, the university pays the city about 1/4 of what it would pay in property taxes, given the immense value of its real estate. The regular folks in Providence see privileged kids from all over the country and the world getting their ticket to a life in the upper reaches of business, finance and academia that their kids have no chance for. Why should the city subsidize this enterprise when all the people see when the students come in September is New Jersey license plates?

That seems fair enough but the matter is somewhat more complicated. In the first place, that real estate wouldn't be worth whatever gazillions of dollars if it didn't happen to be Brown University. Take away the university and Providence turns into a ghost town. All those stores and restaurants on College Hill would close, the apartments would all go vacant, the price of taxable real estate would collapse. The university puts the city on the map. I'm sure all this was argued over in endless circles during the negotiations.

Still, I believe that it is both an ethical imperative, and long-term very much in the university's interest, to move aggressively to tear down the ivy-covered walls between the institution and its communities. (Metaphorically ivy-covered that is. Brown has a strict policy against ivy. If you see a wall with ivy, it's RISD. Just an odd factoid.) We need to democratize the way we do science and education. Sure, the opportunity to get a degree from Brown is always going to be limited to winners of an intense competition. We can certainly do better about the criteria, but the prize is only valuable because it's rare and that is essential to the prestige of the institution and much of its raison d'etre, which no protest from YT is ever going to change.


However, there is a lot that we can do differently. I'll have more to say on this theme.

A tough problem . . .

. . . but there are solutions, or at least ways to improve the situation. A newly recognized consequence of the epidemic of prescription opioid abuse in the U.S. is a huge increase in the number of babies born addicted. Most, though not all (for reasons not well understood) of the babies born to women who are chronic opioid users will go through withdrawal (called Neonatal Abstinence Syndrome, NAS). Doctors give them opioid replacement, such as methadone, and wean them off gradually. They end up spending typically 16 days in the hospital at a cost of over $50,000, mostly paid for by Medicaid.

Stephen Patrick et al, in the linked report, find that the incidence of NAS increased from 1.2/1,000 births in 2000 to to 3.39/1,000, in other words almost triple. Investigators have yet to sort out the direct long-term consequences for these babies -- they often have problems later but their mothers, not surprisingly, are also disproportionately likely to smoke, drink alcohol, have poor nutrition and so on, and the babies go on to have a disadvantaged social environment. They have an increased risk of low weight birth, but whether that is a direct consequence of opioids is unknown. In any case, it's a humanitarian catastrophe and oh yeah, it costs a lot of money at a time when Medicaid programs everywhere are under strain.

I've discussed this opioid epidemic here before, but just a reminder, the driving force is misuse of prescription opioids. Some people who start with prescription drugs do end up using heroin because it's cheaper; but women tend not to like needles and so the epidemic prescription opioid abuse has meant a higher proportion of women get into trouble.

The difficulty is that there are completely legitimate uses for opioid analgesics, in fact they are a great boon to humanity and some people would suffer horribly, and unnecessarily, without them. But it's difficult for doctors to tell when somebody really needs them or just wants them because she or he is addicted, or intends to sell them. But here are some ways to improve the situation:

1. Shut down pill mills. Florida had a big problem with this, clinics that exist only to write scrips for dope. The governor refused to take action for a long time (maybe he had friends in the business), so Florida also has a disproportionate problem with NAS. These operations can be identified pretty readily, and there's no reason to tolerate them except that law enforcement doesn't make it a priority. We'd do a lot more good concentrating on them than on marijuana growing and trafficking.

2. Many states have registries for opioid prescriptions. They all should have them, and doctors should be trained (and perhaps required) to check them before writing a new scrip. That way they can find outif the person has recently filled opioid prescriptions elsewhere.

3. Offer treatment on demand. Stop locking up addicts in jail, which is very expensive and doesn't do any good. Have drug courts that divert them to treatment, and actually have the treatment available (which it often is not).

4. Create more comprehensive pain programs. There are alternatives to opioid treatment that will work well for many people, but there aren't enough physicians trained in comprehensive pain management.

5. Have universal health care, including dental care. Lots of people develop chronic pain because they have untreated conditions. They show up in Emergency Rooms and they need pain relief. ER docs can't tell the people with real dental pain (or whatever) from the fakers, so they write scrips indiscriminately. If they could just have the people seen right away by a dentist, that particular tactic would instantly become obsolete.

