Map of life expectancy at birth from Global Education Project.

Friday, July 31, 2009

Child Abuse

While people are experiencing swelling waistlines at all ages, the most alarming obesity trend is its astonishing rise in children. Today, 35% of American children are overweight or obese. What is today called Type 2 diabetes used to be called adult onset diabetes because it was essentially unheard of in children. No more. We don't know how many children have it because it usually goes undiagnosed, but CDC is currently trying to find out.

As you can imagine, developing Type 2 diabetes in childhood is likely to be a very bad thing to have, but we don't yet have enough experience with it to describe the long-term consequences specifically. Presumably, however, it means that all the bad stuff that happens to older people with diabetes -- heart disease, kidney failure, neuropathy and amputations, blindness -- will happen to people at a younger age, particularly if the disease goes uncontrolled. And these kids have all the other consequences of obesity to contend with.

This is not, however, a sudden epidemic of failure of responsibility or spontaneous gluttony on the part of school children. It is happening for specific, identifiable reasons. In the Annual Review of Public Health (and I am very sorry this is subscription only, the abstract is here), JL Harris and colleagues tell us about one of the most important.

  • The average child in the United States sees 15 television food ads every day, that is 5,500 per year.

  • Food companies also market their products in schools and on the Internet, and they place products in TV shows, movies, video games and music

  • More than 98% of TV food ads seen by children are for high-calorie, low nutrition foods -- full of fat and sugar

  • There is consistent, direct evidence that TV food advertising causes kids to eat the advertised foods

Now, this is obviously not the only influence on children's diets, and parents still have something to do with it. But with more parents working longer hours, more and more of them depend on prepared and take-out foods. The ads targeted largely at adults, for fried chicken and bacon cheeseburgers and pizza delivery, also end up shoving that stuff into children. Our agricultural policy, that subsidizes corn and its sugar that find its way into most of that junk food, either directly or by fattening up the chickens and cattle, makes toxic junk food cheap compared to fruits and vegetables.

This is not a failure of personal responsibility or even a cultural failing. It is a political issue. It is a public health crisis caused by corporate greed. The irresponsibility is not on the part of fat kids and their parents, the irresponsibility is on the part of "food" company executives and the politicians who take their campaign contributions and do their bidding. I put "food" in quotation marks because not so long ago, most of this crap wouldn't even have been recognizable as food. Cheetos? You're supposed to eat that?

Thursday, July 30, 2009

Fat City

The public health perspective on obesity is actually quite well developed by now, but that doesn't mean we have good answers. Let me respond to some comments and then expound a bit from my own point of view.

Revere at Effect Measure is obsessed with influenza, for some reason. Obesity is certainly associated with respiratory difficulties, including obstructive sleep apnea, in which people repeatedly wake up during the night because they stop breathing -- often without knowing that it is happening. Since the cardio-pulmonary system -- the whole set of functions that gets oxygen to the tissues -- is already stressed in obese people, obviously any respiratory infection -- and I don't know why you'd single out flu particularly -- is going to be more difficult to deal with and more dangerous.

Bix is 100% right -- obesity is clearly strongly socially determined because the prevalence varies dramatically across time and place. It is meaningless to assert that the current epidemic in the United States is "caused" by a sudden, spontaneous deficit of self control or responsibility.

Addressing obesity as a problem in social epidemiology is greatly complicated by the cultural issues people have raised. Sadly, there is a stigma associated with obesity. We currently have a prevalent aesthetic that strongly prefers very lean bodies, especially in women; and what is worse, many people view fat people with moral disapproval or presume their condition is their own fault. Fat children are commonly ridiculed and bullied, and there are all sorts of cruel jokes that people tell about fat people. The National Association to Advance Fat Acceptance addresses body diversity as a civil rights issue, and combats both discrimination and prejudice.

Unfortunately, NAAFA can go a bit too far in denying the demonstrably real negative health effects of obesity. It may be a defensible stance that since obesity is often intractable, we should look for ways of promoting the best possible health among the obese rather than focusing solely on weight loss; but it simply isn't honest to deny that people are better off without excessive adiposity. Sure, the conventional standards are set too low -- there is growing evidence that people who CDC classifies in the "overweight" category aren't really at great risk, especially if they exercise and maintain good cardiovascular fitness and blood lipid profiles. Yo yo dieting and fad treatments are worse than just staying fat. Stigma, moral disapproval, and discrimination just compound the ill effects of obesity and actually make it harder for people to control their weight.

But -- obesity is bad for your health. We're talking osteoarthritis, diabetes, heart disease, stroke, sleep apnea, limitations of mobility and stamina, and shortened life expectancy - a whole lot of problems, and as we discussed yesterday, a substantial burden of medical costs. At the heart of the cultural challenge of getting people to see obesity as an affliction rather than a personal failing is our deeply embedded, and faulty, view of free will.

Eating is not simply a choice. It is a fundamental drive that does not originate in the cerebral cortex, the seat of consciousness and planned behavior, but in the oldest parts of the brain. Most people are as helpless to override this as they are to stay awake for a week straight or to force themselves to die of thirst.

Next: The etiology of the obesity epidemic: political, economic, and social dimensions.

Wednesday, July 29, 2009

Back to Public Health

What with the Capitol Hill health care reform circus, I feel I've been neglecting our mission here. Let's not forget that for the most part, health care is all about spending too much money too late to partially fix problems that never should have happened in the first place.

Here and there in the corporate media we saw a tiny bit of attention paid to this analysis by Finkelstein and the gang in Health Affairs, which they are kindly allowing you to read, which finds that the increasing prevalence of obesity in the U.S. (from 18.3 percent of the population in 1998 to 25.1 percent in 2006 -- an astonishing, overwhelming disaster) has contributed substantially to rising medical costs. Medical spending on obese people in 2006, they estimate, was $1,429 higher than for people of normal weight. Obesity accounted for 6.5% of all medical spending in 1998, and for 9.1% in 2006.

This report in JAMA (abstract only for you common rifraff) finds, based on a prospective cohort study (which is the very best kind of epidemiological study) that what the authors call "lifestyle" factors can double the risk of heart failure in men -- or rather, specifically, male physicians, which is an odd sort of cohort in many ways but since they presumably get top notch medical care it is a particularly good one for isolating other factors. This is no small matter on a population basis because we are talking about a 21.2% lifetime risk among the guys who don't eat their veggies, smoke, don't exercise, etc. compared with 10.1% among those who do what grandma told them to do. And you really do not want to develop heart failure. (Non-physicians are at higher risk overall, BTW. 21.2% is comparable to the overall risk for the general population.)

Now, compare these extremely urgent, very expensive and deadly public health problems with the absurd amount of attention being paid to swine flu. Why do you think the focus is so strongly in the wrong place?

Tuesday, July 28, 2009

Distinctions and Differences

Whenever scientists air dirty laundry, as Steven Greenberg has done, people get anxious that they will give ammunition to denialists and cranks. Well, they will -- but so will just about anything. The best defense of science, in the long run, is encouragement of self-criticism because that way lies the truth, on which the power of the entire enterprise rests.

So, to be perfectly clear, the question of anthropogenic global warming (AGW) is completely unlike the case of the role of Beta amyloid protein in inclusion body myositis for several important reasons.

1) The community researching IBM is, by comparison, very small and insular. It is subject to almost no outside scrutiny (until now), it rests on a narrow disciplinary base, and it has only a single significant source of funding, the National Institutes of Health. It is not hard to see how such a (metaphorically) incestuous group could develop a premature consensus. AGW, by contrast, is a theory based on the combined efforts of thousands of scientists doing basic research across a wide range of disciplines, in the glaring light of media scrutiny and under unrelenting political challenge.

