I'll retire to Bedlam . . .

As I have mentioned now and again, I am afflicted with a lengthy commute, during which I tend to OD on National Pubic Radio. (Did I commit a typo?) Lately it's been absolutely unendurable -- nothing but an endless stream of ridiculous bullshit about how ordinary imperfect operations of government are the worst thing since Hitler or something. Meanwhile, stuff is happening in the world that you know, actually matters, but we obviously don't need to know about it.

Sure, as Ezra Klein lays out very clearly, perhaps with a bit too much restraint, it's all about nothing, so he expects it just to go away. Unfortunately, it is completely irrelevant whether any of this crap is meaningful, has anything to do with president Obama, or is even wrong. If the Republicans keep talking about it, and the corporate media keeps channeling everything they say and Cokie and Mara keep yammering on about how the Obama presidency has now officially failed, well then -- that will be the reality.

There's nothing we can do about it.

Science and Evidence

This may not be the most entertaining post ever, but it's necessary in order to get on with our story. Clumsy exposition, if you will.

Many people make a distinction between science based medicine, and evidence based medicine. They're closely related, to be sure, but not quite the same.

Science depends on evidence, and respects evidence. But it does consist only of evidence. It includes deductions from evidence; hypotheses -- conjectures to be tested; and theories, which are explanations about the causal relationships among phenomena and the unobserved structures that underlie observations.

I'm sure most readers already know that the word "theory" is widely misunderstood, as being synonymous with "hypothesis." It is sometimes casually used in that way, by people who should know better, but I have been trying to discipline myself not to do that. Theories can be conjectural -- some of them also have the status of hypothesis -- but they aren't necessarily. Some of them are very well tested and as certainly true as anything can be, subject to refinement. Often a broader, more embracing theory will swallow up an old one, without exactly falsifying it. For example, Newtonian gravity still works well enough for many applications, but it does break down where conditions are extreme or we need extraordinary precision.

Anyway . . .

There are empirical remedies, that seem to work even though we don't know why. Often, alas, they don't work very well, or they don't work with everybody who seems to have the indication, or the balance of good and bad effects is not what we would like it to be. Psychiatric medications are, at best, in this category. People with disabling psychoses generally calm down and have reduced delusions and hallucinations if they take anti-psychotics, but nobody knows why. Randomized controlled trials provide evidence for effectiveness -- along with a lot of terrible side effects -- but there isn't any real scientific understanding of psychosis.

On the other hand, we now have a good understanding of how, say aspirin works. For millennia willow bark was an empirical remedy, then acetylsalycilic acid was isolated in the 19th Century, then we figured out -- or rather John Robert Vane did, in 1972 -- that it inhibits the synthesis of cell-signaling molecules called prostaglandins and thromboxanes. The former accounts for the anti-inflammatory and analgesic effects, the latter for the anticoagulation effect. (I think -- I'm not a real doctor.) Anyway, knowing that we can figure out a whole lot more about aspirin's good and bad effects, and try to find drugs that have more of the good ones and less of the bad ones. (We've made some serious mistakes along the way with that, but that's another story.)

Philosophically, this distinction is very important because the strength of new evidence depends not only on the inherent properties of an observation, such as the design of the experiment that produced it, but also on its prior plausibility. The famous p value is almost universally misunderstood. If we do an experiment and get a p value below .05 for a result which is a priori highly implausible, we cannot conclude that the chance the observation is true is 95%. It just isn't. It's likely just a fluke. On the other hand if we do a trial and get a p value of .2 or .3 for a highly plausible result, the hypothesis is very likely still true - in fact, we should be more confident that it is true than we were before, even though our observation is officially called "statistically insignificant." This misleads many people into thinking that the study undermined the hypothesis, when it did no such thing.

A very good example is the Oregon Medicaid experiment. In fact, enrolling in Medicaid almost certainly does ultimately have beneficial biological outcomes for people with diabetes and high blood pressure. Contrary to general interpretations, and in fact to its own authors' stated conclusions, the study did not provide evidence to the contrary.

I'll try to explain further as I go on to discuss evidence.

