Science for Sale

This has gotten a bit of coverage in the corporate media, but they don't do a particularly good job of explaining, so I'll take a shot. Abstract only for the common folk, I'm afraid, but Dr. Vedula and colleagues, taking advantage of discovery in lawsuits against Pfizer and Parke Davis got documents pertaining to studies they had sponsored on the drug gabapentin (brand name Neurontin). They have been naughty indeed.

As regular readers know, once a drug has FDA approval there is nothing to stop doctors prescribing it for purposes other than the ones for which it is approved. However, drug companies are prohibited from marketing drugs for "off label" purposes. However again, there's nothing to stop them from doing studies of the drug for off-label purposes and getting those studies published, without bothering to go through the more rigorous requirements of actually getting approval for said purposes. However yet again, there are plenty of ways to get studies published in order to create an impression that a drug is useful for some purpose whereas you haven't actually proven any such thing. But you can make money if you make doctors think your drug is useful for all these off-label indications and prescribe it, even though you're just bamboozling them. But who cares about the health and well being of patients when you can make money off of them, right?

So here's the basic technical concept behind cheating. If you do an experiment in which half the people get the drug and half get the placebo, there will be differences between the two groups just because of random chance. So-called statistical significance is a calculation, based on the size of the two groups and the size of an observed difference, of the probability that the difference is due to chance -- a number called p. If it's less than 5%, by convention, we accept that there's a real difference. Yes, that's arbitrary, and there are better ways to assess whether a drug is really useful, but that's the basic starting point.

This only works, however, if you specify exactly what effect you are looking for ahead of time. If you just go ahead after the fact and make a bunch of comparisons between the two groups, chances are something will be different, but the p value for that difference will be bogus. You were just fishing, you happened to find something that is probably purely coincidental, but you can always lie and say that's what you were looking for all along.

Well, that's what Pfizer and Parke Davis did. Actually they did even worse than that. Gabapentin is approved to prevent seizures, but that's not a big market, so the drug companies wanted to be able to sell it for more common problems, specifically migraines, bipolar disorder, neuropathic pain (pain from nerve damage), and nociceptive pain, i.e. what in the vernacular you might call "real" pain, from damaged tissue. So they did a bunch of studies. However, if the study did not find the drug was effective for the primary, pre-specified endpoint, they tried to find a difference in the positive direction for some other end-point. If they succeeded, they lied and said that was what they were looking for all along, and published the study. If they couldn't come up with something, they just didn't publish the study at all.

That way, they hoped to bamboozle doctors into prescribing the drug to people for whom it probably wouldn't work. They have had to pay fines because they were caught doing off-label marketing in this case, but those fines are just a cost of doing business. As Dr. Vedula et al tell us, this stuff undoubtedly goes on all the time but we're just lucky enough to have caught them at it in this one case. Since they aren't trying to get FDA approval, they don't have to register their trials in advance, make any raw data available, or make unpublished studies public. So they can cheat all they want. And they do.

Scum of the earth.

Treasure your endosymbionts

I don't mean to cause any identity crises, but you aren't an organism, you're a whole biome of ecosystems. (You can get the abstract only of the original article here.)

Costello et al have mapped the 100 trillion or so microorganisms inhabiting the bodies of each of several volunteers. There are distinct communities in various places, from navel to knee to gut. And you are distinctive -- the composition of these communities varies from person to person as well, although each individual's various ecosystems tend to be fairly stable.

I hope you aren't paranoid about germs -- these little guys are your friends. They keep the bad guys from taking over. Take it from me, because I've had two separate bouts with opportunistic infections that resulted when antibiotics wiped out some of my own little buddies. Once I got candidiasis -- a thrush infection -- in my throat after I took a course of antibiotics for an ear infection. The other time was much worse, a bout with the horrific C. difficile (y es muy difícil, take it from me) when I was hospitalized after surgery and the powerful antibiotics they were continually pumping into my veins wiped out the symbiotic colony in what was left of my colon.

So this is one more example of why more is less in medicine. Sometimes antibiotics really do save lives or prevent serious consequences such as amputations or rheumatic fever. But taking them when you don't need them is double plus ungood. Avoid them if you possibly can (but not if you can't!). I once again commend to your attention my friends and colleagues at the Alliance for the Prudent Use of Antibiotics. By reserving antibiotic use for when it's really, really needed, you will not only be taking care of your endosymbionts and therefore your own good health, you'll be helping to preserve the usefulness of antibiotics for all of humanity.

Oh yeah, don't eat factory farmed meat either. Antibiotic abuse in factory farming is just one of many good reasons.