I can think of a few more but you get the idea. This is a problem that can be solved, or at least greatly ameliorated, if we take off the ideological blinders and approach it pragmatically. And that requires a government that responds compassionately to human needs.

Civilization and its Discontents

You have likely heard about a new study that finds that treatment of Type 2 diabetes in juveniles is very likely to fail. Here is the linked editorial in NEJM in which David B. Allen make a succinct statement of our doom:

[T]his is the essential, maddening conundrum of the epidemic of type 2 diabetes — collective failure to adhere to a lifestyle healthy enough to prevent the disease. A critical point is that the participants in the TODAY study were not adults, but youth immersed from a young age in a sedentary, calorie-laden environment that may well have induced and now aggravates their type 2 diabetes. Fifty years ago, children did not avoid obesity by making healthy choices; they simply lived in an environment that provided fewer calories and included more physical activity for all. Until a healthier “eat less, move more” environment is created for today's children, lifestyle interventions like that in the TODAY study will fail.

Please note that 20 years ago, nobody had ever heard of Type 2 diabetes in children. As a matter of fact, what we now call Type 2 diabetes used to be called Adult Onset diabetes. Nowadays, however, Type 2 diabetes is just as prevalent in children as Type 1 diabetes (an unrelated autoimmune disease with similar symptoms) which used to be called Juvenile Onset diabetes. This is a public health catastrophe that threatens all the gains we have made in life expectancy and health, and threatens every strategy to contain health care costs.

Yeah yeah, I keep saying it. We keep hearing from conservatives about personal responsibility and how people who develop health problems because of their own bad behavior don't deserve to have the rest of us pay for their health care. But the truth is that our behavior is a function of our social and physical environment.

We evolved to eat whatever food was available because there might not be any tomorrow; and to rest when we could because chances were rare and almost all the time, we had to keep moving if we wanted to keep eating. The human organism is adapted to an environment in which it no longer lives. The result is, many of us get fat. This isn't because we are irresponsible or gluttonous or slothful -- or rather, of course we are gluttonous and slothful, that's how we are made. It's not our fault that we have these faults, it's our nature.

So what is to be done? We can't just target and treat individuals who have this problem. We urgently need to change the cultural, physical and economic environment. There are a lot of ways to do that, first of all by defining junk food and sugary beverages as something other than food, and treating them accordingly. No matter how much the purveyors of this garbage pay corporate think tanks and phony scholars to yell about the Nanny State and personal freedom. What they mean is their freedom to rip us off and kill our children. 

Stayin' Alive

Yeah, it's not a very imaginative title. Anyway . . .

I live in a small New England town. The town center consists of a general store, a one-woman post office, a Congregational Church, a Catholic Church, the town hall, and an auto/tractor/whatever repair business. That's pretty much what it was 200 years ago, except that the auto/tractor/whatever business would have been the blacksmith. About a mile down the road is the old cemetery, which stopped taking new customers shortly after the Civil War.

Some history and genealogy buffs have made an inventory of the headstones, and the result is very relevant to the main concerns of Stayin' Alive. The list is in alphabetical order, which is almost as good as random, I guess. Here are some excerpts.

Adams, Mary, wife of Captain Thomas Adams, died Sept. 17, 1814, age 76
Allen, infant daughter of Asahel & Desire, died Apr. 23, 1772, age 4 days
Allen, infant son of Ezra & Lydia, died June 11, 1804, age 14 days
Allen, Anna, wife of Levi, died Mar. 5, 1834, age 23 yrs
Allen, Asahel, died Mar. 19, 1825, age 82 yrs
Allen, Charles H., son of Joseph R. & Susan M. Allen, died May 21, 1855, age 9 mos
Allen, Charlotte, wife of Erastus, died Jan. 2, 1875, age 86 yrs
Allen, Deziah, wife of Asahel, died Nov. 2, 1820, age 75, footstone
Allen, Erastus, died Aug. 28, 1856, age 74 yrs
Allen, Ezra, died Aug. 23, 1852, age 77 yrs
Allen, Joseph, died Aug. 28, 1815, age 76 yrs
Allen, Lydia, wife of Ezra Allen, died Mar. 10, 1855, age 70, footstone
Allen, Rebecca, relict of Joseph, died Nov. 17, 1819, age 87, footstone
Avery, infant daughter of Alfred & Fanny, died Oct. 24, 1853, age 2 mos
Avery, infant daughter of Alfred & Fanny S., died Oct. 24, 1853, age 2 mos 4 days