Science is Hard

Yes it is. Or it certainly can be. Back in Flexner's time and right through mid-Century, obviously, even though we didn't have any high quality randomized trials going on, doctors were doing stuff. Some of it was probably helpful much of the time. For example, they knew to amputate severely injured limbs, especially if there were signs of putrescence. If there's an accessible tumor, cutting it out can be helpful. It it isn't malignant, it's curative. Digitalis was used for heart disease since the 18th Century, and it is indeed helpful. There were other so-called empirical remedies back then as well, by which we mean remedies that appear to work but we don't know why.

Digitalis has survived as a useful treatment, but a lot of what doctors have done routinely for many years has not. In the 1946 National Formulary of the American Pharmaceutical Association, pills containing mercurous chloride were listed as treatment for "biliousness," a condition thought to be caused by insufficient flow of bile and characterized by constipation, headache, and general malaise. Mercury was thought to stimulate the liver; it did definitely counteract constipation, to put it mildly. Of course it is actually poisonous and long-term use of this compound was deleterious indeed.

So why did doctors believe in ineffective or even dangerous remedies? (It wasn't long before this time that they had given up bloodletting.) There are a few reasons.

The most basic is that most conditions that cause discomfort or suffering either get better on their own in a while, or fluctuate in severity. People are most likely to consult doctors when they have symptoms. Whatever nostrums or mumbo jumbo the doctor provides will then likely get credit for the patient shortly feeling better. This is how superstitions generally get started.

Furthermore, similar symptoms may have multiple causes. Even if half the people don't get better after consuming mercury, the treatment will end up getting credit for those who do. It might even really help some people, but harm twice as many. Nevertheless, thanks to confirmation bias, those who believe in it will continue to use it and be persuaded by their observations that it is sometimes effective. (Those it helps + those who get better regardless all redound to its credit; it is presumed unconnected to the harms it causes, because we have no such expectation.)

Another reason is that people just tend to like it when doctors do something, anything. The so-called placebo effect is greatly misunderstood and over-hyped, so I'll steer clear of the term for now. Let's just say that confirmation bias, and perhaps other psychological mechanisms,  mean that if people expect to feel better, they will say they feel better and perhaps, in some sense, will feel better. "Feeling better" is, after all , a purely subjective state. I could have exactly the same physical symptoms but be less troubled by them. And our experience of pain is very much affected by how much attention we pay to it. Whatever signals are coming from the peripheral nerves, we may have very different degrees of caring about them. A doctor's kindly ministrations and our presumption that we're going to feel better could be all it takes to make it so, for a while -- even if the cancer is still spreading.

All of the above, in addition to inflicting the practice of licensed, scientifically trained physicians, is of course the foundation of all forms of quackery.

In extreme cases, what we call anecdotal evidence can be quite valid. As a classic example, no-one says we need a randomized controlled trial of parachutes. Everybody knows what will happen, pretty much inevitably, if a person falls from a height of 2 miles. That people usually do it safely using a parachute is all we need to know. The curative power of insulin for people with Type 1 diabetes falls in this category, as does lemon juice for scurvy. Dr. Lind would not actually have needed his various active controls to prove the point. But these cases are rare.

Next time, a bit on the difference between the concepts of science-based medicine and evidence-based medicine.

The Fog of Science

As you may recall, in our last episode, Abraham Flexner has persuaded the world -- or at least the space between the North Atlantic and the North Pacific -- to put medicine on a scientific basis. But, it turns out that is very easy to say and very hard to do.

Back in 1910, people knew more about human biology than they did in 1850 or 500 BC, to be sure. But the usefulness of that knowledge for making or keeping people healthy -- whatever that means, and remember we still haven't figured that out -- was very limited. To take stock briefly of our relevant knowledge at the time, we knew something about pathogenic microbes and the importance of sterilizing surgical instruments and wounds. We didn't have any antibiotics, however. There were some empirical remedies, such as opioid analgesics, and, well, that's about it. We didn't know anything abut endocrinology, genetics, the immune system, neurology, oncology, you name it. You could be doing laboratory research and dissecting cadavers and peering at cells under a microscope but none of it was doing your patients any good.