2) In the case of AGW, there is no alternative set of observations which has been suppressed or ignored. There have been disputes about the validity of some measurements of surface and ocean temperatures over the years, but these were openly aired, investigated, and have been largely resolved. The fact that CO2 concentrations in the atmosphere have been increasing throughout the industrial age, and continue to increase, is not disputed; nor is the warming which has occurred during the past 50 years or so, nor the shrinking of mountain glaciers and arctic sea ice, nor poleward expansion of the historic range of various temperate zone flora and fauna. There is no underlying factual dispute. (Skeptics point out that the rise in average global temperatures appears to have stalled for a couple of years. Nobody denies that, the dispute is over its significance. We are talking about a long-term trend in which year-to-year fluctuations are not important.)

3) There is, at present, no developed theory of the pathogenesis of IBM. Investigators observe that there are abnormalities in muscle tissue accompanied by an inflammatory immune response, but that's about all they know. The presence of Beta amyloid is just an observation, not part of a clear explanatory theory. Were there a convincing theory of IBM, one might be strongly predisposed to choose between the conflicting observations. Since there is not, it would seem the essence of wisdom to look more carefully once again and to determine with greater certainty whether this observation is correct.

In the case of AGW, however, there is a highly developed and compelling theory. We know to a moral certainty why the surface of the earth is warm, while Mars is cold and Venus is blazing hot. It's because our atmosphere is largely transparent to visible and ultraviolet light from the sun, which warms the ground and ocean; they then radiate heat back at longer infrared wavelengths, to which the atmosphere is largely opaque due to the presence of CO2 and vaporous H2O, along with some methane, and so heat gets trapped at the surface. The balance is affected by the concentration of CO2, so more CO2 means warmer temperatures. There are many complications, but that's the basic idea and various testable predictions can be made on that basis. And guess what? The big puzzle pieces fit, numerous predictions in this field have been borne out and so the program of research is productive and continues to provide compelling evidence.

Does that mean there aren't some blind alleys and premature conclusions scattered among the various specific, smaller programs of investigation associated with climate science? Of course not, there probably are some. And over time it will become clear that they aren't paying off. That's how the enterprise works.

I was glad to hear from someone who is living with IBM, who is of course among those who will be most badly disserved if the search for an effective treatment is delayed by a wild goose chase. I confess I didn't know anything about IBM myself so I once again invoked by awesome Googlistic powers and found some background info. This source accepts the Beta amyloid observation without question and suggests it is highly significant, although more technical discussions I have read place much less emphasis upon it. It appears there have been a variety of abnormalities observed in the inclusion bodies, including several abnormal proteins. Clearly there is an a destructive inflammatory process going on but it is not clear why, or what role abnormal proteins may play as trigger or as consequence, if any.

One more thing: Heretical Ideas is a really cool, free online magazine. You might want to start with Alex Knapp's "defense" of the birther movement.

Monday, July 27, 2009

Weird Science

I have more than once had the experience of seeing a research report cited in one article as supporting one or another point, getting the cited report, and discovering that no, it doesn't say that after all. We now have an important study by Steven Greenberg, of the World's Greatest University, that shows how the scientific enterprise can go awry in a big way for a long time. (BMJ has been making its peer reviewed research reports, such as this one, open access, while closing the rest of the journal to subscribers only. I find this policy annoying since it is usually the commentaries, policy analyses, and lay summaries which are of more interest to the general public, but I have faith in y'all to wade through this rather technical discussion if you are so inclined.)

Greenberg selects a rather arcane proposition for scrutiny: that the protein beta amyloid, well known for its association (though not necessarily causal) with Alzheimer's disease, is also associated, perhaps in ways that suggest a causal role, with an uncommon muscular disorder called inclusion body myositis. He finds that initially, there were four papers, all from the same laboratory and probably based on only 3 different sets of observations, that supported the hypothesis; and 6 papers that contained data which undermined or weakened the claim. However, the positive findings got almost all of the subsequent citations in other peer reviewed articles, while some of the negative findings got none at all.

It gets worse. Later review articles tended to selectively cite the positive findings, and review articles in turn generally receive many citations. This tended to further amplify the dominance of the positive view. Other articles cited previous articles which presented the association between Beta amyloid and IBM as a hypothesis, but described it as a finding. Others even cited research which refuted the hypothesis as supporting it, or articles which had essentially nothing to do with it. Using the Freedom of Information Act, Greenberg was able to discover that these same biases existed in funding proposals to the National Institutes of Health.

Why does this happen? Are scientists unconcerned with the truth after all? No, but we are all subject to forces which bias our assessment of evidence. One fundamental problem is publication bias: it is much easier to get papers published that confirm a phenomenon than papers that find no association. The former seems like news, whereas the latter seems less interesting to reviewers and editors. But in fact, both make an equal contribution to knowledge. Ruling out is just as much new information as is ruling in, but it doesn't stir the passions.

Second, funders such as NIH are strongly committed to hypothesis driven research. Exploratory research which is intended to describe phenomena and generate new hypotheses has a much harder time finding sponsorship. So once a hypothesis such as this one is out there, the way to get funding is to pursue it. A proposal claiming that we don't actually have any good idea of what causes IBM and asking to poke around with an open mind is just not going to shake down the long green, so long as there is an ongoing program of research based on a generally accepted model.

The result is that large chunks of the scientific establishment can become committed to a wrong idea, and invest a lot of time and money in it, in a self-perpetuating process. Now, Greenberg has exposed only a single case. We don't know how common this sort of amplification of weak hypotheses may be. Obviously many biomedical hypotheses have proven fruitful and the programs of research based upon them have yielded effective treatments. But this is nevertheless an important cautionary finding.

I am personally committed, in both research reports and funding proposals, to reading the literature as thoroughly as possible, to going to primary sources and not relying on review articles or the description of findings in citations, and to being as balanced as I can in presenting both supportive and critical findings regarding my own hypotheses and conclusions. Of course I may try to make a case for one conclusion or another, but I pledge to do it honestly and to accurately present objections. Unfortunately, there is no real accountability right now for citation abuse. On the contrary, it is rewarded. We have got to fix this.

Sunday, July 26, 2009

Toxicodendron radicans

You may have learned that poison ivy is in the genus Rhus, but evidently the International Society of Poison Ivy Genusologists has decided that it should now be assigned to the genus Toxicodendron. Whatever. In Windham County, I would venture to guess it's the most common leafy plant. Turn around for five minutes, and it's winding around your downspouts. Through my awesome powers of googling I have learned some curious facts about this exquisite ornamental. (And yes, some fools took it over to England to plant in gardens.)

It turns out that the only species in North America to which T. radicans is toxic -- technically outrageously allergenic -- is H. sapiens. Bears and deer actually munch on it, and its fruits are a favorite of many birds -- happily for poison ivy since the birds go on to deposit the seeds in a nice, nourishing blob of guano, which is why the stuff keeps showing up where it isn't invited. You might conclude that this makes evolutionary sense since one would expect that humans are also the only species which has the cognitive chops to associate T. radicans with the highly unpleasant contact dermatitis that, for many people, follows looking at it sideways, since it takes anywhere from several hours to a couple of days for the rash to emerge.