Bass, Betsey, wife of John Bass, died Jan. 9, 1837, age 42
Bass, Captain Ebenezer, Revolutionary War stone, died Mar. 6, 1814, age 67 yrs
Bass, Eunice, wife of John Bass, died Nov. 12, 1820, age 25 yrs
Bass, John, died Sept. 30, 1865, age 78 yrs 11 mos, footstone
Bass, John, son of John & Betsey, died Dec. 24, 1833, age 16 mos
Bass, Nancy, wife of Nathan Bass, died Nov. 23, 1834, age 44 yrs, footstone
Bass, Nathan, born Apr. 15, 1792, died Oct. 8, 1856, footstone
Bass, Ruth, relict of Captain Ebenezer, died Dec. 27, 1834, age 86
Bass, Ruth, daughter of Captain Ebenezer, died Nov. 21, 1794, age 1
Bingham, infant son of Gamaliel, died Nov. 30, 1804, age 3 wks

And it goes on like that. You will, I hope, notice something interesting. Lots of people lived to what we would today consider a respectable age, well into their 80s (there are a few in the 90s which I didn't happen to capture in the cut and paste), mid 70s is a typical age of death. But what is different from today is the many infants and children, and the women of child bearing age. These people were farmers and local artisans, for the most part, and the place was sparsely populated. In the cities, I expect there was more opportunity for infectious disease to carry off young adults and the middle aged. But out here, if you made it past age 4 or so, you could expect to get your three score and ten unless you died in childbirth. (There are a few men killed in the Civil War on the list, but that was a brief interlude in this story.)

This is a point I have made here before, but now we have a very clear and evocative illustration. The tremendous gains in life expectancy we experienced in the past century had little to do with extending old age and almost everything to do with actually getting there. Ruth Bass lived to be 86, but her daughter died at age 1, while her son lived to be nearly 79 and her grandson died at 16 months, while her daughter-in-law died at age 25, quite likely in childbirth. That was life in the good old days.

A world historical schtick dreck

I have sorta kinda been wanting to write something about John Edwards but what can I say that you haven't already thought yourself? Then I realized that he does sorta kinda make me rethink my political science.

Had you asked me, pre-JE, I would have told you unhesitatingly that a politician's personal behavior and integrity in private affairs should be a minor issue in choosing among candidates. Ultimately, politics is about public policy. The reason it matters who gets elected to office is the extent to which candidates run on policy proposals and priorities; and to what interests they will likely be responsive when in office. Ergo, for example, the serial philandering of JFK and Bill Clinton, as far as I was concerned, was pretty much between them and their wives and children, plus whoever was affected on the side of the partners in philandery. (Am I the only person who has noticed that it is impossible for a man to womanize without a woman who is willing to manize?)

But the Edwards case is different, for a couple of reasons. In the first place, by the time he committed his sleazy affair, the context had changed thanks in large part to the Clenis affair. It didn't matter what Kennedy got up to because the media didn't consider it appropriate to report, even though they actually knew. Until Monica, Clinton's behavior mattered only to the extent that it might have cost him some votes among people who didn't think like me, but basically, he got away with Jennifer Flowers and whatever else he got up to so who cares? (There was an accusation of rape by one woman. If that was true, it would be another matter, but there's no way to know. Paula Jones's story suggests pretty strongly that she was miffed only because she expected him to continue to pay attention to her. But I digress, the point is about consensual behavior not whatever else might have happened.)

However, Edwards knew perfectly well that if he became the nominee, and the truth got out, the Democratic party would be crushed in the election, the party brand severely damaged for a long time, and the country and the struggling people he purported to care about horribly maimed for years to come. On that basis alone, his warped character destroyed any rationale for envisioning him as president based on public policy. His narcissism completely trumped whatever he claimed to stand for.

Beyond that, of course, using campaign funds to keep his paramour on retainer, and to finance an elaborate plot to deny his own child, is so sick you have to wonder what he'd do with an army and a nuclear weapon. All this while making what turns out to have been his fraudulent relationship with his very popular, seriously ill wife, a centerpiece of his self-presentation. This guy is as depraved as they come. So yeah, there is a point at which it does matter, where you don't want to vote for a bastard, even if he's our bastard.

A Hard Blow

I've been a football fan my whole life. I remember watching the Houston Oilers beat the Buffalo Bills with a last second field goal on a little black and white TV at my grandparents' house when I was maybe six years old. When I was growing up in Connecticut we were Giants fans - "we" meaning my uncle and grandparents and brother and I. (My father was still hooked on the Philadelphia Eagles.) I've been a passionate follower of the Patriots since I moved to Boston some 25 years ago.