It so happens that in 1747, a British ship's surgeon named James Lind decided, more or less at random, to feed various stuff to soldiers suffering from scurvy. Two of them got a quart of cider every day, two others got vinegar, two got "elixir of vitriol," which is sulfuric acid; two got sea water; and two got oranges and lemons. You know what happened. However, Lind did not want to recommend that the Royal Navy give sailors oranges and lemons because they were too expensive. It took 50 years before the navy got around to it.

Anyway, as impressive as that was, it wasn't until 1943, nearly 200 years later, that anybody got around to doing another randomized controlled trial. It was a pretty good one, even by modern standards: double blind, although not truly randomized. It was done in the UK, to test the effectiveness of penicillin for the common cold. And it was negative, i.e. it didn't work. Here's the even worse news: to this day, prescriptions for antibiotics continue to be written for people with common upper respiratory tract viral infections.

From then on we continued to see more and more clinical trials, of varying quality; and we came up with more and more categories of effective treatment for problems other than infections susceptible to antibiotics. However, the intrusion of knowledge and evidence into medical practice was gradual and almost as often counterproductive as it was beneficial. There are many reasons for this which continue to vex all of us who work in medicine and related fields, and which incite volcanoes of debate and recrimination. I'll tackle the issues in upcoming posts.

Wingnuttery kills

Among the sexually transmitted infections, Human Papilloma Virus (HPV, to its friends) is among the least glamorous. Everyone knows syphilis and gonorrhea, but for some reason HPV doesn't share their celebrity. It should, because some strains of it cause a very common and highly unpleasant problem, genital warts -- or warts wherever people's parts happen to interact, and you can use your imagination. Other strains cause cancer -- cervical, genital, anal, oral and pharyngeal. In fact, HPV is basically the cause of cervical cancer.

So it doesn't take a sodomite to see that a vaccine which is highly effective in preventing transmission of HPV would be a good thing for humanity. Or so one might think. Texas Governor Rick Perry found out the hard way that this isn't so by doing the right thing for what may well be the one and only time in his term in office, and mandating that adolescent girls get the vaccine. All the lovers of Jesus  in Texas immediately raised a massive outcry because they knew that the only reason their daughters weren't having sex with the entire football team was fear of genital warts. Michelle Bachmann figured she had a knockout punch in a Republican primary debate in 2011 when she raised the issue, and said after the debate "There’s a woman who came up crying to me tonight after the debate. She said her daughter was given that vaccine. She told me her daughter suffered mental retardation as a result. There are very dangerous consequences." Sarah Palin weighed in with some cheer leading.

Hoo boy. It turns out that in Australia, the people are not insane. They've been vaccinating girls since 2007, and guess what? The diagnosis of genital warts in women and girls under 21 went down from 11.5% to .85%. It's too soon to say what will happen to cancer, but presumably in a decade or two we'll see that going way down as well. We have not, however, heard of an epidemic of sexual promiscuity in the land of the  wallaby and the billabong.

So let's be clear. Religion is bad for your brain, and your body, at least if you make it a guide to any sort of decision.  We've eradicated smallpox and we've almost done with the guinea worm and polio -- but religion has turned out to be the main obstacle to finishing the job with polio, in this case Islamic leaders claiming the polio vaccine is a Christian plot to sterilize muslims. HPV is potentially eradicable as well. But first we have to eradicate the ravings of idiots.

Okay, back at it . . .

Pardon the interruption. The radical discontinuity in 1910 was the famous Flexner report. Abraham Flexner, who worked for the Carnegie Foundation for the Advancement of Teaching, was commissioned to study medical education in the U.S. and Canada. Back then there were 155 medical schools in the former British possessions, all of which he visited. (He is often said to have studied medical education in North America, but, err, Mexico. I digress.)