But I would say that's too pat. There really isn't much evident advantage to the plant in being repulsive to humans. It's hard to believe the native Americans would have been uprooting large quantities of it for the soup pot if it weren't poisonous, and they would probably do the plant as much good as birds as berry pickers and seed shitters. I suspect that the plant gains some other advantage from the allergenic oil, called urushiol, and that our sensitivity to it is just happenstance.

I am very happy to say that my own sensitivity has greatly declined with age. I can now operate the weed whacker with only mild consequences, but as a youth, the dread PI was the bane of my existence. Any of my college classmates who happen to read this may recall the notorious wine party in the woods, when someone in an impaired state evidently threw a goodly sample of T. radicans on the fire. I was personally out of commission for a week -- got to skip a midterm in fact -- but some of my friends had it much worse. One guy, an organist, was diagnosed with third degree burns on his hands and had to do physical therapy to get the range of motion back in his fingers. He couldn't play for months. One of my roommates had the misfortune to take an ill-timed leak, and spent three days in bed fanning his parts.

Poison ivy exposure is a leading reason for workers' compensation claims among forestry workers and firefighters, believe it or not. Other than that it's not much of a public health concern. It hardly ever kills people, although that doesn't mean never. Fatal allergic reactions are possible. Generally it's just one of the more miserable experiences available to us, and then it goes away. I recommend a solution of zinc acetate and benzyl alcohol, sold as Ivy Dry. A tree feller of my acquaintance swears by washing yourself with gasoline as post-exposure prophylaxis. You know what, if it works, it's probably worth it.

Friday, July 24, 2009

I'm not going to read Orac for a couple of days








Thursday, July 23, 2009

Dr. Fell

I don't know why I didn't get hip to this before, but it seems there is now an association of physicians dedicated to overturning regulations to prevent drug companies from bribing doctors. They're having a conference today at a Major Teaching Hospital of the World's Greatest University. It seems they believe that medical progress depends on their being allowed to accept honoraria, free meals, resort vacations, and baseball tickets from Merck and Pfizer. The Institute of Medicine believes otherwise.

I will only note that this new group's definition of physician-industry cooperation is that industry gives them money and things of value. The IOM, medical schools, and academic medical centers are not opposed to industry-sponsored research, they just want doctors to get paid only for doing actual work, and to disclose their financial ties to drug companies. These greedheads will just have to live with that.

In other news, you have likely already heard about Dr. David McKalip, a Florida neurosurgeon who founded Doctors for Patient Freedom, which asserts that if you have health insurance, you are not free. It seems he sent a racist photoshopped image of president Obama to his teabagging friends. C. Corax did a little further digging and found out that McKalip sued to try to get out of reporting his surgical infection rates to the state. Your god given right to toxic shock syndrome. He is is also opposed to all quality assurance measures or any form of accountability for physicians, and to Medicare and Medicaid, neither of which he accepts. I got news for you doc -- I very much doubt that you give a shit about your patients, except as a source of income.

Wednesday, July 22, 2009

What are YOU afraid of?

I'll be facilitating a focus group this evening as part of a study I'm involved in concerning the health effects of near-highway pollution. (Info about the CAFEH study can be accessed from the sidebar.) I'm going to start out by asking people, in an entirely open-ended way, what dangers they tend to worry about the most concerning themselves and their families, and then I'm going to present them with some alternative philosophical views about risk and responsibility. This is a subject we touch on here from time to time, and I think it's just fascinating.

As a public health specialist, I happen to have a pretty good idea of the statistical probabilities of death and injury from various causes. I also know that it's not all that simple to think about. There are complications including how old you are likely to be when the particular bad thing happens, the multi-causality of events and the differing regard we have for proximal and distal causes, and the individuality of risk. So it is far from straightforward to say what you should worry about a lot and what you should worry about a little.

Nevertheless, I think I can say that the stuff people are most afraid of is pretty hard to justify as belonging high on the list. For example, al Qaeda could fly airplanes into buildings and kill 3,000 people every year from now till eternity and it would constitute about 1/15 of the number of deaths every year from motor vehicle crashes. DemFromCt's fondest wish could come true and we could have the massive killer flu epidemic he's been cheerleading for and it would kill 1/3 as many people as die from tobacco use every year -- and that would happen once, and be over for all time, whereas the tobacco fatalities would just go on. And so on.

Of course one has to disambiguate these statements. Some people will say that 21% of fatal motor vehicle crashes are "caused" by drunk driving, although that is not a valid conclusion. 21% of drivers in fatal crashes have blood alcohol concentrations above .08% but what we don't know is what percentage of all drivers have BAC > .08%, and it's the difference between those two numbers that is relevant. (BTW, there are more drivers involved in fatal accidents than there are fatalities, since many crashes involve more than 1 vehicle, which makes this even harder to interpret.) In any event, if drunk drivers manage to kill 9,000 people each year, why do they get 20 times the attention of 400,000 tobacco-related deaths each year, and 300,000+ obesity-related deaths?

On the other hand, what is really the "cause" of a tobacco-related death? Is it tobacco marketing and advertising? Hollywood glamorization of smoking? Individual irresponsibility? Peer pressure? Parental inattention? Or should we not even care about tobacco-related deaths because smokers have made a "choice" and we should just respect it? And, whatever we think about these questions, what is the appropriate role of government in protecting people from various kinds of dangers, or encouraging -- or even coercing -- people to engage in less risky behavior?

This is at the heart of a lot of political controversy, so tonight I'll see what some regular white folks think about all this, people who live in a blue collar neighborhood in America's most densely populated city. (I've already done Latinos, and we're doing African Americans next.) I'll let you know what the people have to say.

Tuesday, July 21, 2009

New Resource Link

A commenter recently bewailed all those ads on TV for bogus remedies. And no, I'm not talking about the ads from Pfizer and Merck, those are bad enough, I'm talking about coral calcium and homeopathy and shark cartilage and all those other miracle cures "they" don't want you to know about. Unfortunately, the medicine drummers have gotten to members of Congress, notably Tom Harkin, so the FDA has very limited powers to regulate the sale of potions that claim to be "nutritional supplements" or homeopathic "remedies." That's why your local CVS has a whole aisle full of frauds and scams. As long as their claims maintain enough weasel wording, the Federal Trade Commission has a hard time going after their advertising as well.

If you want to check out any such claims, Quackwatch is truly encyclopedic. Dr. Barrett's love child now has a place in our sidebar. It's a lot of fun to explore and includes some very useful basic essays on the philosophy of science and critical thinking in general as well.

Also much fun is the Quackometer. You can actual run any website through the Quackometer and get a reasonably intelligent artificial intelligence rating of its level of quackery. I'm very happy to report that Stayin' Alive gets zero ducks, but Deepak Chopra gets two or three. He probably deserves more. Also, Orac is all over the health scammers, if you prefer a bloggier approach. (Orac is not nearly as hip to health care policy as he would like to think, he's got a touch of the libertarian infection, but he's solid on the science.) So head off and waste some time, you might learn something along the way.

The Senator from Schering-Plough





Monday, July 20, 2009

Doctor Pecuniary

I have been active in health care politics for something like 25 years now (ever since I was in kindergarten?) and my single greatest frustration is that it simply is impossible to make the issues simple. Actually, they are reasonably simple, but our culture is so profoundly indoctrinated with Ptolemaic economics -- the nonsense that is taught to college students by professors who call themselves social scientists but who are actually theologians -- that we have to spend all our time shoveling out the stable before we can get on the horse.

