A reflection on the climate change problem

Specifically, not climate change itself, but the failure of the political system to respond to it. Eric Chivian, one of the founders of International Physicians for the Prevention of Nuclear War, has some thoughts about this in BMJ. (Not sure if this is open access.)

He makes the usual points: scientists are always cautious and hedge their conclusions -- "high degree of confidence," that sort of thing -- whereas the denialists speak with what sounds to lay people like greater clarity; the media finds that controversy sells so they give the denialists equal time and stature; and there's big money behind denial.

But he embeds the deepest point in another -- burying the lede, I would say:

We were, and are, up against the richest, most powerful, most rapacious adversaries on the planet, who since the industrial revolution began have controlled what powers almost everything we do, whose products are the engine for the economies of all industrialized countries and the fuel for the rapid growth of developed countries.

The real issue is not the powerful, rapacious adversaries. They are a by-product of the fundamental reality. Our world, our entire civilization, exists only because of fossil fuels. The human life span, the conditions of life for the overwhelming majority of the world's people, the accumulation of wealth and the pace of technological change were essentially stagnant since the first ape that spoke. Then came James Watts steam engine in 1781, fueled by coal. Everything since then would have been impossible without it. The human population would be maybe 1/50th as large. Maybe. We'd still need more pasture for our horses than farmland, which would absorb the daily, grinding labor of 90% of us. It would take two months to cross the Atlantic, and the only way to get a message across would be to carry it.

We can't undo this world, but finding acceptable ways of fueling it is the hardest thing we will ever do. It's like chewing your own leg off to get out of a trap. But, chew we must.  

A couple of bookmarks

Do check out:

Democracy: A Journal of Ideas

and uh

The Baffler.

Without a doubt, both offer some of the best free content (or any content, for that matter) out there.

Can't figure out how they pay for it, these are well-known professional writers, but you might as well take advantage.

While they ignore the IPCC report . . .

the corporate media are getting all excited about Ebola virus, which ABC news is now telling us may come to the U.S.

Puh-leeze. People contract Ebola virus from wild animals in remote places in Africa. It is highly unlikely any of those people are going to get on an airplane, and if one of them were to do so, even more unlikely that she or he would be headed for Kennedy Airport. Ebola virus is a problem for people who live where it is likely to be encountered, but it doesn't have to be our problem for that to be true.

Here are the true facts, from the WHO.

Yes, it's a really awful disease. The case fatality rate is 90% and there is no effective treatment or vaccine. And people can be contagious during the incubation period in which they are not symptomatic. But . . .

The virus is transmitted only through direct contact with bodily fluids. If somebody sitting next to you on the plane happened to be infected asymptomatically, you would be very unlikely to contract it. The virus spreads when health care workers take insufficient precautions -- gloves and gowns and masks and all that -- and through funerary practices in which people come into contact with the corpses of victims. People in the acute phase of the illness bleed through every orifice, so yes, there are plenty of bodily fluids to avoid, but they aren't walking around and they definitely aren't flying on airplanes! (And, it is present in semen.)

What all that means is that we will continue to see these isolated outbreaks, but unless it somehow mutates to become more contagious, this is not going to become the next Black Death. And don't worry about it coming to the U.S.

Why the "journalists" just can't avoid these temptations is beyond me.

Obviously only one blog post worth making today . . .

That's of course the new release from the Intergovernmental Panel on Climate Change. All the available material is at the link but you might want to start with the Summary for Policymakers, which is only 44 pages long.

The report made the upper right hand corner place of honor in the NYT, but in the smallest possible guise, one column wide. The TV news web sites are still leading with the missing airplane and the mudslide. These are obviously more important than:

i. Risk of death, injury, ill-health, or disrupted livelihoods in low-lying coastal zones and small island developing states and other small islands, due to storm surges, coastal flooding, and sea-level rise.34 [RFC 1-5]
ii. Risk of severe ill-health and disrupted livelihoods for large urban populations due to inland flooding in some regions.35 [RFC 2 and 3]
iii. Systemic risks due to extreme weather events leading to breakdown of infrastructure networks and critical services such as electricity, water supply, and health and emergency
services.36 [RFC 2-4]
iv. Risk of mortality and morbidity during periods of extreme heat, particularly for vulnerable urban populations and those working outdoors in urban or rural areas.37 [RFC 2 and 3]
v. Risk of food insecurity and the breakdown of food systems linked to warming, drought, flooding, and precipitation variability and extremes, particularly for poorer populations in urban and rural settings.38 [RFC 2-4]
vi. Risk of loss of rural livelihoods and income due to insufficient access to drinking and
irrigation water and reduced agricultural productivity, particularly for farmers and pastoralists with minimal capital in semi-arid regions.39 [RFC 2 and 3]
vii. Risk of loss of marine and coastal ecosystems, biodiversity, and the ecosystem goods, functions, and services they provide for coastal livelihoods, especially for fishing
communities in the tropics and the Arctic.40 [RFC 1, 2, and 4]
viii. Risk of loss of terrestrial and inland water ecosystems, biodiversity, and the ecosystem goods, functions, and services they provide for livelihoods.41 [RFC 1, 3, and 4]

Followed, of course, by resource wars, massive refugee crises, and global famine. Ah, no biggie, there's a giant sinkhole in Detroit!

Whizdumb

I haven't had anything to say about that missing airplane, for the obvious reason that I don't have anything to say about it. But, as you know, that hasn't stopped the teevee news from talking about nothing else. That's actually good, because it has distracted attention from Crimea and thereby prevented World War III. If not for the missing plane, the past two weeks of teevee news would have consisted exclusively of Republicans taunting president Obama for being a girly man.

But, even though there was at most a scrap or two of new information each day, none of which added up to answers, the 24 hour data free mindless blathering attracted a big audience. CNN is in the business of selling eyeballs to advertisers, and saying nothing meaningful for hours on end worked very well for the purpose. I actually find this interesting.

Interesting aspect number 1: This event is actually not very consequential in the grand scheme of things -- many more people have died in ordinary car crashes in the past two weeks than died in the airplane, just for starters, and obviously there are innumerable other matters that are much more important. Commercial flying is still very safe. But when many people die at once, in a single event, we pay attention. For some reason we particularly seem to like to pay attention to aircraft-related catastrophes, which is why Al Qaeda is always trying to blow up airplanes even though it's easier to blow up other stuff and could also kill more people.

Interesting aspect number 2: The fact is, we Homo sapiens are hard wired to be very interested in out of the ordinary happenings, and we are driven to understand them. That was essential to survival back in the African savannah days. Our ancestors relied on the predictability of their environment to find lunch and avoid becoming it. When something wasn't where it was supposed to be or did something it wasn't supposed to do, they paid attention, and they tried to figure out why. And indeed, this is a bizarre mystery and it's certainly intriguing. I can't help thinking about what might have happened, and I can sort of understand how people might end up riveted to the TV hoping to get a new piece of information that they can fit into their solution structure for the puzzle.

The information which has been publicly stated doesn't actually fit very well with any of the three plausible broad hypotheses: catastrophic electro-mechanical failure of some kind; a hijacking gone awry; or pilot suicide. (Actually, I'm sorry to say, it probably fits best with the latter, but I shouldn't speculate.) Of course the information we have been told could be wrong. But the strangeness of this event makes it all the more intriguing.

The ultimate conclusion is that television news is not for the most part designed to inform, but rather to entertain. Always keep that in mind.

Sonja Henie's tutu, wait till the Bible thumpers start cogitating on this . . .

At some unknown day in the next couple of weeks (most likely) surgeons in Pittsburgh will put a human into a state between life and death, I suppose you could say. An undefined state. Heisenberg's cat. I don't know what to call it.

Right now, if your heart isn't beating and you don't have any measurable brain activity, Jack you dead. But . . . this is because a person in that state, ordinarily, has had ongoing metabolic activity while the brain was deprived of oxygen. Brain cells can only survive a couple of minutes in that situation. But, if the body is really cold, metabolic activity slows way down. You may have heard of seemingly miraculous cases of people falling through the ice, being pulled out after an hour or so, and recovering. (Follow the link if you want a fuller explanation.)

So, a few years back Dr. Hasan Alam in Michigan did some experiments with pigs. (If you are a PETA member or sympathizer, you might want to round up your posse right now.) He sedated them and then gave them horrific injuries, equivalent to multiple gunshot wounds. Then he drained all of their blood and replaced it with cold salt water. Then he fixed the injuries. Then he gradually reperfused them with blood. They recovered.

So, next chance they get, a team in Pittsburgh will try this on a human being, who comes in with massive blood loss and cardiac arrest. They figure they'll have as much as two hours to operate and fix all the bleeding points, during which time the person will have no heartbeat, no blood, and no measurable brain activity. But, their brain cells will still be alive, just operating at a greatly reduced metabolic level, as will their other cells. Heating them up slowly enough will avoid injuries, presumably.

Now, let's be clear. People who are currently ruled to be brain dead really are dead because you can't do this. It's too late, their brains have been deprived of oxygen for too long while they were warm. But this does somewhat complicate the definition of death. Oh yeah -- suppose these people report all sorts of hallucinatory experiences, which I expect they will, at least some of them. I don't even want to think about the idiotic discussions we are about to have.