But it looks like I may have to find another way to consume hours of unwanted consciousness. It may be all over for North American football. You have to read a British newspaper to really get this story told forthrightly, but it's now incontrovertible that football players, with a very high prevalence, develop chronic traumatic encephalopathy. That means they become demented, chronically depressed, and die early, often by their own hand. We've always known about the osteoarthritis and other joint and ligament problems, but you can see macho men making a choice to accept that risk in exchange for the money and glory. (Actually the glory for most NFL players is very fleeting, and the money not so much as you think.)

But to lose your mind? That's not so easy to reconcile. Now a lot of these players are suing, claiming that NFL executives knew about this but covered it up. And they have a case. The expert physician panel they employed for many years downplayed the risk based on clearly inadequate research, which they interpreted tendentiously. Now that the truth is out, how many mothers will allow their sons to play football? And no, you don't need an NFL career to suffer this catastrophe, it now appears that it can happen to players who never play past college, quite possibly to some who never play past high school.

Football as we know it can't exist without violent collisions. They are simply essential to the game. And helmet technology seems to be about as good as it's going to get. Hardly anyone seems to be facing up to it yet, but it's hard to see how the game has much of a future. Tell me why I'm wrong.

The Memory Hole

There are plenty of good reasons to despair at the state of our politics. One grows weary at the impunity of lies in public discourse; the continual elevation of trivia, name calling, and faux outrage to the headlines; the systematic exclusion of not only viewpoints, but facts, that do not conform with the elite consensus about what is "serious."

The great Paul Krugman, for one, labors tirelessly to muck out the sewers. (He himself is "unserious" because he thinks European leaders should be more worried about mass unemployment and general economic collapse than they are about this year's budget deficits or the fools who bought Greek bonds. But I digress.) Today he again points out the obvious: That for Romney to win the election people will have to forget that the recession began while George W. Bush was president and that job losses stopped nine months after Obama took office; that private sector employment has done better under Obama than it did under Bush throughout his term; that Obama has been unable to implement most of the economic policies he wanted to anyway because the Republicans in congress prevented it; and that Romney wants to return to the very policies that caused the financial crisis in the first place. But Krugman also figures he will likely get away with it: "Are the American people -- and perhaps more to the point, the news media -- forgetful enough for that attack to work?"

Why yes, they are. Thanks for asking. Larry Siems, writing in Slate, tells us that he has read thousands of classified documents obtained by the ACLU under a Freedom of Information Act Lawsuit. And, as we already basically knew, "Our highest government officials, up to and including President Bush, broke international and U.S. laws banning torture and cruel, inhuman, and degrading treatment. Worse, they made their subordinates in the military and civilian intelligence services break those laws for them." The U.S. tortured people all around the world. The U.S. tortured innocent people. The U.S. tortured people repeatedly even when their torturers had decided it was useless. Senior officials lied, suppressed dissent, and destroyed evidence in order to cover it up. Siems writes, "From emails among FBI agents sharing their shock over scenes they had witnessed in interrogation booths in Guantánamo, to letters and memoranda for the record, to major internal investigations, the documents show that those who ordered and carried out the torture did so despite constant warnings and objections that their actions were ineffective, short-sighted, and wrong. It is no wonder that so many of these documents were suppressed."

Have you heard anything about this on the nightly news, public affairs yack shows, Sunday morning gabfests? Heard anything about it from anybody holding public office, including by the way B. Hussein Obama? Didn't think so. Nor will you, I predict. It would be too unserious to decide that the former president is a criminal.