To be sure, even if the economics turns out, in the end, to be reasonably accessible to the de-programmed, medicine itself is still pretty complicated and somebody, somehow, has to make decisions about how to allocate the resources that we do assign to health care. A common argument against meaningful reform boils down to, "We can't trust anybody to do that, so let's not do it at all," in other words let irrational and unjust forces prevail rather than even try to do what's right. (There's probably a Latin term for that, but I don't know what it is.)

But I digress, somewhat. The question is, what is the physician's financial stake in reform of health care finance and why would some physicians oppose universal coverage, as the AMA has notoriously done in the past? And why have they apparently suddenly changed course and endorsed the current Democratic proposal in the House? More specifically, some readers want to know why, since more people insured presumably means more money to pay doctors with, doesn't that make up for whatever doctors might lose?

The bottom line is that it will likely be good for some doctors but make it harder for some others to afford their boat payments and horse fodder. Suppose Congress were to wave its magic wand and, by any means necessary, cause everybody to have good, comprehensive health insurance like the good comprehensive health insurance that some people have now, without changing anything else. That would indeed mean more money going to doctors and hospitals and drug companies and the only losers would be whoever had to pay for it, which you will notice I have not specified. Alas, even if we paid for it with a tax on puppy abusers and Rush Limbaugh,* that well would go dry very quickly, and they'd have to start taxing puppy rescuers and Rachel Maddow, and it would just get worse from there.

The fact is that we have an inextricably entwined double crisis, at the heart of which is not the failure to provide universal coverage, but rather inexorable growth of medical spending. It is the latter which causes the former, or at least makes it very difficult to solve. Closely related is the shortage of primary care doctors and the oversupply, overconsumption, and overpayment of many specialty medical services. Barack Obama, Barney Frank and Ted Kennedy all know that. Primary care physicians who understand what's going on ought to support radical reform that not only gets everybody covered, but also redirects resources to what they do and restricts elaborate, expensive, high technology procedures that aren't worth the cost or even do more harm than good. And many of them do.

The American Medical Association, however, is dominated by specialists who stand to lose if we do what we must. The reason they have decided to support the House bill is because it doesn't -- it just waves that magic wand and causes everybody to have insurance. As I wrote the other day, it can't end there, and it won't. But this is a problem of political tactics. Can we get there by doing one piece at a time? Or will we just mire ourselves deeper in the doo doo? I am not sure.

*Al Franken is now a United States Senator, and Rush Limbaugh is still a big fat idiot. That's got to hurt.

Friday, July 17, 2009

I told you so . . .

As I wrote in this space when Massachusetts first passed its landmark health care reform law, there wasn't enough money to pay for the promised universal coverage, and unless some serious structural reforms to contain costs were implemented, we were headed for a massive crackup. Nah nah nah nah nah. Yes, we managed to get about 97% of the people enrolled in some form of health care insurance, but the cost kept going up relentlessly -- by 8% a year. Now we're dumping legal immigrants from coverage, and the powers that be knew they had to do something drastic if there were to be any hope of maintaining something close to universal access.

What do politicians do when they've painted themselves into a corner? Appoint a commission, of course. This one has come up with what is, in essence, the only possible answer, not only for Massachusetts but for all of us: one way or another, set a global budget and allocate resources within that budget. Since they aren't proposing a single payer system (which would be by far the easiest and most elegant path toward that end, of course), they're proposing a structural reform that keeps the patchwork of competing private insurance plans.

Basically, providers would form alliances that include the range of health care services, then contract with payers to cover your body for a fixed fee. As Globe reporter Liz Kowalczyk writes, "Patients could find it harder to get procedures they want but are of questionable benefit if doctors are operating within a budget." Well obviously, and of course that's precisely the horrific, fascistic, communistic outcome the Republicans are screaming will happen to us if we allow the secretly Muslim terrorist sympathizing non-U.S. citizen president to engage in Comparative Effectiveness Research and a publicly sponsored insurance plan. Of course this commission isn't talking about doing either of those things but they're proposing the freedom destroying practice of rationing anyway.

The obvious question is, why would you want to undergo a procedure of questionable benefit? Personally, I'd rather keep all my parts intact unless I know damn well I have a good reason not to. But that's just me. The larger question is whether this can ever happen politically. So far, the doctors and hospitals here in the People's Republic of Taxachusetts say they will consider it, but they are warning that they don't want to, you know, lose any income as a result. People unclear on the concept. Right now, doctors and hospitals get paid to do stuff to you, so naturally, they do as much stuff as possible and make as much money as possible. The whole idea behind the proposed reform is to gradually squeeze money out of the system, causing them to do less stuff. There will either have to be fewer doctors, or each one of them will have to make less money. QED. And a good thing too. Oh yeah. Less drugs. Less hospital days. Less of a lot of stuff.

This is pretty similar to the managed care experiments of the 90s which the public just would not accept. But it can be done in a way which meets less resistance, I think. Managed care was largely managed by insurance companies that had reviewers who had no contact with patients make often arbitrary or clearly wrong decisions about denying care. Doctors need to be free to work with their patients in making decisions, but they need to have a different consciousness about it, and better information, and different incentives. That's what we're talking about here.

It is a long long way from here to there, and a lot of new infrastructure and resources will have to be put in place as well as a radical change in the culture. But maybe, just maybe, it can work.

Thursday, July 16, 2009

The House Bill

First, a correction, thanks to KWC, who clarifies that Unabomber Ted K's sanity was never actually adjudicated. He was adamantly opposed to the insanity defense his attorneys proposed and did not wish to be declared insane, and so he ended up accepting a plea bargain. As I wrote previously, I don't doubt that he is mentally ill, but I was referring only to this conclusion by psychiatrist Sally Johnson who evaluated him for the court:

In Mr. Kaczynski's case, the symptom presentation involves preoccupation with two principle delusional beliefs. A delusion is defined as a false belief based on incorrect inference about external reality that is firmly sustained despite what all most everyone else believes, and despite what constitutes inconvertible [sic] and obvious proof or evidence to the contrary. Delusional thinking occurs on a continuum and it is sometimes difficult to differentiate between over valued ideas or preoccupations and delusional thinking. It is helpful at times, to review the belief system in association with the individuals behavior over time. In Mr. Kaczynski's case, it appears that in the mid to late 1960s he experienced the onset of delusional thinking involving being controlled by modern technology.

TK may well have delusions or at least stubborn misconceptions about his family, and he certainly meets criteria for one or more personality disorders, but in describing his beliefs about technology as delusional, Dr. Johnson elevated a difference of opinion to a diagnostic criterion for schizophrenia. That was the only point I wished to make. (I should stop there but I will just add that I don't think his ill will toward his family is best explained as delusional; it seems to me that the simpler explanation is that his social skill deficits are responsible for his impaired relationships.)

Now, for today's business, you can read a fair summary of the House health care reform bill here. You probably won't want to read the entire bill because it's more than 1,000 pages and it's going to be pretty thoroughly worked over before anything hits the president's desk anyway so why bother. Among the good or at least good enough points in the bill given that we aren't going to single payer:

  • Requires community rating and bans medical underwriting. In other words, insurers have to take you and charge you what they charge everybody else in the area, except for a differential based on age.

  • Creates minimum benefit requirements including coverage of preventive services, and caps out of pocket expenses.

  • Establishes an insurance exchange so you have one-stop shopping and can find the plan you like the best.

  • It includes a publicly sponsored plan.