(If you got the people even colder, could you stow them away for years while they journeyed to the stars? You'd need some sort of antifreeze but if that could be worked out, maybe, sure why not?)

What fools these mortals be

I've written about this phenomenon before -- people building their houses and farms on the slopes of active volcanoes, eroding barrier beaches, forests that burn every few decades . . .

It turns out geologists have known for decades that hillside in Snohomish county was going to collapse. Geomorphologist Dan Miller, who filed a report for the Washington Department of Ecology in 1997 predicting the disaster that just happened,

could not believe what he saw in 2006, when he returned to the hill within weeks of a landslide that crashed into and plugged the North Fork of the Stillaguamish River, creating a new channel that threatened homes on a street called Steelhead Drive. Instead of seeing homes being vacated, he saw carpenters building new ones.“Frankly, I was shocked that the county permitted any building across from the river,” he said. “We’ve known that it’s been failing,” he said of the hill. “It’s not unknown that this hazard exists.”

Yet one local homeowner, who happened not to be home at the time, said:

“That’s like saying the river is going to flood,” Wood said. “If the hillsides were going to slough away, they were going to slough away. That’s kind of what happens around here.”

Well yeah. But does that mean you shouldn't care about it happening to you? It's a mystery.

Grifters gotta grift

You may have heard of Joel Osteen, a Houston preacher with a really big congregation. And you may have heard that his church was recently the victim of a $600,000 theft. What you may not have noticed is that the stolen loot was the take from the collection at a single, ordinary church service.

Do the math. He's taking in more than $31 million a year. Just from the collection plate. Who knows what he gets from people who send in money after watching him on TV. I pity the fools who enrich this fraud. Well, a little bit anyway. That's the essence of religion - it's a con game. And it's a good one. Nobody ever comes back from the dead to tell the pigeons it's all a lie.

Here's what he told Piers Morgan about his obscene wealth:

"I don't ever feel guilty because it comes from – it's God's blessings on my life. And for me to apologize for God's – how God has blessed you, it's almost an insult to our God."

Well okay then. If I call him a thief and a liar, I'm insulting God, who after all made him a thief and a liar. Fine with me. I insult thee.

An "Invisible" World

I just heard a talk from guys with Project Weber, a program here in Providence for male sex workers. This is not a phenomenon that most people even know exists. I'm not talking about high price rent boys like Jeff Gannon, I'm talking about street workers.

According to Project Weber founder Rich Holcomb, most of them identify as heterosexual and they do it out of desperation, usually because they are addicts. It's a horrible, degrading life. Unlike female street workers, who are usually readily identifiable and attract the ire of neighbors and the attentions of the police, they are unrecognizable to most people and get little or no police attention. But they are obviously at very high risk for HIV and other STDs, do cycle in and out of jail due to drug offenses, and are also at high risk of being raped and murdered. In fact Project Weber is named after a kid named Roy Weber, who was murdered in Providence in 2003. The crime has not been solved.

The project hands out condoms and exchanges needles, has a drop-in center, and helps people get into treatment and out of the life if and when they want to. These guys are as down and out as it gets. I expect most people pass moral judgment on them, but the fact is they were typically abused as children, and a lot of them started out as "throwaway kids," kicked out by their parents at a young age, who got into sex work to survive. The addiction may have come before or after.

Most people don't care about them, but the public health response -- as opposed to the Christian response of threatening people with damnation -- demands treating people with compassion and respect. Stigma and shame equal invisibility and just drive people deeper into the shadows and away from hope and help. Thanks to the clean needles and condoms they get from Project Weber, a lot of the guys manage to stay HIV negative until they get clean. And if they do become infected, they can get into medical care and if HIV is treated effectively, the person is not infectious. That's a big win for us all. Caring about the people who are least fortunate is a nice bonus.

Science Journamalism

Wow. Just wow.  One Marcy Darnovsky, executive director of an institution called the Center for Genetics and Society, doesn't know anything at all about genetics.

Here's the story. Shoukhrat Mitalipov, a Soviet emigré scientist, has figured out how to insert the nucleus of a human zygote (a fertilized ovum) into the cytoplasm of a donor ovum. The reason for doing this is to make it possible for women who have genetic mitochondrial disorders to have healthy biological offspring.

For those of you who need the background science, it's actually a very interesting fact about our deep evolutionary history. The eukaryotic cell, which is what we are built out of along with all the plants and animals, is the product of a very ancient event in which primitive bacteria became endosymbionts within larger cells, probably archaea.* It may be that the archaeal cell ingested a bacterium, but failed to digest it. The DNA of the archaeal cell is now (apparently) essentially the DNA in our cell nuclei, what we call our genome. (It's possible that some of it derives from the endosymbiont. Some of it also derives from retroviruses. It's a long story. But anyway . . .

Those symbiotic bacteria are now what we call mitochondria, organelles within our cells that generate the energy the cell needs to fuel its chemical machinery. They have a very small genome of their own, just enough to keep them alive and functioning within the highly specific environment of the cytoplasm. And their genes do not determine anything about us, whatsoever, other than how well our mitochondria function. We get 100% of our mitochondrial genes from our mothers, the father's genome has nothing to do with it, because the mitochondria in all of our cells are descendants of the mitochondria in the ovum from which all of our cells descend. In other words, the mitochondria do not reproduce sexually and they have their own, independent line of descent which is exclusively maternal.

So here's what Marcy Darnovsky says:

His research has brought persistent criticism. “If these procedures are carried out, it crosses a very bright line,” said Ms. Darnovsky of the genetics center. She said that the current goal, mitochondrial replacement, may be narrow, but that Dr. Mitalipov’s genetic techniques could lead to broader applications and eventually to a situation in which scientists or governments “compete to enhance future generations,” such as producing soldiers who never need sleep.

No. Completely wrong and astonishingly ignorant. Dr. Mitalipov isn't even using genetic techniques at all. He isn't going near the human genome and what he is doing cannot create enhanced future generations or affect people's sleep or anything else about them. The only thing it can do is create a baby with healthy mitochondria. Period. End of story. One would think that the executive director of the Center for Genetics and Society would know the first thing about genetics. Sadly, no.

The additional problem is that the New York Times science journalist who wrote this story doesn't understand this either, and didn't bother to ask anybody who could explain it to her.

* Archaea and Bacteria are two different kinds of single-celled organisms, which are considered separate "kingdoms," which diverged very early in the history of life on earth. They appear superficially very similar but have large differences in their cellular machinery.

Re-reading The God Delusion

Not sure why I picked it up again -- not much in there I don't already know and haven't thought about myself, really. But there is one chapter I don't find satisfactory.

That's chapter 5, where Dawkins tries to explain why religion is so pervasive. His main theory is that a) children are indoctrinated early and his evolutionary psychology hypothesis is that we're wired to believe what our elders tell us with great solemnity. E.g., don't swim in the crocodile infested river, do say the correct mumbo jumbo on Sunday; and b) he invokes his beloved meme theory and notices that religion is full of memes that are well tailored to insure their own survival, such as you will be tortured for all eternity if you so much as doubt this out loud.

Well, yeah, but I was indoctrinated as a child. My uncle by marriage was the pastor of a fancy High Episcopal church in an affluent Connecticut shoreline town, which we attended until I was 7 or 8 years old when we moved to another town and started going to a Congregational church, where I participated in all the youth activities and the choir. My mother was a Sunday school teacher. When I got to be 13, I started talking with my uncle about confirmation.

I attended Phillips Academy Andover, where they made us go to church three days a week with of course a big whomping service on Sunday. One day I was sitting there next to my roommate, and we looked at each other, and I said, "This is completely fucking ridiculous." He said, "Yep." From then on we didn't stand up for the hymns or kneel for the prayers, we just sat there and endured it.

Is there anything super special about us? Dave, my roommate, grew up in a Catholic orphanage, and no, he probably didn't tell me everything about that, but he told me enough that I can guess it might have led him to see through the fraud. But for me, it was perfectly simple. I was old enough to think for myself, and it was immediately obvious that the whole thing was transparent nonsense. I had the advantage of having actually read the Bible, unlike most Christians, just because I was a reading fool as a kid.

But I mean, come on. There were only two people in the world and God told them not to eat a piece of fruit but a talking snake persuaded the woman to do it anyway, therefore all of humanity was cursed throughout the generations until God got a woman pregnant with himself, and then had himself tortured to death, but nothing actually changed, life was still a bitch only now we were forgiven? I mean, I don't really give a shit if God forgives me for having a remote ancestor who ate a piece of fruit, but if he wanted to do it, he didn't have to get himself tortured to death. I could go on, but the point is made, I hope. This is batshit insane, all of it.

How anyone can exist who doesn't see that is baffling.

After decades of struggle . . .

. . . I have finally surrendered. It is impossible to cook dried beans. I'm sticking with canned from now on. It's sad, but one must bow to necessity.

Conservatism is synonymous with ignorance

I first saw this on Balloon Juice. It seems the Fox affiliate in Oklahoma City found the single, fleeting reference to human evolution in the first episode of Cosmos so offensive that they censored it.