It turned out that most of them were not affiliated with universities, but were owned by one or a few physicians. They had what Flexner considered insufficient curricula and clinical training. States generally did not regulate the practice of medicine or have licensing requirements for physicians. Most important, in Flexner's view, medical training and practice was not uniformly based on science. His ideals were the few university-affiliated medical schools of the time, and particularly Johns Hopkins. Flexner's recommendations led to the current model of medical education based at universities, followed by clinical apprenticeship and university-affiliated hospitals,  taught by clinicians who were also research scientists, based on claims for effectiveness based on scientific knowledge and reasoning. Less directly, his work led to the imposition of standards for medical licensing and practice. These were imposed by the states piecemeal, and I have not come across a comprehensive history, but by now we take it for granted that every state does this.

Following this revolution, the number of medical schools in the U.S. at first shrank dramatically, and as it rebounded, all of the new ones adhered to the new standards and philosophy. For better or for worse, medical school faculty came to be evaluated based on their research activities, rather than their teaching. Various heterodox "schools" of medicine, such as homeopathy and chiropractic, lost their claim to legitimacy within the new structure of scientific medicine, because their claims are biologically implausible and not supported by rigorous experiments. (Although, inexplicably, at this late date, they seem to be worming their way back in. But that's for another day.)

Medicine's claims of scientific authority were certainly vindicated by many important developments throughout the 20th Century, notably effective antibiotics, insulin for Type 1 diabetes, incremental advances in surgery and trauma care that ultimately added up to huge benefits, effective immunization against more and more pathogens. As recently as 20 years ago, when I first got into this racket, there was a legitimate argument about whether the contribution of scientific medicine to health and longevity at the population level was very important, or even provably positive; but that is no longer true.

But, history has not ended. Medical practice, and the physician and patient roles and their relationships, remain deeply problematic.

To be continued.

Bloggers are human too

I'm afraid I can't say anything intelligent today because I'm feeling like the lowest piece of crap in the Delta quadrant of the galaxy. At least this gives me a chance to comment on the whole disease ontology thing. I can't claim to be enjoying the highest attainable state of social and psychological well-being right now, and I'm sure a psychiatrist would find something to diagnose me with, but no, i don't have a disease. I suffer from the human condition.

I don't think a robot could console me right now, and I'm not one who benefits from comfort food or shopping sprees. I'll just have to carry on. So shall you.

Yo, Robot!

We interrupt this long-form essay to report on my afternoon at our Second Annual Symposium on Human-Robot Interaction. Really. I was there because I study human-human interaction and I've been roped in -- well alright, I didn't really mind, it's kind of interesting -- to letting computer scientists play with my concepts, and they might be useful for getting machines to communicate with us more usefully.

I won't go into that in a lot of depth here, but what I do want to talk about is where the nerds think this whole thing is headed. You may or may not like it. One of the potential applications for interacting robots is to be companions and caregivers for elderly people. This actually gets talked about a lot. The social problem is that more and more people are living to be old and frail and widowed and socially isolated. It's too expensive to give them homemakers and home health aids plus they're lonely. So maybe we can give them a robot.

I don't know about you but I find that fairly icky. Of course, if you could make such a robot, it could also be a house servant for able-bodied families, a janitor, a waiter -- lots of jobs. Even, yes, a nanny, and they were talking about robots being essentially Head Start teachers as well. Is this good?

Where I come in technically is that basically, Siri works, kinda, because all you do is ask her -- excuse me it -- questions and maybe give some basic instructions in a limited domain, such as calling a number. But your robot companion has to accurately interpret much more complex domains of speech, what we call the full range of illocutionary acts -- such as all the various kinds of questions, promises, and expressions of feeling, even jokes; figure out your intentions, desires, and state of mind; and respond appropriately. Note that I didn't say the robot has to understand anything -- that's different. In fact, what we've learned from decades of failure at artificial intelligence is that we have much more success getting computers to respond appropriately to language inputs if we forget about understanding and just automate the responses based on statistical correlations of language content with illocutions.

Fortunately, we are so far from this that I'm not worried about it happening any time soon. I think. But if we do give robots more and more autonomy and behavioral flexibility, then we have to start worrying about robot ethics. Also, does tossing people a robot as a substitute for human companionship or nurture mean we are meeting a social need, or consigning people to a kind of hell?

health and medicine, continued

(In case you haven't picked up on it yet, I have embarked upon a long-form essay. It will continue.)