  • Subsidies for low income people are probably decent (although there's likely to be a group of people in their fifties and early sixties who fall through the cracks, since their premiums will be high).

  • Wipes out the existing Medicaid payment system for doctors and improves payment for primary care services (see yesterday's post).

  • Closes the doughnut hole.

  • Ends the "Medicare Advantage" rip-off of the taxpayers.

  • Has a play or pay requirement for employers which can be gamed, but will at least slow down the perverse trend toward dumping coverage of employees that would probably happen without it.

Problems? Won't quite cover everybody, some people still won't be able to afford coverage or will prefer to pay the penalty. The latter problem will create some adverse selection, which has the potential to feed on itself if policymakers aren't careful about fine tuning the incentives into the future.

Biggest problem: Doesn't do enough to control costs. Politically, I recognize that will have to come later, but it will have to come or the whole project is doomed within a few years. Update: You don't have to take that from me, having read this post [joke], the CBO weighs in to agree. Still, in its present form, I say vote yes on the House bill.

BTW, Dennis Kucinich still wants a single payer bill which is sweet of him but it ain't gonna happen right now so I figure we need to be dead fish for a while and go with the flow.

Wednesday, July 15, 2009

Health Care Re-Form

The debate in Congress right now is mostly about whether and how to get everybody covered by health insurance and how to pay for it, but as we've discussed here -- ad nauseum, I imagine -- if that's all we do it will be a disaster. We'll just end up bankrupting ourselves and we won't end up any healthier.

One of the essential changes in the way we do medicine that I probably haven't talked about enough (is that possible?) is redirection of resources from specialty to primary care. Health Affairs has made an enlightening discussion of this problem by some heavy hitters available to you, the unwashed.

As Sandy et al review the history, specialty care -- procedures such as imaging and surgery, and services by specialists who focus on a particular body part or disease process -- has acquired and retained much higher remuneration and prestige than primary care -- basic health promotion and care coordination by a doctor who deals with people as whole people and has ongoing relationships with patients. As a result disproportionately many physicians are drawn into non-primary care specialties, primary care providers are overwhelmed by their caseloads, and health care spending is misallocated away from health maintenance and disease prevention and toward expensive and often non-cost effective intervention.

The root of this problem is really cultural -- the historical ascendancy of an exclusively biomedical model of health, which devalued public health and the bio-psycho-social understanding of personal health and well being -- which became deeply entrenched due to the disproportionate political power of the specialist medical societies. It is a very difficult problem to unravel.

These authors propose, and I endorse, a radical restructuring of payment systems which ultimately produces a health care provider workforce which is 50% in primary care. That means there will be fewer specialists, fewer procedures performed, and more income equity between primary care providers and other kinds of doctors. But, it also means your doctor will have more time to spend with you and more resources to work with you to take care of yourself and your family.

It is in large part due to fear of such an outcome that the AMA and the hospital association are resistant to meaningful reform. Yes, they want everybody insured so they can be assured of getting paid, but they don't want any other changes that will force them to scale back their horse farms. The legislation that we get this year is not going to disappoint the American College of Radiology, but the issue is whether it will lay a foundation on which we can build something that will disappoint them in the end. The publicly sponsored plan and comparative effectiveness research are both essential levers we will need to build a health care institution that truly takes care of people. They have to be non-negotiable.

Tuesday, July 14, 2009

Some thoughts about denialism

Before we can democratize the institutions, processes and findings of science, we have to democratize thinking. That is, a major percentage of the cognitive processes that are reflected in popular belief and public discourse are not of a nature that leads to truth. Really getting to the roots of why people are so bad at thinking, which we usually imagine to be the one thing we really do well and which we fancy distinguishes us from lesser creatures, is beyond the scope of a blog post and could well be a life's work.

Many people have set out to catalog common forms of fallacy. Here is one commendable effort, although on careful reading I find that the author has managed to embed a couple of his own. Well, clear thinking isn't easy, and that's one explanation for why it's often in short supply -- sheer laziness. But that's just the beginning.

The NYT dedicated this week's Science section to the 40th anniversary of the first human landing on the moon. John Schwarz offers a glimpse of the movement, still going strong, that insists the whole thing was a hoax. What an odd belief to cling to -- think of the massive conspiracy required to convince the world that people had walked on the moon on six separate occasions. What is the motive? Why has no one of the hundreds, or more likely many thousands of necessary co-conspirators never come forward? And of course, as soon as anyone knowledgable looks at their evidence it is immediately clear that it is transparently wrong and ridiculous. (A couple of hints: the reason shadows on the earth, as on the moon, are not pitch black has nothing to do with the atmosphere. It's because of scattering of light from solid surfaces. And, the reason shadows do not all point in precisely the same direction, on the moon as on the earth, is because the terrain is not flat, but rather presents varying angles to the sun.)

But evidence and argument make not a dent in denialists, whether the subject is the moon landing, anthropogenic climate change, or evolution. Conspiracies of thousands or millions of scientists are deemed far more plausible than an unwanted conclusion. As it turns out, the Christian fundamentalists actually consider this a feature, not a bug, and they are proud of it. They call their preferred mode of reasoning Vertical Thinking. There's even a "Christian" magazine for young people called Vertical Thinking, but I'm not going to link to it.

The basic idea behind vertical thinking is that you start with your conclusion -- e.g., God, six days of creation 6,000 years ago -- and then you interpret whatever facts you come across so as to conform with your conclusion. If a fact seems not to fit, that's by definition impossible so there must be something wrong with your observation or some arbitrary explanation for it must be found. (E.g., God put those fossils there to test our faith.) Horizontal thinking, which Mike Huckabee and his friends decry, is when you look at a bunch of facts and you try to reason out the most likely explanation for them. New facts may require a reorganization of your arguments and new conclusions. Then so be it.

The advantage of vertical thinking is that you can hang out with all your like-minded buddies, in the church, the bar, or the Internet, and share your regard for each other and your contempt for all those who do not Believe in the Truth. So again, it comes back to a kind of laziness, complicated by cowardice. But this is really a developmental disability. It is constructed in childhood, by our parents, by the way they instruct us and model the human attributes of thought and belief. For an adult to unlearn the delusions of childhood is very difficult.

I should add that some people develop bizarre fixed ideas as adults, which is no doubt the typical story of the moon landing deniers. I don't actually know why that happens. I happen to think that moon landing denial is sufficiently bizarre to qualify as a delusion and might merit a diagnosis, but actually what is and is not a psychotic delusion is purely a matter of social convention. 6,000-year-old earth does not qualify, but Ted Kaczynski's intellectually defensible belief that industrialization was a disaster for humanity did, and was so certified in a court of law. As far as I'm concerned, Ted is just a violent fanatic on behalf of reasonable ideas, whereas creationists are completely nuts. Update: Lest anyone misunderstand me, Kaczynski was convicted for his actions, but found insane by reason of his beliefs, and therefore spared the death penalty. You could look it up. His actions may have been insane, but his beliefs were not.

The point of all this rambling is that we need to equip more people with better critical thinking faculties. That ought to be the main point of education, and it's quite possibly the biggest and most important challenge we face as a species. We can't solve our problems if people refuse to understand them.

Monday, July 13, 2009

Water, water, not everywhere?

The editors of PLoS Medicine want to declare a basic human right to clean water. I buy this as a rhetorical strategy and in particular as an implicit critique of the neoliberal approach to global development which has caused such devastation in the world. Yes, yes, those neoconservatives were just awful weren't they, but they share a lot more with neoliberals than just the prefix.