Obviously, Cosmos, as it continues, is going to whip the refugees from the 12th Century who constitute the Republican base into screaming, barely articulate rage. Maybe, just maybe, it will help to move their atavistic idiocy out of the acceptable mainstream.

I have no idea whether Herbalife is a pyramid scheme . . .

. . . but it's a scam anyway. (Legal disclaimer: In my opinion.)

The company is in the news because a short seller is trying to knock the share price down with a campaign to show that it doesn't really make money from selling it's snake oil, but from roping in new distributors. Whatever, the products are a fraud.

Here's a typical example. This garbage "Supports the body’s absorption of micronutrients and promotes cellular energy production.*" The asterisk is to tell you that, no it doesn't. "Supports" is the favorite verb for peddlers of fraudulent nostrums, because it doesn't really mean anything. Are you not absorbing your micronutrients? Highly unlikely. Does your cellular energy production need promoting? Only if you have a mitochondrial disease. And no, antioxidants do not "support" healthy aging. As innumerable studies have shown (much discussed here) there is no evidence whatsoever that any antioxidant supplement is associated with any health benefit whatsoever -- and some of them appear to be harmful.

This is 100% crap. It wouldn't surprise me if the whole thing is a pyramid scheme but on the other hand, people do buy similar junk in the CVS, which is not ashamed to sell it. Congress has basically made it impossible for the FDA to regulate this market so they keep getting away with it. Also note the false advertising on TV -- people wearing tinted contact lenses to make their eyes all shiny, telling you to buy special items to "support" eye health. Special vitamin formulations for women, old folks, people who do crossword puzzles, whatever. It's all a con job. 

A weird but interesting natural experiment

The European conquerors of what is today the United States have elected to make reparations to the original inhabitants in a very weird way: specifically, to allow them to open gambling casinos. Whatever you may think of this policy in general, for those tribes lucky enough to get a casino, it has undoubtedly brought economic benefits, or at least free money.

I think you'll only be able to read the abstract of this piece by Jones-Smith, et al but that's okay. They used data on Native American children in California from 2001 through 2012, and they compared kids based on the number of slot machines per capita in their school district. (Really!) Slots per capita correlates with the income of the Native American people.

It turns out that getting a new casino on your territory makes your kids less likely to be overweight or obese. This is pretty strong evidence that poverty causes childhood obesity. You can't do a randomized controlled trial of giving money to half the families and not the others, but this is almost as good -- it's what we call and "instrumental variable," a natural event of some kind that produces quasi-randomization of a population. Now, it's barely conceivable that some other factor is correlated with casino revenues that really explains the observation, but it's hard to think of what that might be.

Okay, why would having adequate income make kids more physically fit? It's easy to think of reasons: better nutritional quality, more recreational opportunities, less stressed out families. Maybe you can think of others.

Anyway, this is just one more brick in the ever growing wall of evidence that poverty can hurt kids for life. Once you are an obese child, you are very likely to end up as an obese adult, and that limits your economic potential as well as your life. I think we owe the Indians something better than the erratically awarded opportunity to run a casino, but at least we have learned something from this. Are you listening Paul Ryan? No, I didn't think so.

No, I'm not Bartcop . . .

. . . whose death was announced today, in case you were worried  Back when people actually read this blog many people thought I was. (The name I use real life makes the connection, but actually, his name was not Bart, whereas mine is.) However, I did correspond with him, around the time he was first diagnosed with cancer. I also had some correspondence with his friend Marc Perkel.

Bartcop was one of the most important liberal bloggers to emerge early in the reign of Chimpoleon the First, Emperor of Mesopotamia, AKA George Bush II. His palpable anger was always fully justified, his wit was sharp, and his reading immense. Eventually Bartcop faded into the blogosphere as it grew vastly larger, but he was seminal in getting the whole thing started.

Where I'm at

I'm in DC for a grantee meeting of the Patient Centered Outcomes Research Institute (PCORI). I may have had a bit to say about PCORI before, can't quite remember, but it's important for the masses to know about.

PCORI is the product of a little-noticed provision of the Affordable Care Act. More specifically, along with the Medicare Independent Payment Advisory Board, it is one of two Death Panels. (Ha ha.) Actually, it has been characterized in that way, as being a way of "rationing" health care. What it really does is fund research, specifically comparative effectiveness research. In other words, the mandate is to learn what medical interventions work best for what people. The "patient centered" in the name means that PCORI has to define outcomes in terms of what matters for patients, and the way they do that is by involving patients as collaborators in all stages of the research process. By law (and very unfortunately), PCORI is not allowed to calculate cost effectiveness or even use Quality Adjusted Life Years as an outcome measure. Still, if you find out that intervention A costs more but intervention B is more effective and gives you less pain along the way, presumably you'll choose B and we will save some money.

PCORI is funded by a surcharge on health insurance premiums. Yes, a tax. Since it will presumably help insurers save money, they ought to be for it, but so far they haven't been talking. PCORI is a private non-profit, congressionally chartered corporation, not a government agency. So congress can't defund it by inaction. As long as the Dems have at least one house of Congress or the presidency, it should continue on. But it sunsets in 2019, and will have to be reauthorized before then.

With NIH funding being steadily reduced, this helps a bit to fill the gap in health care research. But the focus is very specifically work that NIH does not fund so much of. We aren't about making new biomedical discoveries, we're about using the technology we already have wisely. We're about making it easier for patients to understand what's going on and make decisions in their own interest. How that's rationing or death panels I can't quite figure out, you'll have to ask a Republican.

I'll say more about this, including my own work, anon. The challenge of getting doctors and the medical institution to change course and really be built around serving patients is huge, but that's what PCORI is trying to do. And they're sincere about it. Write your congressritter.

Granny on the ice floe?

There's been plenty of froo frah over people being injured by avoidable errors in hospitals -- back in 1999 the Institute of Medicine reported that at least 44,000 people, and maybe 98,000, died in hospitals every year from preventable errors. That was a famous report and we've been talking about it ever since.

Now the Medicare Inspector General says that more than 1,500 nursing home patients died from preventable errors in August, 2011, with much larger numbers being harmed. Also, this results in preventable hospital admissions costing Medicare $208 million per month.

Skilled nursing facilities vary a lot in quality, but I can tell you from my own experience that a) they are generally physician-free zones; and b) staff are often harried and resort to drugging people to keep them quiet and docile (called a "chemical straitjacket.") There are a few solvable problems here but one is that financial incentives can be perverse. The skilled nursing facility isn't penalized for avoidable hospitalizations. I don't think Medicare reimbursement rates are inadequate, but the same facilities have Medicaid patients (who have exhausted their Medicare long term care benefits and personal assets) for whom they are being paid less. And yes, some operators are unscrupulous.

Unfortunately, there aren't enough beds in the really good facilities and they won't even take Medicaid patients. This isn't my personal area of research but it's something we all need to take personally because we have parents or grandparents who end up in these places, or we will ourselves. We need to do better.

Killing Kim Jong Un

You may have noticed the recent UN report on North Korea that tells us what we already knew: not a nice government at all. In fact the most hellish place on earth. As I say, not exactly news. But I have an entirely different point to make.

One of the first commenters on the Daily Kos diary about this wanted to know why we don't just send in the SEALS to kill him as we did Osama bin Laden. There are many reasons why that would not be a good idea, the first being that it wouldn't work. Unlike bin Laden, Kim is very well protected by soldiers with guns, and the helicopters would not just sit there unmolested while the SEALS shot it out with them.  But, Kim is not in hiding. He makes public appearances and I presume the locations of his residences and workplaces are known to western intelligence. So he could be whacked with a tomahawk cruise missile. But that would be an equally bad idea.

I'm sure my Dear Readers can think of all the reasons why. But I'll just short circuit that discussion to say that the people outside of North Korea who have the biggest stake in this and know the most about it are obviously not Americans, but South Koreans. And they very clearly would not want the U.S. to assassinate Kim. In other words, it's not particularly our problem.

So let's turn now to Ukraine. We hear all this yammering from the right about how the crisis in Ukraine is somehow a failure by the Obama administration. "We" failed to do whatever it was we should have done to stop Putin from acting aggressively in the Crimea, and "we" have to defend the territorial integrity of Ukraine, and "we" will be disgraced and look like wimps if Obama doesn't do whatever it is he's supposed to do about this, which is not specified.

The fact is, what happens to Ukraine matters to Ukrainians, and to their neighbors, but it really doesn't have anything to do with the United States. That the Crimea is part of Ukraine today is actually the result of a historic oddity. (Kruschev attached it administratively to Ukraine when the whole thing was part of the Soviet Union so it didn't really matter. The Crimea was always a part of Russia and its population today is majority Russian. People of other ethnicities were expelled during Soviet rule but that's water over the dam.) So for Crimea to revert to Russian control would not be an injustice, per se, although I expect most of its current ethnically Russian inhabitants are leery of the Putin regime and the neo-fascist philosophy he has cobbled out of the wreckage of Stalinism. But that's yet another story.