So what is “medical” attention? It is well known but seldom seen as remarkable that most societies known to history and anthropology, even small scale ones with limited hierarchy and division of labor, have cultural roles for specialists in healing people. In societies large enough to support full-time specialists, as far as I know there is always a full-time healing profession. In some times and places these people have also been more generalist priests, with additional assigned powers, and priests can always try to get you some divine intercession, but usually there is a secular healer role as well, or more than one. There are some systems in which shamans can heal or sicken, curse your enemies, make it rain, make your object of desire fall for you, or whatever. There’s certainly variety. But in Europe and its metastasis to North America, since classical antiquity, physicians and priests have been distinct, as they are now generally around the globe.

One reason I find this remarkable is that for most of history, almost everywhere in the world, these people couldn’t actually do much, if any, good, in most cases. They may have had some useful skills – to set broken bones, maybe to cut out or saw off rotting parts, perhaps out of their formulary of dozens or hundreds of concoctions a few were truly beneficial. But as we now know, most of what they did was at best useless, but often harmful, they best-known example being bloodletting. But it’s perhaps less widely recognized that, lacking any concept of pathogenesis, surgeons and obstetricians were probably the world’s leading source of infection, and thereby managed to kill innumerable patients and birthing women.

The scientific revolution that upended cosmology and physics starting in the 16th Century (Copernicus died in 1543, Newton in 1727) didn’t really get going in biology until the 19th Century, and even then it did not at first have a great deal to offer to medicine. Darwin obviously caused quite the brouhaha, but his theory was not immediately relevant to medical practice. Ignaz Semmelweis figured out the importance of hygienic practices, such as physicians washing their hands and instruments between patients, around 1850. But he didn’t have any scientific explanation for his observations, and he was generally scorned. Once Pasteur figured out about a decade later that microbes can cause disease, we were getting somewhere; surgery and childbirth became more hygienic by the end of the century, and Pasteur’s work also led to the development of vaccines in addition to the long-available cowpox inoculation against small pox. (That was based on empirical observation, with no explanatory theory.)

So, by the beginning of the 20th Century, medicine was doing less harm than before, but still couldn’t do much good. Effective treatments for the vast majority of human ills still did not exist. Just about anybody could open a medical school and confer a medical degree, and just about anybody did. Most of these schools were owned by one or two doctors, existed to make a profit, didn’t teach much science, if any, and had low requirements for entrance and degrees. There were many competing systems of thought about the nature and causes of ill health, almost all of them completely bunk, some of them unfortunately still with us, such as homeopathy.

Then a radical discontinuity occurred in 1910.





Next: The Flexner Report and the Dreams of Reason

What is health? (continued)

A synonym for the medical enterprise in the English speaking world is “healthcare,” which you will note has now become one word. (It was still two words when I was a child, and for a while I corrected my students’ papers if they made it one.) So medicine – the social institution led, at least until recently, by people possessing the credential Doctor of Medicine – is purportedly dedicated to caring for our health.

When people visit physicians, they usually do so voluntarily. Presumably, they do this because they want the physician to make them healthier, or keep them healthy. What exactly does that mean? What are they seeking?

This question appears simple. We use the word health all the time. Most people don’t reflect on its meaning any more than they reflect on the meaning of “breakfast” or “basketball.” They answer the question at the top of this post with little thought. It’s obvious, right? Health is . . . .

Actually that’s a very tough question. The preamble to the constitution of the World Health Organization, written in 1946, used this definition: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Not only that, but “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” The second quote is chiseled into the façade of the main building of the Harvard School of Public Health. That is definitely uplifting.

It is also completely nonsensical. Start with the idea of “complete . . . well-being.” Do we really want to say that we’re unhealthy if there is anything we wish for that we do not have? And even if we can come up with a more realistic definition of complete well-being, is there any point in proclaiming that every human being has a right to the highest attainable standard of whatever it is? If we do endorse such a right, it’s not just “one of the fundamental rights,” it’s the only one, because there wouldn’t be anything left over.