Specifically, we have had a consensus in the capitalist capitals since the time of Ronald Reagan (and not, by the way, including Nixon) that the path out of poverty for the great mass of humanity went through shriveling of government investment in social welfare and human development, and turning loose the magic of private enterprise and free markets. You can read all about it here, thanks to Global Issues.

In the case of water, specifically, this meant alienation of the public domain -- handing over what had been provided freely by nature to private ownership -- and requiring people to pay money which hundreds of millions of them did not have to acquire one of life's most basic necessities. According to the WHO, providing clean water to everyone would prevent 6.3% of all deaths worldwide. As I have said here many times, "preventing deaths" is, in itself, a nonsensical metric because, well, we're all going to die, we're all going to die! Yes we are. However, deaths from contaminated water largely affect the young, in particular the very young. They are also the tip of the iceberg of an immense burden of disease -- 9.1% of the global burden, sayeth the WHO, including parastic diseases that destroy the productive potential of young adults.

But simply declaring water to be a "basic human right" doesn't accomplish anything. Rights are only effective when they place enforceable obligations on others. Institutions with the power to deliver clean water must actually be made to do so. This creates immensely complex problems including international conflicts over watercourses and lakes, and demands for infrastructure that poor nations cannot meet. Climate change, with accompanying drought and more rapid evaporation, just makes it harder.

So make sure this very big challenge is also on your list. Petroleum, phosphate, topsoil, water, seafood -- all going, going, gone because of the tragedy of privatizing the commons. We got it horribly wrong.

Sunday, July 12, 2009

How we live

Long time readers know that I own property in Windham County, Connecticut where I plan to plant a pear orchard. Yesterday, while waiting for the Domicile Deepott to deliver kitchen appliances -- of course they never showed -- I cleared a corner of land to make way for an additional dozen trees or so. Yup, it's back to the land and the simple life and all that, if you happen to possess, as I do, a tractor with a front end loader, a brush cutter equipped with a circular saw blade, a Stihl Farm Boss chain saw for felling and a Poulan Woodshark chain saw for lopping and cleaning up the saplings, a hydraulic log splitter, and a wood chipper, both with Honda engines. To finally prepare the ground, I'll have to pull my tiller through it to rip out the small stumps, roots and rocks.

It was still quite a lot of hard work for me, but think about the Europeans who first planted orchards in Connecticut in the 19th Century. They had to chop out the brush with hand tools, fell the trees and take them apart with axes and hand saws, and plow the ground with a team of oxen. (Major muscle is needed to get a plow through raw forest soil full of tree roots.) Back then, very few men my age could have contributed much to that effort, those few who were lucky enough to be alive.

Food today is as much fossil fuel as it is biomass, not just to operate the equipment, but to build it in the first place, from mining the metal ore to forging and machining and assembling and shipping it; to manufacture synthetic fertilizer; and of course to ship the produce all around the world. Our dilemma is that it takes fossil fuel to produce biofuel, to manufacture wind turbines and solar panels. There's scarcely any net payoff to much of the technology that's being promoted today. The distance from here to a sustainable post-petroleum economy that could evenly come close to supporting the current human population seems nearly impossible to traverse.

After my father died, my sister happened to find a Mitchell's New Atlas of North America, dated 1867, in the back of a cabinet. The map of Massachusetts, Connecticut and Rhode Island shows a network of major roads, that more or less follow the routes of most of the present Interstate Highway network. I-95, for example, essentially duplicates U.S. Highway 1. Back then, however, the traffic on those roads was horses and horse-drawn conveyances. There were no highway bridges across the Thames or the Connecticut River; travelers on the Post Road took ferries. A journey by road from Boston to New York would have been a substantial undertaking. Most people never traveled farther than the nearest market town. (The New York, Providence and Boston railway opened in 1837.)

Our lives today are so strange, so radically unlike the circumstances under which we evolved, that it is astonishing how easily we seem to function. But it isn't going to last very long. Yet another very different world is coming, but no-one can see its shape, even vaguely.

Friday, July 10, 2009

Fear of an Enlightened Planet

As a member of SWA -- Sciencedorks With Attitude -- I'm not in the least surprised, but still plenty bent out of shape, by the latest Pew poll done in collaboration with the American Association for the Advancement of Science. Which helps explain my perpetual state of high curmudgeonliness. (Yes, I've finally attained the age where I get to be a curmudgeon.)

Of course, the people labeled as "scientists" aren't unanimous about anything, but 87% of them believe in evolution without any of that ID pishtosh (disappointingly low) and 84% believe that global warming is occurring due to human activity. (I'm willing to cut a little slack there, it's not something you have to be personally down with to study the Quantum Hall Effect.) And, as we already know, the public is approximately divided into thirds over the question of whether life evolved by natural processes; life evolved under divine guidance; or humans have always existed in their present form. Only 2% of "scientists" agree with the latter -- and scientists are not immune from dementia and mental illness, so that is to be expected.

No news here, but reason yet again to ponder the ugliness. It is ultimately our fault, as scientists, for thinking that it's enough for us to do what we do and know what we know. We get to talk our own secret language. We store our arcane lore in libraries you aren't allowed to enter and thousand-dollar-a-year journals you aren't allowed to read even if you could make any sense of them. We won't let your kids become initiates into our secret societies because you can't afford to pay for college and they don't score high enough on the SAT anyway. And when, as one would expect, you end up not believing our jive, we just call you a bunch of dumb hicks.

Here's what has to happen. Science must remake itself as a participatory, public enterprise. Ten percent of every NIH grant, on average (the appropriate amount depends on the type of research) should be allocated to public programs, including community based participatory research designs, public outreach and science education -- not just in school but everywhere people can be reached -- and the democratization of scientific infrastructure and enterprise. It is possible to do science in a whole different way that eliminates those walls between the research and teaching enterprise, and what has always been to scientists the "outside" world, i.e. humanity and society. This remoteness and outside perspective has even been affected by social scientists, which is a logical absurdity.

I have a lot of ideas about specific ways to do this. I'll bet that if we really changed, people would come around to understanding our point of view and agreeing with us about the stuff we're good at proving. And guess what -- we might learn a thing or two as well. More to come on this.

Thursday, July 09, 2009

More stuff you probably didn't know

It appears I misunderstood the situation -- for so long as Michael Jackson remains dead, and Sarah Palin remains a narcissistic doofus, the public discourse will consist of nothing else. We are doomed to hear about these two individuals, the not-so-quick and the dead, relentlessly, and exclusively, until the extinction of humanity. So, I guess it's up to me to tell you some of the news that isn't fit to print.

Did you know that President Obama, on June 29, acted to abort a Bush administration initiative that could have led to the resumption of nuclear fuel reprocessing in the United States? The nuclear power controversy was big time in my youth but it has been quiet lately, so readers may need a brief review of the reprocessing issue. The Union of Concerned Scientists gives a primer, including a discussion of the now extinct GWB plans. Briefly, as the enriched uranium in nuclear reactors fissions to produce power, it's breakdown products include plutonium, as well as a whole lot of shorter-lived, highly radioactive species. In reprocessing, the plutonium and unburned uranium are chemically separated from the rest of the junk, the idea being that both can then be re-used in reactors.

The problems with this? You've got a whole lot of highly radioactive, very dangerous stuff being shipped around the planet -- the very dangerous spent fuel from reactor to reprocessing plant, and the plutonium heading back out to reactors. Unlike uranium, which requires elaborate technology to enrich from reactor to weapon grade, plutonium can be separated out chemically, by a smart college kid.