What is at stake here is the means by which intra- and international disputes are to be settled, and borders drawn. The potential for an unfortunate precedent -- well hardly a new one, but one we had hoped was inoperative -- is real. But the cost to Russia would be great. Instead of good relations with a unified Ukraine, they'd have a relentlessly hostile neighbor aligned with a newly enraged Europe, in return for biting off a slice of territory in which they already had a military presence. This would be an unfortunate development, bad for the world, but there is nothing in particular that "we" can do about it nor is it in any way the fault of some sin of omission on the part of the United States.

So, in sum, we have got to get over the mindless reaction of thinking that everything that goes on in the world is all about the United States, that we're responsible for fixing everything, and if we don't, it's a failure by somebody. We should do what we can to make the planet better, but sometimes that isn't very much. Have the wisdom to know the difference.

Treatment decision making

I study how people make decisions about medical treatments, and how they talk with their doctors about those decisions. That's what I do for a living.

So now I'm trying to observe myself, and see what I can learn from it. That's surprisingly difficult.

The story is that I have arthritis in my left hand. Specifically, I have a total loss of cartilage at the base of the thumb -- the joint between what's called the carpal bone, and the metacarpal. The carpal at the base of the thumb is called the trapezium. This was very painful; for much of a year, it ached constantly. I finally got a cortisone injection, which stopped the aching, but didn't stop it from hurting when I use it. The issue has really been forced since my friend talked me into buying a guitar, and getting back into playing it. I also can't really play the sax comfortably, because the left thumb operates the register key, and I realize that's why I pretty much put the sax down as well.

So, the choice is surgery. What they do is to completely remove the trapezium and fill the gap with a tendon harvested from the wrist. Supposedly I won't miss  the tendon. However, the procedure means I'll be in a cast for a month, then have to go in for physical therapy twice a week for several weeks, and it may take a full year to completely get back to full functioning. After that, supposedly, more than 90% of the time, you have great results and never have pain again.

So, that's a bit of a daunting prospect. The difficulty is that I don't really have much insight into how my own brain is processing this decision. I would hope to get at least 20 and preferably 30 years of having my left hand working perfectly, playing music, woodworking, farming, and all the things I want to do which will help make life worth living; to get there, I have to go through a few months of pain and inconvenience.

It seems like a no-brainer when you put it that way but it's actually hard. I have to screw up my courage to make the call to schedule the surgery. Of course there's an instinctive aversion to having my body cut open and pieces chopped out and rearranged. There's a fear of the small chance of something going wrong. And there's time discounting -- the pain is in the near future, the gain in the farther future. All this may be classified as "irrational" but I'm not sure that makes sense -- it's how our minds work.

Well, here goes . . .

Why are rich people stupid?

Kevin Drum notes that Walmart is suffering because it's customers don't have any money to spend. Less food stamps, loss of long-term unemployment insurance, shrinking value of the minimum wage, continued high unemployment due to austerity . . . Their sales and profits are down and so is their stock price.

Well now I wonder whose fault that is? Hmm. Could this have anything to do with it?

The Walmart Political Action Committee spent more than $2 million influencing federal elections in three of the last five federal election cycles, according to a report released Tuesday by Making Change at Walmart, a group of advocates, Walmart workers and others aimed at transforming the company. The report also said that members of the Walton family, the billionaire heirs to the Walmart fortune who own over half of Walmart common stock and hold three seats on the company's board, spent more than $1.3 million on federal elections last year, along with hundreds of thousands more at the state and local level. . . . .

In the case of both the Walmart PAC and the Walton family, much of their spending has gone to candidates supporting conservative causes, the report found.

Go figure. But make sure you don't use any of that fuzzy math with letters in it.

Having it too good?

Connecticut lacks any major league pro teams, unless you want to count the WNBA. So the state is divided between Boston and New York. But, we do have UConn basketball. Both the men's and women's team have been successful over the years, but the women much more so, making this one of the few places in the nation where a women's team is the top media interest and sells the most tickets. Indeed, it's because of the interest inspired by the UConn team that we have the WNBA franchise.

That said, maybe there's such a thing as being too dominant. Since the NCAA championship was inaugurated in 1982, Connecticut and Tennessee have each won 8 times. No other school has won more than twice. Tennessee maybe gets an edge in all-time dominance because they have also lost 5 championship games. Connecticut has never lost one, meaning they have no runner up ribbons. On the other hand, the main reason Tennessee has lost so much is because UConn has beaten them 4 times.

Tennessee last won in 2008, and their long run among the top teams may be over with the retirement of head coach Pat Summit due to early onset Alzheimer's disease. Since then, UConn has won 3 times, including last year. That team is mostly back only better. In spite of having only 8 scholarship players on the active roster, they absolutely crush everybody. They've had only one meaningfully competitive game this year, against Baylor, which they ended up winning by 11 points. More typical was last night's 92-41 demolition of Houston.

They haven't played Notre Dame this year, which is the only remaining plausible rival, but it seems there are two subdivisions of NCAA division one women's basketball: UConn and everybody else. It's hard to say whether this is good for fans or not. You always want your team to win, but it's those nailbiters and comebackers that mean the most. Rolling over everybody like a Sherman tank in a cabbage field is kind of fun. You never have to feel disappointment and you don't risk a heart attack. It may be good for the game in the short run, just as the domination of UCLA under John Wooden was good for the men's game, and the young Tiger Woods was good for golf. It creates interest among casual fans and non-fans. The phenomenon creates fascination.

But it's only good if it inspires more people to start playing the game and more universities to invest in their programs, so that competition finally emerges. The story right now is that there just aren't enough players at the level of Breanna Stewart and Stephanie Dolson and Moriah Jefferson to go around. Jefferson, the diminuitive 5' 7" point guard, is cat quick and whippet fast, and has astonishing inside moves along with a jump shot and 141 assists and 69 steals in 26 games. She is completely alone in her skills.

So, we'll see what happens. If it goes on like this for too many years, it will get boring. But it's fun for now.

This and that from the BMJ

Yes yes, America is the Greatest Nation on Earth, a Beacon to All the Nations, with better Pizza than Italy and better marijuana than Mexico. That said, we don't have the greatest medical journal, in my opinion. BMJ gets the honor because for them, medicine is just as much about society as it is about biology. A few tidbits from this week that caught my eye:

Switzerland, which has the second most costly health care in the world because it essentially has Obamacare, which is better than whatever it was we had before but not by much, is considering dismantling its screening mammography program. That's because their medical board can read and has gotten the 4-1-1 that it is very unclear that screening mammography does more good than harm. It certainly costs a boatload of money. And, of course, we get the fully predictable howls of outrage from the radiologists and oncologists. How are they going to pay for their Rolexes and giant wooden trumpets? My guess - not going to happen. But we shall see.

Australia now requires "plain" tobacco packaging, which means no branding and also isn't exactly plain because it does have to carry the quitline number. Result? A 78% increase in calls to the quitline. Don't know yet into how much quitting, or how much less starting, that leads to, but it can't be bad. Of course, the Supreme Court won't allow that here because Freedom. Like being addicted to tobacco is Freedom.

Children who live near a lot of fast food outlets are more likely to be obese. Now, this could be an error of causal inference. Presumably those are more socioeconomically underprivileged areas. Still, intriguing enough to be worth further study.

This meta-analysis finds that people who quit smoking end up being happier with less diagnosed psychiatric disorders. The authors attribute this to not continually going through incipient nicotine withdrawal but it could be simpler than that: you have more money in your pocket, you're less worried about lung cancer and heart attacks, you don't have to keep ducking out of the office into the rain and freezing cold, and you're free baby, you're in control, you beat this thing, you rock. Yay!

Home sick

No post yesterday because I was suffering from a Flu-Like Illness, as we say, and still forced to spend half the morning digging my car out of a snowbank.

If I had posted, you would have learned about my proposal for a revised version of speed golf in which the strokes aren't counted at all, it's only time that matters. (There is an untimed break between holes, other rules  I won't go into -- it works though.)

Also, the four different ways that science fiction does interstellar travel, e.g. the Star Trek method in which the ship just accelerates past the speed of light and you can see stars streaking by through the window; the "jump" version in which the ship gets from here to there nearly instantaneously in a special condition of reality; the "wormhole" version in which you need to use pre-existing flaws in space-time; and the actually possible version in which the journey between stars takes 1,000 years or more and you need to have either suspended animation; frozen zygotes, artificial wombs, and robot nannies; or multi-generational voyages.

Also too, proposals for humanitarian interventions to kill Kim Jong Un.

Fortunately, I refrained from spilling the ravings of the febrile brain. A real post later today.

The needle and the damage done

The Guardian has asked heroin addicts to describe their thoughts and experiences. These responses are often eloquent and always revealing. One says,

Heroin encases you in a little cotton-wool house and nothing hurts anymore. When times are hard, heroin encases you in a little cotton-wool house and nothing hurts anymore. If you haven't put in the work to become truly mindful, it's very easy to relapse. We know what heroin feels like, even twenty or thirty years after a hit. The memory of that wonderful warm feeling remains.

I have had vague thoughts that in years to come, growing old with heroin wouldn't be such a bad way to fade out of this life. But those thoughts are emanating from my 'addict brain' not my rational brain.