We must begin by accepting the human condition. We are all of us born with an incurable, inevitably progressive disease which, beginning in our third decade, gradually degrades our physical and mental capacities and is ultimately fatal. We are, in other words, mortal, and we grow old. What is more, our initial endowments differ. If a congenital condition deprives us of complete well-being, have we suffered a violation of our fundamental human rights? Or is there perhaps a more constructive way to look at that situation?

It doesn’t take much thought to see, further, that my well-being may conflict with yours, and that determinants of my own well-being may conflict with each other. I have the privilege of living in a beautiful place in the country, and having a very desirable job in the city. But this privilege is conferred by the internal combustion engine, which spews ultrafine particles into the atmosphere that contributes to heart and lung disease; causes crashes that kill 36,000 Americans every year and seriously injure many more; and is changing the global climate threatening mass extinctions and unimaginable human misery.

I could go on about this, even write a whole book about it. But our present purposes do not demand it. People don’t go to physicians to claim their fundamental human right to the highest attainable standard of health. They go because they have a particular complaint that they think may be amenable to medical intervention, which is sufficiently disturbing to make the trouble and possible expense worth the trouble and downsides of medical attention.

More on this anon.

A simple question

In general, would you say your health is excellent, very good, good, fair or poor?

Believe it or not, how you answer that question is a good predictor of how long you will live -- whether you are a young person, or an older person with cancer. It doesn't much matter exactly how it's worded -- you can ask, "How would you rate your overall health during the past week?" or "How do you regard your health?" or anything similar. It doesn't really matter what response categories you offer either -- the excellent to poor scale I used, or a 100 point visual analogue scale, or a seven point scale. And it doesn't really matter if you ask people to compare themselves to others their own age, or just ask the question in a very general way.

The power of this question is a bit of a mystery. People are presumably using different comparators -- e.g. how they felt before they were diagnosed with Annamannapunna, or people they know, or their parents at the same age, or some imaginary ideal. Who knows?

And health obviously means different things to different people. It's actually impossible to define compellingly. "The absence of disease" seems basically circular, since the only way to define disease is as a state of less than optimal health. "Well being" might be a synonym but then what does that mean? People usually think of health as having biological, psychological and social components -- some people want to sneak in spiritual but I think that's just a psychological state. But which of those is most important? If you're happy even though you have MS are you healthy? What if you're the world decathlon champion but you're sad?

None of this seems to make any difference. The question is better correlated with the highly specific and reliable end point of longevity from time now than most physical indicators. Why do you think that is? And what does it mean to you?

Sad, Mad, or Bad?*

Until the last century, and really to any large extent not until somewhere around the middle of it, people were lucky if their physicians did them more good than harm. But then medicine achieved great triumphs and claimed immense cultural authority and prestige. This happened when biological science enabled physicians to identify specific disease processes and offer targeted, effective treatment.

The huge win was antibiotics, which became widely available and effective around the time of World War II. People can argue about whether streptococci or mycobateria are really the ultimate cause of disease, or if it isn't the strength of our immune systems or our conditions of hygiene, but there is no doubt that if you give people the right antibiotics -- at least until lately -- the symptoms caused by infection with these organisms will disappear and the people will be all better.

The magic we can work with heart disease, the various diseases in the broad category of cancer, autoimmune diseases, and others, is less wondrous. Still, doctors understand fairly well what is going on with these afflictions and often they can do a lot to extend life, relieve disability and suffering, and even in some cases cure them. Sure, there's diagnostic uncertainty and controversy about the clinical or lab findings that merit a disease label and call for treatment, but these are largely pragmatic arguments over costs and benefits, the interpretation of statistics, or the reliability of observations, rather than deeply philosophical quandaries.

In most fields of medicine, however, we encounter entities called syndromes -- collections of symptoms which are often seen together, for which the cause is not understood, but for which people have proposed names. Some current notable examples are fibromyalgia, which is usually treated by rheumatologists, and metabolic syndrome, which may end up in the purview of an endrocrinologist. People often argue over whether these are "real diseases," or perhaps coincidental co-occurrences, or two or more unrelated processes that look similar, or perhaps separate processes with common risk factors. Further investigation often resolves these questions. For example, we now know that tertiary syphilis is not the same thing as schizophrenia, and it has passed from the purview of psychiatrists to infectious disease specialists.