All of the stages in this cycle make excellent targets for attacks by depraved maniacs, whether to cause a disaster on the spot or to steal material for use in weapons. Terrorists aside, plain old accidents would be unacceptable. Furthermore the process generates a stream of highly radioactive liquid waste which is hard to dispose of. Reprocessing and other technologies to extend the nuclear fuel resource may become part of the global energy mix in the future, but that won't make sense until we have nuclear disarmament -- so the plutonium is not subject to diversion -- and a technological regime which can implement these processes safely and securely. We are nowhere close to that yet.

In other news apparently equally unfit to print, Obama appointed Eric Goosby, M.D., as U.S. Global AIDS Coordinator and the Senate confirmed him a couple of weeks ago. He was an HIV policy official in the Clinton administration and then head of the Pangaea Global AIDS Foundation. There is a lot going on in global AIDS policy right now, not least the evident failure of the universal treatment campaign -- we're actually rolling out treatment more slowly than the pace of new infections; the impact of the economic slowdown on AIDS prevention and treatment efforts in the poor countries; Obama's breaking his campaign promise to provide $1 billion a year in new funding for the President’s Emergency Plan for AIDS Relief; and PEPFAR's emphasis on abstinence and monogamy in HIV prevention, which is not effective with the people at highest risk, including married women who cannot control what their husbands do. Many of us are expecting positive changes.

I choose these two items because they are of particular interest to me, they are very important, and the corporate media have largely ignored them. I'll accept other nominations.

Wednesday, July 08, 2009

The back pages

Now that it's clear that Michael Jackson is going to stay dead and Sarah Palin is going to remain an incoherent ignoramus and pathological liar, I believe the nation can finally afford to pay attention to other issues, no doubt less important but still worthy of notice.

One you have undoubtedly not heard about is legislation which would reverse the effect of the 2008 Supreme Court ruling in Riegel v Medtronic. A summary of the issues is here, in a NEJM editorial. The Court's ultimate ruling was that the 1976 Medical Device Amendments to the Food, Drug and Cosmetic Act prohibit all lawsuits against medical device manufacturers by people who are injured by devices which have FDA approval. Of course, the 1976 legislation doesn't actually say any such thing: it just says that federal regulation pre-empts state law in this area, not tort actions. But you know, those activist judges, legislating from the bench . . .

Anyway, as we know, the FDA does not do an adequate job of establishing the safety of medical devices. In particular, they rely on trials run by the manufacturers, who have an obvious conflict of interest, and the agency does not adequately oversee these trials to ensure their integrity and the reliability of the results. Oh -- you don't have to take it from me. You can take it from George W. Bush's Inspector General of HHS. So, device manufacturers can slip shoddy science past the FDA, you can be injured by their products, and you can't sue them. Thus sayeth John Roberts.

You can read a summary and text of the House and Senate bills here, at the Library of Congress's "Thomas" service. Just click on the "bill number" radio button and then search for HR1346 or S 540. BTW the site has a lot of other great features, you can find out all about what's going on in Congress there. The bill, very simply, would restore the orginal intent of Congress and overturn the Supreme Court's judicial activist intervention by restoring your right to sue if you are injured due to a faulty medical device. Power to the People! Call your representative and senators and tell them to vote yes.

And let's stop appointing activist judges like Roberts, Alito, Scalia, and Thomas who don't respect the democratic process as reflected in the plain language of the law, and instead substitute their own judgment for that express will of Congress.

Tuesday, July 07, 2009

Occam's Razor

The chattering classes are all in a twitter over the reasons for Sarah Palin's bizarre resignation announcement. What is her ulterior, nefarious, elaborate plot or plan? Actually there is a very simple explanation: She's a blithering idiot.

Why is the death of a weirdo song and dance man the biggest news since Pearl Harbor? (Bigger by far, by far, than the president signing an agreement with the Russians to reduce nuclear arsenals by 25%) Simple: Everybody has heard of Michael Jackson and thinks they know something about him. Hardly anybody knows anything about the U.S. and Russian nuclear arsenals, including the international affairs reporters for the major TV news channels, so why should they be expected to talk about stuff they don't understand?

Why do self-righteous moralizing puritanical christian fundamentalists bluenoses keep getting caught in tawdry and often downright bizarre sex scandals? Projection.

Why do the ill-informed, frequently dishonest, bigoted and atavistic bloviators for a discredited, defeated political movement who are destined for the ash heap of history hog most of the air time on the teevee blather shows while the party that is actually in power and responsible for shoveling the mountains of shit they left behind can barely get a word in edgewise? Ahh, that one's not so easy.

Monday, July 06, 2009

Stay out of the clutches of doctors

That's not always possible, and it's not always good advice, but it's very important to put the entire enterprise in perspective, particularly as we consider restructuring our health care system. Specifically, I've come across two recent articles -- both subscription only -- that remind us that Ivan Illich had a point after all. In the July 1 JAMA, Charles Kilo and Eric Larson -- both of them well established on the Dark Side, holding M.D.s -- review the harmful effects of health care. They actually name That Which Can Not Be Named: "On balance, the data remain imprecise, and the benefits that U.S. health care currently deliver [sic] may not outweigh the aggregate health harm it imparts."

Uh oh. Now that would be a pretty serious waste of 17% of the U.S. economy. Direct physical harm from adverse effects of treatment is well known and justified as the inevitable consequence of placing bets where the odds are on your side but you will sometimes lose on the flop or the turn. However, the truth is that physicians very often do not have good information about the odds of benefit or harm associated with particular treatments. This is partly because adverse effects often emerge only after long experience, long after drugs are approved, viz Rofecoxib or a lesser known debacle, the Swan-Ganz pulmonary artery catheter which sold millions of units for billions of dollars for 35 years before it was ultimately found to be harmful.

However, as Kilo and Larson note, "[B]oth physicians and patients generally embrace techology enthusiastically -- implicitly trusting in its benefit before adequate assessment is made."

But there is also emotional harm, such as anxiety from false-positive test findings. One which they do not mention but which I have thought about a bit lately is the opposite effect -- the considerable distress patients often feel when doctors tell them that symptoms such as chronic pain, for which the doctor can find no physical cause, are of psychological origin. This can make people feel stigmatized, disbelieved, and devalued.

Then there is the opportunity cost. Every dollar spent on a useless or harmful treatment is a dollar not spent on something else, be it feeding a hungry child or improving public education. Either of the latter would do far more for the public health than medical intervention can do. "Although health care's objective should be to improve health, it's primary emphasis has been on producing services." We simply have no good measures of the overall impact of health care on population health.

Ian Scott in BMJ (also off limits to the rabble) discusses errors in clinical reasoning. His literature review includes the following highlights:

  1. The correct diagnosis is missed in 5-14% of acute hospital admissions.

  2. Autopsy studies find diagnosis error rates of 10-20%.

  3. Even with the correct diagnosis, up to 45% of people do not receive the recommended evidence-based care.

  4. From 20-30% of investigations and prescriptions are possibly unnecessary

His point is that a lot of this has to do with the ordinary human fallibility of physicians. Doctors suffer from the same biases in decision making and sometimes erroneous shortcuts in reasoning that plague us all. There are other structural and cultural causes of medical error, of course, which may be just as important. But it is salutary for physicians as well as patients to keep in mind always that they are engaged in an enterprise characterized by a great deal of uncertainty and potential for error, which nonetheless has a strong bias toward action.