And this:

Hoffman's death has not resulted in feelings of sorrow, but thoughts and feelings of nostalgia. After been clean for 3 months. I am at a stage now where I'm starting to feel good again about myself and my life. But Hoffman's death has aroused a whole new fresh public discourse around heroin addiction, and I must say that its effect on me has not resulted in feelings of sorrow, or relief, but thoughts and feelings of nostalgia. The fact that nostalgic thoughts and feelings have been aroused from hearing about the tragic death of this great actor, just shows how utterly irrational the addicted mind is. It's not thoughts of relief that I have, such as "Wow that could have been me, I'm so lucky." But rather it is thoughts of reminiscence; thoughts of how euphoric he must have felt in those last few weeks of relapse, or even in his last few moments. The addicted mind is a selfish mind, no doubt, but also an utterly helpless one.

And many more like that. The point is, heroin addiction is not a moral failing or a lack of willpower. It is a permanent change in the brain, a physical fact about a person. First of all, of course, don't start. Second, don't put people in jail, that's utterly absurd. Third, provide treatment on demand -- and that includes methadone and buprenorpine maintenance therapy, because for most addicts, that's the only thing that works. Fourth, needle exchange and naloxone availability to keep people alive while they are using.

Oh well, dream on.

Cognitive bias

By now most people have heard about the Canadian breast cancer screening trial, just published in BMJ. Hate to say "I told you so," but I did: screening mammography of the general population of women is a bad idea. This ought to be the nail in the coffin, but it won't be.

So here's the 4-1-1. Back in the 1980s, Canadian researchers randomized almost 90,000 women either to get mammographic screening every year for 5 years; or not. Twenty five years later, there was no difference in the mortality rate from breast cancer between the two groups. None. Zip. Zero. In fact, more of the women who were 40-49 who had been screened died than those who had not, although the difference was not statistically significant. But, there were 106 more cancers diagnosed in the screening arm. Doing the math, 22% of diagnosed cancers represented "overdiagnosis," i.e. cancers that would never have become clinically significant, in other words those women underwent unnecessary and in fact very harmful surgery, plus chemotheraphy and/or radiation.

This is a randomized controlled trial with long-term follow up. It is the strongest possible study design. But it confirms what we have already been seeing from epidemiological studies. Now don't get me wrong -- this is a study of indiscriminate screening of the total population of women. The math might be different for women at higher risk but it also might not be. It turns out that with modern treatment, the difference between a lesion detected through screening and one detectable through physical examination might be too small to make a difference, in other words early detection isn't important after all. That's what the evidence seems to be saying.

By coincidence, in the New England Journal of Medicine, appearing the day before, Lisa Rosenbaum, M.D., discusses the meaning of breast cancer within the culture, and particularly among women. She starts off wondering why women seem to be so much more worried about breast cancer than they are about heart disease, while in fact heart disease is overwhelmingly a more common cause of death, and far more prevalent. (We are talking 400,000 deaths every year from heart disease, vs. about 40,000 for breast cancer, in other words 10 to 1.) Then she says this:

In 2009, the U.S. Preventive Services Task Force recommended decreased frequency of mammography for most women younger than 50 years old, noting that the potential harms outweighed the benefits. Although the recommendations were based on an unbiased review of decades' worth of data, a public outcry ensued. The recommendations were criticized as an assault on women's health, and a 2009 USA Today poll found that 84% of women 35 to 49 years of age planned to ignore them.

So intense was the outrage over these evidence-based recommendations that a provision was added to the Affordable Care Act specifying that insurers were to base coverage decisions on the previous screening guidelines. Rather than acknowledge this blatant dismissal of new guidelines, many political leaders, physicians, and advocacy organizations argued that we simply didn't have enough data to justify the new recommendations. But data have shown for years that early mammography screening doesn't save lives, just as data show that preventing heart disease, through certain lifestyle modifications and appropriate use of medications, does. So why do we resist these data?

Her answer is essentially that preoccupation with breast cancer is a symbol of female solidarity and a feminist cause -- it's a marker of tribal identity, in a sense. That's part of it, but it is also the case that the American Cancer Society represents the interests of surgeons, oncologists, radiologists, and pharmaceutical manufacturers -- that's who finances it. And they all make money off of screening and ensuing unnecessary treatment. So they scream and yell that this cannot possibly be true and they lobby congress, successfully.

They also routinely misinform women, as by for example making claims about five year survival being better for cancers detected through screening. As they well know, this is caused by what's called lead time bias and ascertainment bias. Lead time bias means that, if the cancer is going to kill you, of course it will take longer if it's detected earlier; but that doesn't mean you wouldn't have died at the same time anyway, it's just that the diagnosis came earlier -- subjecting you to earlier futile treatment. Ascertainment bias means, as we have already seen, that many of the "cancers" found through screening are harmless, so of course you survive. You would have anyway, and you would have been better off because you never would have been told that you had cancer and you would not have had surgery and been poisoned and irradiated.

It is also true that it's very difficult for most people to perceive that doing less, and even knowing less, can actually be better.  Of course we want to know! Of course early detection is better! But it isn't.

However, this information is not going to shut down the industry. It probably won't make much difference at all. But, I told you so.

Moral Idiocy

I've written a few times about the epidemic of opioid addiction and overdoses. There is an antidote, called naloxone (brand name Narcan) that can be injected or used as a nasal spray. EMTs normally carry it, but there's a movement to expand availability to other first responders, to friends and loved ones of opioid abusers, and to abusers themselves. You can read more about it here, and props to JAMA for making this article available to the rabble. (Most of JAMA is still subscription only, but I have to give a scrap of credit for this.)

Opioid overdose is now the most frequent cause of accidental death in the United States, ahead of motor vehicle crashes. We're talking more than 38,000 deaths a year. And it's particularly appalling that most of them are young people. Phillip Seymour Hoffman died alone, so presumably naloxone couldn't have helped him, but lots of opioid addicts use the drug with others, or live with family or friends who can intervene. A shot of naloxone costs just 8 bucks. Boston Mayor Marty Walsh wants to have all first responders -- police and firefighters, not just EMTs -- carry naloxone. And there's a bill in the Maine state legislature to do the same, which sounds like a good idea, because heroine overdose deaths in Maine quadrupled in one year.

Well, the depraved lunatic who Maine voters somehow elected to be their governor opposes the bill, because he thinks it would give addicts a feeling of "invulnerability." This is the same reason many people oppose needle exchange programs to prevent HIV -- and it's the law that federal funds can't be used for needle exchange, and many states continue to outlaw it.

What this means is that people -- conservatives, actually -- think that addiction is a moral failing so profound that addicts deserve to die. That's the entire logic of it. There is absolutely no evidence that making naloxone or clean needles available encourages drug abuse. On the contrary, people who engage with these services that can save their lives are more likely to enter treatment because there's an opportunity to talk with them and refer them. Also, too, you can't get treatment and you can't get clean if you're dead. But if you're a junkie, according to governor Paul LePage, that's what you deserve.

LePage is the scum of the earth. And an idiot.

Well duhhh . . .

Farm Bureau report says "enforcement only" immigration reform will lead to a sharp increase in food prices. Now, it is true that if farm labor offered better pay and working conditions, we'd need fewer undocumented immigrants to fill those jobs. And yes, food would cost more. The teabaggers may or may not understand this, but to the extent they do, they are likely to say that instead of us letting furrriners into the country, some of those shiftless moochers who are currently getting Medicaid and food stamps should take those jobs even under current conditions.

Of course, if they took those jobs, they'd still be eligible for Medicaid and food stamps. It's one thing to come up north for nine months out of the year, work 70 hours a week and send enough back to Michoacan to keep your kids alive, it's quite another to try to do that for your family in LA. The Farm Bureau wants to split this baby with a guest worker program that would at least make the people legal -- even though they wouldn't be allowed to stay in the U.S. long term -- and give them some legal protections. But that doesn't seem quite right either.

Here's what I think. Farm workers should be paid better, meaning that food should be more expensive, but we should raise the minimum wage and create a full employment economy -- by making investments that put people to work -- so that everybody could afford that more expensive food. No need to split any babies!  We just need for rich people to pay taxes. Oh wait, that's never going to happen.

 

Coriolis Effect?

I notice that the figure skaters exclusively spin counter-clockwise. No idea why that is.

I think they should get extra credit for being able to spin in both directions. Maybe the rules should even require that they do one or two clockwise tricks. It would be twice as interesting to watch.

Two easy ways to stay alive

1) Don't eat sugar. This is the tobacco "controversy" of our day. The linked study notes that refined sugar accounts for more than 10% of the energy intake of most U.S. adults. They're getting it in soda, baked goods, and even processed savory products such as sauces. (Ketchup is largely sugar.) If you get more than 10% of your calories from sugar, they find that your chance of dying from heart disease is 30% higher. If you get more than 25% of your calories from sugar, as many people do, your risk is 2.75 times as high. This is after controlling for body mass index. In other words, it's not the calories, it's the effect of eating sugar on your metabolism. (I've talked about this many times.)

Now, the "food" industry denies all this and resists all public policy initiatives to get people to eat less sugar. Soda and so-called "energy drinks" are poison. This is very easy. You want something sweet? Drink fruit juice. Eat fruit.