The unbearable heaviness of fandom

With specific reference in this case to the Boston Red Sox. Baseball has an aesthetic quality. Just as chess masters can see elegance in a position that tells them it is strong even without close analysis, connoisseurs of baseball can perceive elegance in a team's play that speaks to its prospects. The analogy isn't perfect because there is a random element in baseball, so you need to look at several games before that spiritual sensibility can emerge. We can now proclaim that the Red Sox are a putrid, stinking, excrescence. Yesterday, while Phil Humber was completing the 21st perfect game in major league history on the west coast, the Sox were blowing a 9-0 lead, in Fenway Park, to the New York Yankees, in the nationally televised game of the week. This was just the latest in an unrelieved series of atrocious debacles dating back to the last month of last season. The players have no respect for new manager Bobby Valentine, whose mind is on vacation while his mouth is working overtime at his regular radio show, in New York City, with the New York Yankees play-by-play man. Really. Oh yeah, Valentine, in addition to being manager of the Boston Red Sox and a radio commentator for Yankees fans, is Director of Public Safety for the City of Stamford, Connecticut. Truly. But here's the thing about fandom. The fans have nothing to do with anything that happens. They wear lucky shirts or turn their hats around or leave the room when there's a critical moment on TV because they think they're bad luck or whatever, but really folks, it's not about you. At all. The emotional investment of sports fans in the fate of their team is difficult to explain. Red Sox fans, who are nearly suicidal right now, were euphoric a few years back, but their lives have actually been unaffected by the team's fate. I'm old enough now to have figured this out. (I didn't drop that pass, Wes Welker did. Not my problem.) But many people never do. It's a mystery.

Bad News

Coca Cola's earnings jump due to big growth in sales. "Revenue grew 6 percent to $11.14 billion, compared with $10.5 billion in the first quarter last year, propelled by a 5 percent increase in sales volume driven by even larger increases in emerging markets. After India [20% growth!], China experienced the greatest growth, 9 percent, followed by a more modest 4 percent in Brazil."

Good news if you own stock in the company, I suppose, but bad news if you are a human being. The Coca Cola corporation sells poison. That's the business they are in. They make their money by killing people. Kelly Brownell and colleagues explain the benefits of a tax on sugary beverages that would be steep enough to push down sales. But the merchants of obesity and diabetes have more than enough political clout to prevent this from happening. Coca Cola funded the American Legislative Exchange Council to do some of their dirty work, and of course we got Stand Your Ground and other noxious legislation as a side effect.

We have got to stop these evil scum. That is all.

Unintelligently designed

That would be us. Frank Bruni is a restaurant critic who for some inexplicable reason was awarded an endowed chair in punditry at the NYT, but today he's writing about food so I guess that's okay. He isn't saying anything we don't already know, or that hasn't already been said right here, but it's good to repeat it and with luck, focus our attention on the real problem and possible right solutions.

The reason we (collectively speaking, not necessarily you or I specifically) keep getting fatter is simply that we're swimming in an ocean of calorie dense food. Bruni could add that we also sit on our butts all day, but that's part of the same picture. For pretty much all of the history of life on earth, but certainly including 2 million years of genus Homo, having too much to eat was pretty much never a problem. If there was abundance, it only lasted a few days, then the elephant started to rot. And the amount of work our ancestors had to do in order to get what food there was burned as many calories as they were able to eat - and that's if they were lucky. So whenever there was extra food around, people would snarf up all they could, trying to put on a couple of extra pounds to get them past the next missed meal.

That wasn't a matter of choice -- it was hard wired into their brains. And it still is. The problem is, obviously, that the situation has completely changed. We weren't designed for the current environment, we evolved in a different one.

The solution to this problem does not lie in gastric bypass surgery, or inventing a miracle diet pill, or switching to a diet of nothing but grapefruit. It lies in changing the food and calorie expenditure environment. There are ways to do this through public policy, but the industries that create the current food environment won't let it happen. Also industries that create the built environment and associated transportation system. This is fundamentally a problem of the political power of vested interests. And it's making us sick and killing us.

I'll have more to say anon.

Revenge turns sour

Quite to my surprise, my home state of Connecticut is in the process of eliminating its death penalty. (At this writing I believe the governor has yet to sign the legislation but he has said he will.)

It may not seem all that surprising that our relatively liberal state would join its neighbors in Massachusetts and Rhode Island in taking this step, but the timing is notable. We have recently endured the second of two death penalty trials in a notorious case that made national headlines. It was even the occasion for one of those New York Times in-depth, four full broadsheet page reports, specifically on the life and family of one of the murderers. (Joshua Komisarjevsky was adopted into a somewhat withered branch of a distinguished clan.)

The surviving victim, Dr. William Petit, whose wife and two daughters hideously tortured and murdered, along with extended family members, demanded the death penalty. Accordingly, prosecutors rejected offers from both perpetrators to plead guilty in exchange for life without parole. Connecticut law requires a trial of guilt, as well as punishment, in capital cases, so the defense could not simply stipulate to the facts. Two juries had to endure the trauma of viewing evidence too horrific to publish, while our community endured the dutiful recitation of its description every evening on the television news, in repeated episodes nearly a year apart. My mother would hit the mute button on he remote whenever the story appeared, as I suspect a lot of people did. Dr. Petit had to testify to his unimaginable experience, twice. No one felt any right to publicly question the ultimate penalty in this case while his ordeal continued.