In psychiatry, alas, the problem of classifying and naming diseases is ubiquitous. Suffering occurs in the brain and according to the scientific world view is the subjective manifestation of physical processes. However, psychiatrists generally have no idea of what these processes really are, and to the extent that they're starting to get an inkling, they can't point to or specifically treat any known abnormalities of the brain or its functioning. All they can do is propose clusters of complaints or behavioral observations and give them names.

In The Book of Woe, my friend Gary Greenberg tells the tale of the latest revision. I won't attempt to summarize the twists and turns -- it's a good read, goes down easy, and says most of what needs to be said, so give it a look. I will just make a couple of framing observations.

Psychiatrists not only have the difficulty of deciding whether the thing exists, they also have to decide whether it should be called a disease. Obviously we're all unhappy sometimes, but when exactly do we need our heads shrunk? It might be easy enough to say, whenever somebody shows up asking for help, they should get it, but there are many problems with this. One is that insurance companies won't pay for treatment if you don't have a disease. But labeling somebody with a psychiatric disease has all sorts of social implications. If you're homosexual, you don't want to be labeled with a disease because you don't think there's anything wrong with you. If you believe you have Asperger's syndrome, you want a label because you want to get special education services and you'd rather be known as having a disease than be called a dork. If you commit a crime, claiming that a disease made you do it might be seen as exculpatory. Alternatively, it could let the authorities lock you up indefinitely, as a risk. In fact, people may get psychiatric disease labels who aren't even suffering subjectively -- they're just making other people suffer. All this is a lot to wrestle with, and I'll demur for now, but Gary does it all.

Another problem is that if you don't have real diseases and the expertise to treat them, you aren't a real doctor. Having the power to name your pain and the purported unique scientific expertise to select the One True Treatment is essential to the prestige of the medical profession. Psychiatrists desperately want to be members of the club.

Alas, as Gary probably doesn't need to tell you, people become unhappy, or anxious, or lonely, or obnoxious to others because their unique selves, as forged by inheritance processed through their youthful environments confront shit that happens. A wise counselor might be able to help, but putting you into a box first and sticking a label on it is unlikely to help.

*I'm sure somebody has used that title before, but it's obvious and I made it up anew.

The sound of thundering hoofs in the distance

That's the implementation of the Affordable Care Act next year. The Commonwealth Fund's annual survey of health insurance coverage has just come out, and it's obviously not like former versions because it must talk about the future as well as the recent past (2012). The Affordable Care Act -- Obamacare, if you will, although it might be more accurate to call it CongressCare since the prez was notably passive during the whole sausage factory episode -- has already reduced the proportion of young adults 19 to 25 who were uninsured at some point during the year from 48% to 41%. That's 1.6 million people who have insurance who wouldn't otherwise.

Otherwise, we've been stuck in neutral, with almost half of all adults under age 65 either uninsured at some point, or underinsured, i.e. their out of pocket costs were so high that they couldn't afford them. Which, no surprise, means they are likely not to be buying needed medications:

Note that if you don't take the pills referenced in the chart, such as for hypertension or diabetes, you are likely to get sicker, and incur even higher medical costs. This is rationing. This is death panels.

Next year, the number of uninsured people will fall. Yes, it's likely that the cost of insurance will go up for more affluent people who aren't eligible for subsidies, because all of these sick people will now be in the pool. I say, tough shit. You can afford it, and it's your society too.

There are bound to be all sorts of problems, as there are with any major policy initiative. Normally, once we try it and find out what needs fixing, Congress fixes it. Unfortunately, we have a Republican majority in the House and an obstructive minority in the Senate that wants this to fail. So maybe it will.

Dog my cats and Rowrbrazzle

So apparently U.S. intelligence believes the Assad regime in Syria has used the organophosphate nerve gas sarin in its battle with insurgents and now everybody agrees that SOMETHING MUST BE DONE, notably president John McCain. Oy.

Having cut my blogging teeth explaining the bogosity of the whole Weapons of Mass Destruction™ thing in the months prior to the U.S. illegal war of aggression against Iraq, I must now apparently go back to the beginning and do it all over again.