2) Don't talk on the phone while driving. I can't tell you how many times I've nearly been run off the road or run over while crossing the street by some moron with a phone stuck to the ear. I always give the finger to people who are talking on the phone while driving. It's just as dangerous as driving drunk, maybe more so. What the hell is wrong with people? Fifteen years ago, this was impossible, and we got along just fine. Who the fuck are they talking to? What are they talking about that can't wait ten minutes?

Don't be an irresponsible, dangerous, selfish idiot! Don't do it!

One very good reason Bill Nye should not have agreed to debat Ken Ham

This is exactly what we feared. CNN is promoting the debate and treating it as a legitimate discussion between two equally credible points of view. That's what Ham wants out of this -- to be granted equal status with science by the corporate media. And he got it. That's why we don't have public debates any more with holocaust deniers, HIV denialists, tobacco denialists, or global warming denialists.

There is nothing to debate. They are all either deluded or liars. The facts are not in question. But the purveyors of anti-scientific nonsense have a big advantage in these public debates precisely because they feel no responsibility to be honest, logically coherent, or parsimonious in their conclusions. Scientists feel compelled to assert their open-mindedness and say things like, "rabbit fossils in the Cambrian would change my mind," but to the average viewer, that just makes it seem like they are unsure of their beliefs. Which makes them less credible.

The science denier can just spew out a whole bunch of preposterous assertions, which the defender of science then tries to systematically rebut but he can't get through 1/10th of them, and meanwhile he doesn't get around to what he wants to say. Viewers don't have access to the large body of evidence or the technical means by which scientists evaluate it so argument by assertion works just fine. All you see is two people making contradictory claims, one of whom is ponderous and hard to understand, never manages to present a complete and coherent argument, and seems to lack the courage of his convictions; the other speaks in simple sentences, manages to marshal 5 times as many [apparent] facts, and to present a coherent whole argument. 

It's a fool's errand, Mr. Nye. I wish you wouldn't do it.

It's in the New York Times!

A few things today, actually, that stimulate me to comment.

The blogosphere is aflame over Nelson D. Schwartz making official (by saying it in the Times), what has been widely noted elsewhere, i.e. with all the money flowing uphill, businesses that serve people with moderate incomes are losing customers. It is a very obvious point that such as Krugman, DeLong and Duncan Black keep repeating -- if people don't have money, they can't buy stuff, and that means, if you are in business, you can't sell your crap. Ergo, we're stuck in a listless economy and ultimately, the Gilded Age is unsustainable. Capitalists figured that out in the 1930s, but the class of plutocrat we have today is evidently as stupid as it is psychopathic. Go figure.

The death of PS Hoffman has shocked people around the world, but we shouldn't be so shocked. I've said it here many times, we have a horrific epidemic of opioid addiction in this country and it typically follows the pattern we saw with Hoffman. People get hooked on prescription drugs but they're relatively hard to get (and expensive, though that probably didn't matter to Hoffman) whereas heroin is everywhere and cheap. So they go on to heroin. Unfortunately, the dose is not precisely measured as in prescription drugs, and sometimes people get a hot shot, which kills them. So why is heroin everywhere and cheap? Well, therein lies a tale. It's because after all the blood and billions of dollars we have spent on the military occupation of Afghanistan, the country is still completely lawless and the opium growing and heroin manufacturing industries are cranked up to the max. When the Taliban ruled the country, they outlawed it. And it worked. Just sayin'. (Go here for the latest on Afghanistan. My post yesterday was particularly interesting.)

And, right next to the other two stories on page A1, Gina Kolata discusses the Center for Medicare Innovation getting some criticism for funding demonstration projects, but not randomized trials to fulfill its mandate to study innovations in health services organization, financing and delivery. Well, this is pretty much inside baseball. I think their procedure has been reasonable -- analogous to doing Phase 1 and Phase 2 clinical trials before going to full scale RCTs. We need to learn a little bit about how to implement changes and get a sense of what works and how before we invest in controlled trials. Yes, people are impatient but that's life.

Now, go to the op-ed page and check out Krugman (of course), and Harlan Krumholz (who you probably haven't heard of before but who is a big name in my field.)

The Gray Lady comes in for her share of criticism, but she is an indispensable institution. We need her to stay financially healthy so that we still have an aggressive, investigative newspaper of record.

American Exceptionalism

The good people at New England Journal of Medicine have made available, free, to the Great Unwashed, an interactive graphic that lets you compare various categories of health care spending among the wealthy countries. I expect everyone to have fun checking it out but here are a few points that might surprise you.

Obviously, the U.S. spends far more per capita than any other country -- we already knew that.

But, what you might not have known:

Government spending per capita is higher in the U.S. than in any country but Norway.

Out of pocket spending per capita is higher in the U.S. than in any country but Switzerland. (Congrats Anna, you beat us there.)

Spending on inpatient care is higher in the U.S. by far --actually about double the #2 country, which in this case is Switzerland.

Private insurance spending in the U.S., at $2,877 per capita beats the number 2 country by more than 5 times. Can you guess who is #2 on this one? It's Canada, at $555.

The U.S. is #1 in public health services, but only by a tiny bit -- $272 per capita, compared with $261 in Canada. But our total spending on health care is $8,175. In other words, we spend 30 times as much money trying to fix sick people than we do preventing disease.

This is a ridiculous, inexcusable, disgraceful waste. Making people buy private insurance and pay out of pocket isn't even saving tax money -- we spend more taxpayer money on health care than just about everybody else anyway. If we had a single payer system that was as cost-efficient as Canada's, we could cover everybody with excellent health care for the same amount of tax money we're spending right now, and you wouldn't have to pay one dime out of pocket. 

Truth.
 

Only in New York

Guy goes to emergency department with a rash. He's sitting in the waiting room for 8 hours then a security guard finds him dead in his chair.

My sister lives in Manhattan. Once the subway came and she saw one car miraculously empty, so she got on. Turns out there was a dead guy at one end. He'd been going back and forth from Yonkers to the Battery, apparently, and nobody bothered to remove him.

But you know, New York is the greatest city in the world.

What I can't really figure out

Not sure whether you uncredentialed rabble are allowed to read this, but here's a thumbsucker by Abeezar Sarela, a British surgeon, in BMJ, which is the jumping off point for this post.

It used to be, before the Great Humanitarian Cultural Revolution of the '60s (which lasted from 1964 to 1972), that everybody took it for granted that you went to the doctor, he (and it was he) told you what to do, and you did it. "Doctor's orders." In the formulation of Talcott Parsons, that was an obligatory social exchange. If you were sick, you maybe got out of some responsibilities, but that was only morally acceptable if you took on the full responsibility of obeying the doctor.

Well then, lots of smart and humane people, including notably among many others my mentor Irving Zola, started to question that. There are tradeoffs that come with medical interventions -- risks and side effects -- and we ought to have a say in making them. Doctors may be are motivated by financial incentives that we have a right to question. They aren't just writing prescriptions, they're deciding if we can get time off from work, receive disability compensation, have sex. Once we started to audio record physician-patient interactions we discovered doctors giving people lectures about morality and responsibility. This is our body, our life we're talking about and we ought to be the ones in charge. Medicine was viewed by men as patriarchal; oppressive in terms of gender, race and class; imperialist in trying to colonize more and more domains of life and classify difference as disease. You get the idea.

So we saw the rise of patient-centered medicine. It's supposed to be about us, as whole people. Doctors need to understand our lives and our values, and respect our goals and preferences. Even that turned out to be too weak and now we have shared decision making and concordance -- the doctor is supposed to do what we want. And we've had forests laid to waste publishing studies showing that they don't.

Sarela gives us a wake-up call. The whole point of going to the doctor, the reason they make the big bucks, is because they're experts and we aren't. It's hard enough for them to figure out what treatment is likely to be most effective, let alone tell us to do it. And the fact is, patients don't want to decide, for the most part. They don't have the requisite knowledge and they don't trust themselves. When doctors try to push decision making off on patients, patients often feel abandoned.

So exactly how we can be empowered in our dealings with physicians is far from clear. If my auto mechanic tells me the reason my car won't start is because I need a coil, I'm not about to say no, please replace the fuel injectors. That would be idiotic.

Crime Pays

This happens all the time, though not necessarily on this scale: a for-profit hospital chain is sued by whistleblowers for conspiring to admit patients who did not need to be hospitalized, in order to bill Medicare and Medicaid. (The law allows whistleblowers to sue in cases of Medicare fraud. The Justice Department has joined several of these lawsuits against Health Management Associates.)

This is nothing new. As big, for profit corporations take over more and more of health care we're likely to see ever more of this. But here's the point of this here blog post. First:

[W]hen H.M.A. announced the Justice Department’s involvement in the lawsuits, investors and analysts shrugged, and the stocks for both companies involved in the merger barely budged. Sheryl R. Skolnick, who follows health care for CRT Capital, recently wrote in a note to investors, “Investors seem to think that D.O.J. investigations, qui tam suits and allegations of serious Medicare fraud are simply a cost of doing business.” Many settlements run only into the tens of millions of dollars. That’s a corporate slap on the wrist for companies whose stocks typically soar when executives push the profit envelope. Only if the penalty is at least $500 million, Ms. Skolnick said, are corporations likely to find the cost a deterrent.