Neither of these defendants is a poster boy for the injustice of the death penalty. They are both white, both career criminals, well into adulthood, sane and of normal or above average intelligence. And yet, after all this, the legislature chose this moment, to little or no observable public outcry.

Sam Harris discusses the currently most compelling intellectual argument against revenge here. A warning: he very matter-of-factly recites the events of this case. I doubt many legislators or voters are thinking about the illusion of free will as they consider this issue. However, both defendants seemed not so much evil as helpless and almost pathetic, even if it's hard to feel sorry for them. They seemed perplexed by their own actions, lost in their situation. Sure, they're psychopaths and they aren't apparently remorseful, except for the consequences to themselves. But killing them just seems pointless.

The law is not retroactive and they, and the other nine men on Connecticut's death row could, in principle, face execution some day. ("Death row" is metaphorical -- Connecticut doesn't have a dedicated housing unit for the condemned, they are scattered about.) But it takes decades for these cases to wend their way through the courts, and costs the taxpayers millions. By the time anyone is executed, the reasons for it have faded in memory.

Michael Ross, the only person put to death by the state of Connecticut since the Supreme Court allowed executions to go forward, ordered his lawyers to stop defending his life. The judge had to struggle with whether Ross could take it upon himself to embrace his own execution, but finally allowed it. Ross had specifically and horribly traumatized the rural area where I live. People talked about his death with sadness, but no real satisfaction.

So, in the end, I think our people just recognized that capital punishment isn't worth it, doesn't accomplish anything good, and only adds to the trauma and cost of already evil events. Why the folks in Texas and Alabama don't feel the same why, I'm not really sure.

You know what? Medicine really has come a long way.

I was just hanging out with a couple of physicians around my own age, and they go to reminiscing about the old days when they were interns and such. Their earliest memories of doctoring were of young men showing up with wasting and generalized lymphadenopathy and disseminated cytomegalovirus and dying -- one after another after another, and there was absolutely nothing they could do about it. That was AIDS.

One of them is now a cardiologist. The age adjusted death rate from heart disease in this country has fallen by about 50% since then. (I don't feel like looking up the exact number, but it's in that ballpark.) It's not because we're eating better, or exercising more -- on the contrary. It's because of pills, mostly, and clot busting for people who have just had heart attacks. Childhood leukemia and other cancers of childhood are now largely curable. The death rate from many adult cancers has also fallen sharply. We're living longer and longer.

When I was in graduate school, the general picture was that the huge gains in life expectancy during the 20th Century didn't have a whole lot to do with medicine. They had a lot more to do with public health (e.g. clean water) and higher standards of living, mostly better nutrition. It was even possible for Ivan Illich to write a highly respected book, that everyone had to take seriously, that made the claim that medicine, on balance, did more harm than good. (It's called Medical Nemesis, if you're interested.)

Well, you just can't say that any more. Yes, we'd much prefer for people to exercise and eat right and not smoke and drink only in moderation and practice safe sex and all that good stuff. But the incontrovertible truth is, when we do get sick, we've got a much better chance, and that's now the biggest part of the story of increasing life expectancy.

It's important to remember that this is why universal access to health care, and medical costs and affordability, have become such a crisis. 60 years ago, medical intervention just wasn't as important. Doctors couldn't do nearly as much, there was much less on which to spend money even if you had it, it really was possible to take care of the basic needs of poor people through charity and for country docs to accept chickens from struggling farmers. If you had cancer or heart disease, you were just going to die anyway so que será será.

It isn't like that today. It's important to keep all that in perspective.

Conservadoofism

There seems to be a cornucopia of studies lately finding that conservative political beliefs and attitudes are associated with a paucity of brainpower. The latest of this bounteous harvest is from some folks in the universities of Arkansas, Kansas and Wisconsin, whose home states will not feel flattered. Scott Eidelman and colleagues find that it's not necessarily low IQ, but also essentially cognitive laziness, that generate conservative ideological orientation. They define "conservative" as including presumptive attribution of personal responsibility for individual outcomes; endorsement of hierarchy and status differences; and default preference for the status quo. (Note that logically, the first two tend to conflict with each other. Just a passing observation.)