Chemical weapons are battlefield weapons. They are no more massively destructive than guns or bombs. Does it really matter to you if you are blown up or poisoned? I don't care personally. By the way sarin evaporates rapidly and any place where it is used is safe within a few hours. That is not necessarily true of explosive ordinance. BTW, our friend the marathon bomber has been charged with using a weapon of mass destruction™, specifically a homemade bomb. This language is essentially meaningless.

Our problem is that the propaganda used to justify the War on Terra has now trapped us. We had to invade Iraq because Saddam Hussein might possess such weapons -- even though we have always known that Syria does. (Israel, by the way, possesses nuclear weapons, but we haven't invaded them yet.) If Assad has crossed this arbitrary line, some sort of military response by the United States -- why the U.S. and not, say, Uruguay or Lichtenstein? -- is obligatory. This is all so obviously silly.

The Syrian civil war is very ugly and it's causing a whole lot of death and misery. It would be highly desirable for it to stop. But you know, it's complicated. The insurgency consists of many different groups with varying ideologies and objectives, some of which I or president McCain might like and some of which we don't like -- not necessarily entirely the same set between us. The consequences of whacking the Assad regime in some way are completely unpredictable with respect to who ends up running what parts of Syria and how. Regardless of whether the Syrian army continues to use sarin gas, it will certainly continue to fire rockets and missiles, drop bombs, and shoot guns at people, thereby killing and injuring them. And various factions will shoot at the Syrian army. Many people, including many non-combatants, will be injured, killed and displaced. Gas or no gas. Doesn't matter one whit.

Dzhokhar Tsarnaev

There, now that I've gotten the search traffic . . .

Am I the only sane person in the universe? It turns out that of the three categories I originally proposed, the Boston Marathon bombing was most like option A, the perpetrators were acting on instructions beamed directly into their brains from Alpha Centauri. While it is apparently true that they are/were Muslims and in their own minds thought that what they were doing has something to do with some form of radical Islamism, it did not in any coherent or meaningful way. They could just as easily have attached their folie a deux to Rosicrucianism or the Reptiloids for all the sense it makes. They were unconnected to any movement, conspirators or ideology outside of whatever the hell was going on inside their heads.

So why is this particular bizarre evildoing supposed to change the U.S. relationship with Russia, derail immigration reform, break out the waterboards, repeal the Fourth and Fifth Amendments, or put a surveillance camera on every corner? Because we are plainly incapable of rational thought.

It is indeed extremely disconcerting that two room temperature IQ nobodies, spending a couple of hundred dollars, can create such havoc. Every deranged doofus with a TV set now knows exactly how to replicate the feat. Channel 4 in Boston sent a reporter to the New Hampshire fireworks store where Tamerlan got the explosives. The helpful clerk explained exactly what products he bought and displayed them for the cameras. You get the pressure cooker at Walmart and the battery at Hobby Lobby. A quick Googling and you've got the complete instructions. Now you can go to the throng outside the ballpark, the free outdoor concert, or the Amtrak station and be the most famous person on earth for 4 1/2 days. That's just wonderful.

So what should we do about it? First, get a grip. This has been true, more or less, since the invention of gunpowder. Right now, mass murders, defined as 4 or more people killed in one incident in addition to the perpetrator, happen about twice a month in the U.S. It's certainly unusual for so many people to be injured at once, but here's a list of rampage killings in the Americas since 1900 which includes plenty with injuries in the two dozen range. 

Second, as far as I can see, since we're committed to continuing to allow the essentially unregulated sale of firearms and explosives, the only meaningful public policy responses have to do with making life better for people. What do I mean by that? People -- mostly young men -- get alienated and angry because they don't have opportunities for meaningful and remunerative employment, because they fail in school, because they have social difficulties and nobody offers any help. I don't know whether anybody could have detected the BoomBoom Brothers or Adam Lanza ahead of time, but but in both cases one can imagine that a better educational, social and mental health safety net could conceivably have prevented disaster.

Trashing our constitution and our liberal traditions, however, would not.