Okay, that's nothing new either. Actually this story appears right next to the story about Jamie Dimon getting a $20 million raise. But what the Times story doesn't mention is that admitting people to the hospital is very bad for them. .

Elderly people who are hospitalized often suffer a decline in health. They become disoriented and delirious, lose physical fitness as they lie in bed, and eat poorly. There is a danger of hospital acquired infections. And of course you worry, you lose your freedom, and you may not have the opportunity to do essential chores at home, lose work time -- there's all sorts of danger and damage.

In other words, this is not just a financial crime, its kidnapping and assault and battery. Who knows, it might even have killed people. Oh -- the corporate president who drove the scheme, Gary D. Newsome, was paid $22 million before he quit and went to Uruguay to, err, lead a religious mission. Really. Any chance he will ever be separated from any of that $22 million, or do 20 years to life? What do you think.

Another open door crashed through

But still, worth noting. The Robert Wood Johnson Foundation has issued a report with the astonishing conclusion that medical care isn't the most important determinant of people's health.

We have always known this but it just has to be repeated and repeated and repeated until it finally penetrates the concrete skulls of the voters and policy makers.

Most people think about health and health care together, said Mark McClellan of the Brookings Institution, who co-chaired the Commission with Brookings colleague Alice Rivlin, in a webcast marking the report’s release.  But “when you start looking at the evidence, looking at what’s working on the ground to actually have a meaningful impact on the health of people,” you realize that “you can’t get there just by putting more resources into health care.”

Well duhhh. They recommend investment in early childhood education, community development and integration of social services ("for example, investments in housing or transportation could reduce health care costs, and a portion of those savings could then be invested back into health-promoting neighborhood development."), along with finding ways of integrating social and medical services.

Sounds great, but of course we're going in the opposite direction. I'd like to pick out transportation, just for the heck of it. Excellent mass transit gives people in poor communities access to jobs, educational opportunities, better and cheaper groceries and other goods, and cultural resources. It also reduces air pollution that causes ill health (as I have discussed here earlier), and it reduces greenhouse gas emissions. It encourages mixed use development around transit stops and builds stronger community ties. And building mass transit will give people jobs.

Oh wait. Rich people would have to pay taxes to pay for it. Okay, forget about it.

On religion

Martin Luther King Jr. was of course a Baptist preacher and a doctor of divinity. The organization he chaired, the Southern Christian Leadership Conference, was an association of preachers.

But is he remembered as a religious leader? Definitely not. He would use biblical quotations and references in his speeches, but only as a source of rhetoric, not to make any theological claims. The movements he led were secular. Their goals were cultural and political, their membership had no regard for religious affiliation, and they had no particular religious content. That the civil rights movement was based in the black churches of the south was a function of social reality: the churches were the principle organizational infrastructure that existed in the southern black community. They were the place to find leaders, buildings and affiliation.

I say movements, plural, because of the effort to scrub King's legacy clean of elements that make the powerful uncomfortable. He moved on from the civil rights movement to what he called the poor people's movement -- a broad demand for social justice without regard for race -- and of course the anti-war movement which went beyond opposition to the war in Vietnam to a fundamental criticism of U.S. imperialism.

The latter two movements have, so far, utterly failed. If anything we have regressed.

That said, as a youth I admired King and all he stood for, and I still do. His example made me think of religion largely in benign terms, though I abandoned it myself as soon as I was old enough to think independently. But I no longer see religion as a potential force for good. Any worthy cause is better off without it. Yes, some people are inspired by it but it's just as easy and as likely that they'll be inspired on behalf of evil ends as good ones. Religion is irrational and arbitrary. If you're going to advocate for any worthy end, the only honorable and constructive way to go about it is to make arguments based in reality.

King's causes are a prime example, of course. Christianity was the common source of moral justification for slavery, just as today politically active Christianity in the United States is a champion of plutocracy and militarism. Some Christians feel otherwise but there's no sense arguing about what Jesus really wanted because nobody really knows and the entire exercise consists of just making up whatever you want to believe.

I don't understand why religion persists. It belongs to the childhood of our species. It's long past time to abandon it.

Too much month at the end of the money

With Congress poised to cut benefits of many food stamp recipients by $90 a month, as a "compromise", it's worth noting what actually happens to the lazy moochers when their benefits don't last the month.

People with low incomes generally get most of their benefits near the beginning of the month, and run out of money before the end. People with diabetes who are taking medications to lower their blood sugar, but who don't eat, get hypoglycemia -- acute low blood sugar -- a medical emergency which can result in brain damage or death.

It turns out, according to the linked study, that hospital admissions of low-income people for hypoglycemia in California increase by 27% in the last week of the month. This doesn't happen to high income people, and it doesn't happen for conditions that aren't triggered by starvation. The authors don't translate this rate into raw numbers, so I can't tell you exactly how much this costs, but a back of the envelop calculation tells me the number is many hundreds per year, at least. The average cost of a hospital admission is about $10,000. You could feed a lot of people with that money.

The Big Buffoona

The MSNBC evening yackers are obssessed with Chris Christie and Bridgeghazi. I can see why. They figure he's gonna be nailed like a sheet of 1/2" CDX*, so they're strapping on the tool belts and picking up the hammers because they want to be in on the pounding. What fun!

I expect they're right. Christie's story is utterly preposterous, even though his fawning acolytes in the corporate media are still granting him credibility. There are at least five or six people who as far as I can tell have no reason not to flip like pancakes, first and foremost Bridgette Kelly. He kicked her into the storm drain, by his own account without a word to her, and publicly denounced her as an idiot and a liar. Now she's unemployed and unemployable, divorced from an impecunious husband, according to the NYT profile, and what the hell does she owe to Christie at this point?

Then there's David "Wildthing" Wildstein. Christie says he barely knew the guy, because back in high school Christie was a BMOC and Wildthing was a nobody nerd who a popular jock like Christie wouldn't let sit down at the same lunch table. If it strikes you that there's something unattractive about a man who would say that, you might also note that the guy he said it about isn't going to exactly be grateful. Wildthing ostentatiously stapled his lips together at the legislative hearing on the affair, but he let it be known that if he gets immunity, he'll sing like the Mormon Tabernacle Choir.

Christie is still full of bluster and braggadocio, and he doesn't seem to believe he's really going down. But I'll be very surprised if he doesn't.

*That's plywood used for sheathing houses. It gets an 8d nail every 8 inches on every stud. Studs are on 16" centers, so that works out to 64 nails for a 4' X 8' sheet. Plenty for everybody!

Our bodies, our selves

My cousin-in-law talked me into buying a guitar. I was learning to play a little bit several years ago (I play horns but I wanted to be able to play more than one note at a time, basically), then I loaned my strat to my brother and never saw it again. So what the heck, I need a new hobby. I bought a beautiful Gibson Les Paul guitar and a Fender mustang amp.

So I'm relearning what little I could do and hoping to go beyond. But, unlike the previous episode, I now have arthritis in my left hand and I'm not sure I'll really be able to achieve the level I hope for. Fortunately this is not a major issue for me, except maybe for blowing $1,200, since being a guitar God has not been among my ambitions. But it did make me think about professional musicians or dedicated amateurs who run into physical problems -- including a friend of mine who will probably read this, who had to give up his career as a trumpet player.

A physical disability that directly aborts your profession or avocation is obviously a huge challenge to identity. But in fact any chronic disease -- even one that is so far asymptomatic, and exists only as a label -- forces a person to remake the sense of self. It means taking on new obligations for self-care, perhaps abandoning some cherished goals, being forced to present yourself to others differently, maybe even planning for a shorter life.

Many people wonder why people don't take their pills, or keep their medical appointments, or make other changes they need to improve their health. This is called the problem of "non-adherence." Much of the time, it's pretty simple: if I take these pills every day, that will mean that I have this disease. I don't want to have it. Therefore I won't take the pills.

My arthritis is obvious to me, denial is impossible. But I don't like to tell people about it. I hesitated about fessing up here, in fact. Why? Because it means I'm telling people I'm getting older and the machinery isn't working as well as it used to. And I don't want people to think of me that way. I still want to be in my 20s. Well, I'm not. Now you know.

One more reason we need single payer

One of the major flaws in the Affordable Care Act is that, as with Medicare Part D and Medicare Advantage plans, it puts the burden on the consumer to wade through a lot of complicated choices and try to pick what's best for that individual. So, another open door crashed through: most people don't have a clue about key concepts of health insurance.

Since the link is to a subscription-only journal, I'll do my usual unpacking for you. The survey didn't actually test people's knowledge; it just asked if they were "confident" that they understood concepts such as co-payments, co-insurance, deductibles and premiums. Most people said they were not. But I'll bet it's even worse than that -- if you ask people whether they understand something, they'll say "yes" even if they don't. Because a) they don't want to seem ignorant and b) you don't know what you don't know.