They find that controlling for education, self-identification as liberal or conservative, and gender, people hanging out in a bar tended to endorse more conservative statements as their blood alcohol level increased. In other words, even if you start out considering yourself a liberal, beer goggles actually make you more conservative.

In other experiments, they got similar results when people were multi-tasking; and when they were given only a short time to formulate their responses. The basic idea is, it's a lot easier to come up with answers and explanations that are consistent with conservative ideology. If you do a little work and think about issues harder, you start to grasp more liberal ideas.

So yeah, it seems more liberal ideas are generally a little more complicated. That person isn't poor because he's a lazy slob, or belongs to an inferior race, it's because the economic order both perpetuates initial disadvantages and fails to provide adequate opportunity for everybody. Slightly more complicated, and also more likely to be a) true and b) potentially ameliorable, which would also of course mean that things would have to change. And this explains the appeal of the moronic ranting of the vulgar pigboy. He speaks to the intellectually lazy, not just the stupid.

Can consequences trump ideology?

I recently had the opportunity to talk with an actual professor of constitutional law at an Ivy League university (not my own, we don't have a law school). He thinks that the Affordable Care Act is constitutionally valid, but that the conservative majority on the SC would just love to find some reason why it isn't because conservative jurisprudence means coming to conclusions that are politically congenial to conservatives.

However, they do confront a difficulty. There is no limit to the sophistry they are willing to employ, viz. Bush v Gore. But in the latter case, the consequence of their action was that GW Bush occupied the office of president, which was fine with them however disastrous it was for the rest of us. However, in this case, here are their alternatives:

They go along with the Scalia plan, i.e., the individual mandate is unconstitutional and it's obviously just too much to ask for them to actually read the bill and decide which parts are inextricably linked to it and which parts aren't, so rather than forcing Justice Scalia to work after 5:00 pm they will just throw the whole thing out.

Since Scalia hasn't read the bill and apparently never will, he doesn't know this, but I'll let y'all in on the secret. There's a whole lot of stuff in there that has already happened. This includes the creation of the Patient Centered Outcomes Research Institute, which already has a funding stream which does not come from the federal budget or from congressional appropriations and which is a private non-profit corporation. It has paid staff and reviewed proposals, for which it will make funding awards in May, presumably before the justices rule. (Disclosure alert: I might even get one.) Similarly, the Center for Medicare and Medicaid Innovation has already spent money and will make substantial awards (maybe a billion clams) before the court rules. (Disclosure alert: They have paid me and several hundred other people $500 as an honorarium for reviewing proposals.) So what happens if the act is struck down? Are these entities dissolved? Do we all have to give the money back? What about people who have been paid salaries by PCORI and CMMI?

Then there are the high risk pools, from which people already have purchased insurance. The people under 26 who are staying on their parents' plans. The grants to states to set up insurance exchanges. What happens to all that? The result would be total chaos.

So let's say Scalia decides he can at least assign his clerk to read the bill and decide what is and is not severable. Is there some consistent, defensible constitutional basis for doing this? What about the medical loss ratio requirement? The insurance exchanges? Guaranteed issue? (Could that survive without the community rating requirement? I don't see why not.) Ban on recissions? If they do sort all this out then, a fortiori (yeah, fancy pointy headed Latin term) they will have to analyze and accurately describe how insurance markets work, which means the whole broccoli analogy and the rest of the right wing blog jive Scalia and the others quoted in oral arguments will blow up like a Pakistani wedding hit by a predator missile. They will have to conclude that the individual mandate is essential to congress's legitimate purpose in regulating interstate commerce in order to fix real problems in the market for health insurance.

As a matter of fact, my friend said that arguments on the third day, regarding severability, suggested to him that Roberts and Kennedy may have had the light bulb go off. They may have seen that the argument for severability essentially unmakes itself; whereas if they don't find severability and strike the whole thing down history will remember them as irresponsible lunatics. The question is whether they care about option B. (Scalia, Thomas and Alito clearly do not.)

A brief moment in history?

Margaret Hostetter, as part of NEJM's 200th anniversary celebration, reviews the history of pediatrics. She tells us that the very concept of pediatrics - of children as a group with particular medical needs - did not exist until the end of the 19th Century.