Rather than producing more medicine, we need to produce somewhat less, but distribute it more equitably and wisely. This is one way of understanding the fundamental struggle that is going on in Washington right now. As the Washington Post reports (in the small window of opportunity remaining before it closes the impending sale of its newsroom to lobbyists), the health care industry is currently spending $1.4 million a day on lobbying. You read that correctly folks, that is $1,400,000 every day to buy the votes of Max Baucus and Joe Lieberman. And why are they doing this? As reporters Dan Eggen and Kimberly Kindy write, "The aim of the lobbying blitz is simple: to minimize the damage to insurers, hospitals and other major sectors while maximizing the potential of up to 46 million uninsured Americans as new customers."

Exactly. They want to get paid to provide services to 46 million more people, but they don't want to have to prove that they are actually doing those people any good. We need rationing. We want rationing. Rationing is good, rationing is wise, rationing will save you money, rationing will make you happier, rationing will make you healthier. Please bring on the rationing.

Friday, July 03, 2009

Bazz Fazz

I'm heading out to the poison ivy farm for a couple of days. Reflecting on the nation's birthday, I have to say I'm really torn between optimism and pessimism. The corporatist regime established after the collapse of the populist movement in the latter part of the 19th Century is seemingly as entrenched as ever. The peculiar pathologies of our culture seem equally enduring. These include radical individualism, and its strangely entwined, totally opposite identical twin, irrational cultism and militant conformity. Paradoxically, these largely co-exist in the same people, and the same cultural, media and political spaces.

We're in an economic crisis which I happen to think is much worse than the corporate media want us to believe. We're hurting everywhere but the good people of California are about to learn the hard way that in the end, you have to pay for what you get, and they're going to really going to miss what they refuse to pay for. The rest of us are going to learn it less abruptly, but we're still going to have to learn it. Over six decades, we've come to believe in eternally growing wealth and power as a law of nature. That's over now, for a long time to come. We're still a wealthy country and we can meet our people's needs with less than we have had in the past, but whether we have the wisdom and the generosity to do so is far from clear.

We are very far from truly accepting and confronting the world's multiple environmental crises. We're still hopelessly addicted to war and petroleum. Our mass media are shallow, corrupt, and cowardly. Yes, we have big problems.

But let's give ourselves some credit as well. We're in the midst of real social change. Gender inequality is still eroding, albeit slowly, and so is racism. (I'm not going to get involved in arguments over which is further along. I know we have a long, long way to go on both fronts, but you can't deny that there's real movement.) The pace of liberation for sexual minorities has been nothing less than astonishing.

Most important, the power of enlightened critical thinking in our discourse is growing. New information technology helps -- the corporate media find themselves having to answer for their sins, and we can even have these public conversations without them. We also have a much better understanding of the world than we used to, simply because science marches on and we just keep on learning and figuring stuff out. The planet is in crisis, but at least we are aware of it and have some ideas about what to do about it. More and more of us think of ourselves as planetary citizens and the claims of nationalism and tribalism are weakening in much of the world -- granted that they also benefit from a strengthening backlash elsewhere. And, nothing concentrates the mind like a hanging.

So, I believe we can overcome, even though we need to overcome a lot. La lucha continua.

Thursday, July 02, 2009

Okay, you've convinced me

I was wrong, creating a publicly sponsored health insurance option for all Americans would be extremely dangerous. As this Health Affairs policy brief argues:

There's also worry that people with private insurance would transfer into a more attractive publicly funded health plan — a phenomenon known as “crowd-out.” As private plans then disappeared, that could lead to what opponents fear most: a “single payer” health care system in which government pays all the bills for health care.

A prospect so horrific they have to repeat it:

Finally, opponents are concerned that the increasing bargaining powers of a large government plan could destabilize the marketplace, controlling prices and choking competition. Economists call the phenomenon a “public monopsony.” As private plans were driven out of business, government could become the predominant payer. And if pressures mounted to subsidize public coverage, in effect the government might come to finance all health insurance — leading to what in effect would be a single-payer system.

Oh yeah: "Opposition to the notion of a public plan comes from health insurers’ leading trade association, America’s Health Insurance Plans (AHIP), as well as from some conservative Democrats and many Republicans." What it does not come from is the large majority of the American people. But who do you think Joe Lieberman and Max Baucus are listening to?

Update: You might be interested in seeing where Holy Joe gets his dough.

Wednesday, July 01, 2009

On liberty

The dictionary defines "power" and "liberty" in very different terms. Power is construed positively, as the ability to do or accomplish what one wishes; liberty is construed negatively, as the absence of constraint. On reflection, though, they are near synonyms, or at least overlap substantially in denotation. Liberty is a precondition for power, obviously; one way to lack power is to be constrained. But we are constrained as well by our inherent limitations: power is equally a condition for liberty. It is absurd to say that I am at liberty to play in the NBA, so long as I do not have the power. I could show up for a tryout, I suppose, but they wouldn't take me.

Power in general is not a zero sum game (or a constant pie, as the political scientists absurdly say). I can increase my power without reducing yours. Indeed, I can augment your power along with mine. For example, if I succeed in finding ways of making physician-patient collaboration more effective, you might end up feeling more powerful, even as I grow more capable in my field and perhaps better paid. (Just dreaming, of course.)

Where disputants often stumble is over not noticing that power over others is a special, and distinct case. Power's sibling liberty has precisely the same inflection point. It is an entirely distinct matter when one person's liberty infringes another's.

It is astonishing how often people miss the obvious in pondering the question of liberty. Homo sapiens derives its unprecedented power as a species precisely from its socio-cultural accomplishments: the accumulation and dissemination of knowledge and technology over generations, the immense achievements made possible by division of labor and organized enterprise, the availability of support and assistance in time of need. The powers which are preconditions for our liberties do not arise from us as individuals, but our created for us by society.

As a microcosmic example, when we go to the doctor, we want that doctor to be very powerful: highly intelligent, stuffed full of the latest information, equipped with special legal authority, resourced with high technology equipment and whole teams of specialists. We want the doctor to have all sorts of powers we do not have. At times, we surrender completely to the physician, allow her to render us unconscious, cut us open, dissect out body parts; bombard us with radiation; or pump our veins full of toxic chemicals. We depend on this extraordinarily powerful individual to preserve our own capacities and secure our own liberty to live independently, perhaps to work or pursue our relationships and avocations.

It can all go wrong, of course. We can end up feeling infantilized, be manipulated, exploited, abused, or just let down. The asymmetry of power can end up constraining our liberty, but it can also expand it. The only solution to that dilemma is to make rules and regulations: requirements for physician licensure, restrictions on the choices physicians can make, ethical norms for the practice of medicine. And that arguably restricts our own liberty to choose doctors who don't measure up and can't get or keep a license. It makes us pay more for physician services. But without such rules we would not be at liberty to surrender ourselves to the potentially empowering power of physicians with any confidence that our choice would succeed.

And here I think is the essential distinction between liberalism and libertarianism. We're all for "liberty," hence the shared etymology. But liberals understand that liberty is not the creation or possession of individuals. It is created and bestowed upon us by society. We need society, we need in fact constraints on our own liberty and that of others, in order to create and preserve the greatest possible measure of liberty, or any liberty at all for that matter. Society can also fail us in this regard, so liberals are deeply concerned with what kind of society we have, committed to using their own individual power and liberty to struggle toward a society that creates and defends liberty. Libertarians think they'll be free if society goes away. That is a fundamental, absolutely fatal error.