And for people with limited education, cognitive impairments, mental illness, or just plain too much in their lives to deal with, having to take the initiative to do this and wade through complicated choices they don't understand is just not going to happen. The ACA did of course provide some money for "navigators," people in community organizations who can help. But Republican governors are doing everything they can to sabotage the navigator program, and even where it is available people have to be connected with a community organization to avail themselves.

BTW, are you confident that you know the difference between premiums, co-payments, co-insurance, and deductibles? Do you feel confident that based on knowing about these, you know how to pick the plan that's best for you?

If we had universal, comprehensive, single payer national health care, everybody would automatically have good insurance, already paid for through progressive taxes. It would cost less overall and deliver far more. Insurance company executives wouldn't be hoovering up the cash, it would be much easier to detect fraud, control overuse and control prices, and care would be much better coordinated. Anything else is a travesty.

Just a small personal observation

You've probably seen the news about the people who stole the FBI files showing J. Edgar Hoover's FBI smashing the constitution like a crystal goblet have finally come forward. This happened in 1971, at the Media, Pennsylvania FBI office. I arrived as a freshman at Swarthmore college in 1972. Media is just down the street, and as it happened I wound up living in Media.

Swarthmore had been a major hub of student activism and some people who became prominent in Students for a Democratic Society went there. We had more than our fair share of radical professors as well. Everybody assumed that the perps were associated with Swarthmore but it turns out the ringleader was a physics professor at Haverford College, our archrival in men's sports. (Haverford was male only at the time, with women attending Bryn Mawr college next door.) So my alma mater has lost that special distinction I thought it had.

Anyway, what those folks did was heroic and 100% praiseworthy. They evaded capture but they were prepared for it -- they even made arrangements for people to raise their children if need be. They exposed the FBI actively trying to disrupt and destroy anti-war and civil rights organizations, including an attempt to blackmail Martin Luther King Jr. into committing suicide. But Hoover's name is still on the FBI building. How about that?

Edward Snowden is just as much a hero. He deserves a presidential pardon or at least a plea bargain to 200 hours of community services talking to high school kids about the Fourth Amendment. But it won't happen.

Well, at least he apparently believes in evolution

"Republican" has apparently become synonymous with "idiotic." Here's Newt Gingrich claiming that global warming is not to worry, because the earth did just fine back in the age of the dinosaurs when it was much warmer than it is now.

I don't imagine I need to explain to any of my readers why this doesn't make perfect sense, since I presume I don't attract blithering idiots. But this malignant clown gets to go on all the Sunday morning yack shows and otherwise get all of his ignorant pronouncements transcribed by corporate media throughout the nation. It's truly baffling.

Philosophicalness

One important reason we often fail to understand each other is what we call a category error. Jurgen Habermas's formulation is congenial to me so let me restate it in fairly simple terms (something Habermas, alas, is incapable of doing.)

Most of what we say to each other, contrary to centuries long obsessions of linguistic philosophers, is not actually about representing reality. Words create reality. The umpire says you're out, you're out. Doesn't matter whether the ball hit the glove before the foot hit the bag. That's actually an entirely different question. But we also create reality with very mundane speech. I make a promise, I've created an obligation. I ask a question, I place a social obligation on you to answer, assuming my question was appropriately put. I give you an instruction, you may be obliged to follow it if I have social standing to give you orders; or you may choose not to thereby creating resentment in me. Whatever, you can play out all the examples in your mind.

What I actually say, the content of my utterance, is called the locutionary act. But depending on context, the same locutions can constitute many different illocuations, that is the social act embodied in the utterance. Then there's the perlocution -- what happens inside your head in response to what I say.

Okay then. There is a diverse category of illocutions called assertions or assertorial acts. Yes, they do purport to represent reality but they also create reality. You now may have a new belief -- either that what I have told you is true, or perhaps that I'm a liar or a fool. You may form a new intention. You may have an emotional response to the information. (E.g., your cat is dead.)

Habermas reminds us that there are three main kinds of "validity claims" contained in assertions, and we get into a lot of trouble by confusing them.

The First World -- the world "out there," intersubjective reality, facts that can be proved or disproved by evidence accessible to anyone in the right place and the right time with the right sensory apparatus. (Maybe aided by a telescope.) This world is subdivided into what we can directly apprehend, and the realm of inference perhaps requiring expert knowledge or rigorous deduction. This is the realm of The True, as Plato has it.

The Second World is the social world, including norms and values, status and social structure. These can be asserted in first world terms, e.g. "England was ruled by a hereditary monarch in 1600," but the assertion that England should be ruled by a monarch or that you have a duty to bow to the queen is a different kind of claim. You can't prove it by a randomized controlled experiment, or by observation. You might try to support it by an argument that IF England is ruled by a monarch THEN some desirable consequence will ensue, which is at least partly back in the First World although probably very hard to demonstrate. But we have to know exactly what kind of claim you are making in order to criticize it validly. This is the realm of The Good.

The Third World is what's inside us, what each of us feels and wants individually. The only validity claim here is sincerity. Do I really love you? You can perhaps make a Second World claim that people should not feel that way but that is different from saying that I don't feel what I say I feel. This is the realm of The Beautiful.

So what's really going on when I say that Jahi McMath is dead and her parents say she isn't? Are we talking about the same thing? If they truly believe that she will one day open her eyes and say "Hi Mom," then I suppose we are. But I don't think that's what's going on, not at all.

That river in Egypt runs deep

No doubt you have noticed the disturbing case of Jahi McMath, the fourteen year old girl who died from complications of routine surgery, whose parents do not agree that she is dead. Terry Schiavo's family has gotten involved in the case and is trying to "save" Jahi.

Jahi is dead because her brain has no function. There is no circulation to her brain, she is brain dead. However, she is on a respirator and her heart is beating. Here's what the Schiavo spokesperson says:

Jahi McMath has been labeled a 'deceased' person. Yet she retains all the functional attributes of a living person, despite her brain injury.This includes a beating heart, circulation and respiration, the ability to metabolize nutrition and more. Jahi is a living human being.

 Actually, her respiration is provided by a machine, and the whole dispute is that the hospital wants to turn off the machine. The family and the meddlesome Schiavos want to move her to a long term care facility in Long Island -- on the opposite side of the country -- but first they need a physician to perform a tracheotomy and insert a feeding tube. No physician will do so, because physicians don't operate on corpses. The family is trying to get a court order to force the hospital to comply with their wishes.

Now, Jahi doesn't just have a brain injury: she does not have a brain, other than the kind you might find pickled in a jar. In this respect, she is not like Terry Schiavo was at the time of her own controversy. Terry Schiavo was allowed to die, at her husband's request, but Jahi is already dead. It is technically possible to keep almost any corpse in a state of oxygenation, with circulating blood, for an indefinite but typically quite a long time. If we accept this definition of human life, we will ultimately have millions of corpses in warehouses, attached to machines, at a cost of a couple of hundred thousand dollars a year apiece.

So what is going on in these people's minds? Before the availability of current technology, for all of human history, we defined death as the absence of a heartbeat. The new definition is compelled by the changed reality -- that we can keep the hearts of dead people beating. This wasn't really widely discussed publicly or decided democratically. If it had been, we might have a stronger consensus.

But still, I find this ridiculous. Having a beating heart and artificially supplied respiration does not give someone "all the functional attributes of a living person." A living person has a mind. That is what is valuable about us. What is most puzzling is that the people who claim otherwise generally -- and I don't know about the McMath's but this is true of the Schiavos and their allies -- base their claim in religion. Obviously the Bible, and religious tradition more broadly, don't address this question. They can't, because it was inconceivable until the last few decades.

So what is the religious source of this bizarre claim? I have some thoughts, but I'll let you ponder.

Two points for the price of one

I wouldn't ordinarily link to Dana Milbank as a main source but he gives me a useful twofer.

First topic of discussion: according to a new Pew poll, almost half of Republicans say humans have existed in their present form from the beginning, i.e. evolution is a lie from the pit of hell, while only 43% accept evolution in some form, including that yeah, it happened but it was divinely guided. That's apparently down by 11% from the last time they asked four years ago. Since the total percentage of the population that believes in evolution -- 60% -- hasn't changed, this seems to mean that the people who are willing to self-identify as Republicans is increasingly restricted to religious fanatics.

Okay, that's not a surprise. But then Milbank says this:

This continues a long-term trend in which both parties are shrinking into smaller entities at opposite extremes. The gap on social issues between Democrats and Republicans (and independents who lean toward one party or the other) has nearly doubled over the past quarter-­century.

It's obligatory, of course. If you're a DC-based corporate media yammerer, you face a $50,000 fine and three years in the penitentiary if you fail to say that both sides are equally extremist and both sides do it. What's weird about this is that in the next few sentences, Milbank totally disproves the above paragraph. He does say that Democrats have become more secular, which I suppose he considers to be an "extreme" view. But then he says "The Republican Party is achieving the seemingly impossible feat of becoming even more theological. Democrats and independents haven’t moved much in their views, while Republicans took a sharp turn toward fundamentalism." Evidently the only position that is not "extreme" is non-fundamentalist religiosity. Or is he just compelled to utter the balance mantra even though he is fully conscious that it is nonsense?

I can't tell.