One reason for this, it seems, is that children in general were not expected to live. The wise approach to the death of children was acceptance. Hostetter writes, "By the middle of the 19th Century, a child's death, far from intolerable, was frequently viewed as blessed, a release from the torment of hectic infection or the lingering complications of diseases . . . " The old graveyard in my home town in Connecticut is full of children's tombstones. Yet the death of a child, once a routine occurrence, is today an unbearable, and rare, tragedy -- in North America and Europe, anyway.

What has changed is not so much living standards -- the children of the wealthy had little more chance in the 19th Century than the children of the poor. It is the conquest, by science, of infectious disease. There are three branches of the militant force which has won this world historic victory: environmental public health, antibiotics, and immunization. By environmental public health I mean such measures as the provision of clean water and safe handling of sewage, pasteurization and other food safety measures, isolation and quarantine (seldom needed today), sterilization of medical instruments, environments, and providers -- that sort of thing. Killing the germs before they get to the people, or keeping them away. The understanding of the nature of infectious disease, and measures such as these based upon it, made a tremendous difference even before there was much in the way of medical intervention against infectious disease.

Antibiotics, in fact, did not become important until after World War II. My mother lost an eye to infection as a child, something that would not happen today. Smallpox immunization was available in the 19th Century, or course, but the ability to immunize against a broad range of infectious diseases also came in the second half of the 20th Century.

So nowadays, for the first time in 2 million years of genus Homo, and 250,000 years or more of Homo sapiens, we expect our children to live. We take it for granted, in fact. But will this be true 30 or 50 years from now? Quite possibly not, if we continue with our present folly. This includes indiscriminate use of antibiotics -- including using them to fatten cattle even while maintaining them in unsanitary conditions. It includes the idiocy of people who refuse, and even campaign against, immunization. And it includes increasingly dangerous underinvestment in public health infrastructure. Maybe people who talk about a right to life should think about this.

Some folks may be interested in . . .

Rational Wiki. Quite a lot of useful and generally cool stuff here, although it's all preaching to the choir.

Our purpose here at RationalWiki includes:

Analyzing and refuting pseudoscience and the anti-science movement.
Documenting the full range of crank ideas.
Explorations of authoritarianism and fundamentalism.
Analysis and criticism of how these subjects are handled in the media.

Good for refuting whatever nonsense your Uncle Max comes up with, as well as amusing and enlightening yourself.

The scum of the earth

For some mysterious reason I've been getting e-mails from a PR flack for a company called -- no, come to think of it, I won't even name them. A company that sells homeopathic "remedies," i.e. a scheme to defraud the public. The first thing they wanted me to know is that an unnamed "major pharmaceutical company" is in negotiations to buy them, so it can sell their product line in pharmacies. I have no idea whether this is true, but if it is, there will be hell to pay, let me tell you.

Next, they are bragging that the company "has generously offered their product to India's Minister of Health and Family Welfare to help in their H1N1 Flu outbreak. India has stated it is suffering from an outbreak of H1N1, specifically known as the "Swine Flu". To date, the strand of flu has claimed 12 lives. . . .In a gesture of compassion, [company], Inc.'s CEO Kelly Hickel has informed the Indian Minister of Health that he has a modest supply on hand which he will gladly send over immediately, and should more product be necessary they will gladly donate their net profit as a humanitarian effort to aid in their fight against the H1N1 Flu strain."

Kelly Hickel is depraved. He/she/it is a pure, unalloyed evil. That is all.

Guess what? Climate change is bad for business.

And maybe some persons of richness are starting to figure this out. Via Climate Progress, the resort operators in Aspen are wondering why in tarnation they are paying dues to the U.S. Chamber of Commerce, since climate change is, you know, destroying their business and the Chamber denies that it's happening. Which obviously it is. The answer from the Aspen Chamber Resort Association is weirdly lame: "Officials say that while they fundamentally disagree with the U.S. Chamber's stance on climate legislation, they still value the group's administrative services."

Still, I would expect them, and other local chambers suffering from adverse weather, to defect pretty soon. I'm also wondering why we haven't heard from agribusiness and coastal communities. The warming and acidifying ocean is catastrophic for fisheries, and rising sea levels and more severe storms are really bad news for coastal resorts. There are rich people affected by all of this, who could be giving their money to the Sierra Club and Center for American Progress instead of the Chamber of Commerce and the Heartland Institute -- if they had any sense at all. Evidently they do not.

ABC News, at least, has gotten over the false balance fetish, even though the New York Times has not. This story tells it like it is. We'll see if more of the corporate media join them, but I'm not holding my breath.