Dear Joe Lieberman: Educate Yourself

I could write a book about why competition among private insurers is bad for consumers, gives you less choice, worse health care, and costs you more money, but let me start with one simple example that everybody can grasp, which I think is very powerful.

My previous insurer, which happened to be Blue Cross/Blue Shield of Massachusetts, charges $250 for a colonoscopy in its standard plan. That's a pretty standard copay for what is classified as outpatient surgery. It is more than enough money, obviously, to discourage a lot of people from getting one. Every foregone colonoscopy saves them quite a bit of money, since the provider is probably charging them close to a grand. It means they can offer a lower premium compared to a hypothetical competitor that charged a more affordable co-pay, or none at all.

Now, Republicans like to argue that co-pays like that are good, because they make us think twice about getting health care services and will therefore combat overutilization and keep overall costs down.

Sadly, no. It is difficult to imagine that anyone would go out of his or her way to get a colonoscopy that wasn't medically indicated just because it was cheap. We would only consider undergoing such an onerous experience because our doctor told us it was in our own best interest. The $250 can only make us refuse.

Some readers may dispute this, but it is generally accepted by the people who study these matters that screening colonoscopy, starting at age 50 and then at intervals depending on what is found the first time, is highly cost-effective from a social standpoint. It can actually prevent cancer from occurring in the first place, because the doctor removes pre-cancerous lesions during the procedure. That puts it way ahead of a mammogram. And it can detect cancers at an early stage when they are highly curable, whereas colon cancer detected after it becomes symptomatic is very bad news indeed.

So why doesn't the insurance company want me to have a colonoscopy? Because they figure, by the time I get cancer, I won't be their problem any more. I'll probably be on Medicare, actually, but even if I'm not there is a very good chance I will have changed jobs and be on a different private plan. (As indeed turned out to be the case.)

So what is cost effective from the point of view of society as a whole is that there be no cost barrier to getting a colonoscopy; when it's indicated, people should do it, because the cost is well worth it and indeed, it might even save money in the long run. But that is not cost effective from the point of view of the insurance company, which doesn't want to pay for my colonoscopy on the pretty good bet that ultimately, they won't have to pay for my cancer.

Guess what makes that problem go away? Universal, comprehensive, single payer national health care.

lecture notes

I'm trying to put together a talk for next Monday evening in Connecticut about a subject that would actually be simple but is complicated only because there are some seriously false assumptions deeply embedded in our political culture. The outline is something like this:

1. All the stuff you already know about how we spend more on health care than anybody else, but have the worst health and life expectancy of any developed country (and worse than some fairly poor ones), the least satisfaction, highest out of pocket costs, most trouble getting an appointment, and alone among wealthy countries, leave 15% of the population with no coverage at all.

2. The discussion of this problem is seriously warped because people believe in the fictitious economic theory they are taught in college. None of the assumptions underlying the theory of the Glorious Free Market are true, there is no such thing as a Free Market and never will be, but in health care it's even more obvious.

2.1 BTW, health care is a mixed good -- it has (or at least can have) positive externalities that are at least as valuable as the benefits to the recipient. We spend too much, yet at the same time, we manage to underproduce.

3. Paradox is explained in large part by provider-induced demand combined with pernicious effects of the insurance market . . .

4. Competition among insurance companies is bad. It does not produce efficiency or choice or consumer sovereignty, but rather medical underwriting (charging more or not offering insurance at all to people of high risk, no coverage for "pre-existing" conditions, and rescission); annual and life-time caps on benefits; limited benefits (e.g. no dental and no mental); and high co-pays and deductibles intended to discourage utilization.

5. Even the bogus economic theory does not predict just outcomes, but health, and the need for health care, are obviously determined unjustly. Nevertheless, we all grow older and will need more as time goes on. That's one purpose of insurance -- to spread risk and cost and help fix the injustice of the universe.

6. That requires getting everybody into the same pool. Yes, young healthy people will have to pay more than they may be paying now, but they all hope to be older and less healthy some day. It also requires that everybody be required to participate (or those young healthy folks won't), and that low income people get subsidies. But this cannot happen without government intervention.

7. Controlling costs and achieving high quality, however, requires more than universal coverage and community rating -- it requires a radical reorganization of the health care institution and how we pay for health care. That's not in the bill, and it means big trouble down the road if we don't start working on it now.

8. There is no conflict here between justice and liberty, because if I exercise my liberty not to participate today, and only choose to participate when it suits me (presumably because I'm now older and/or sicker), it will cost everybody else money and reduce their liberty. We are only free when we have a modicum of justice.

Now, I have to open up all those points and prove them and knit them together. And I have to be entertaining in the process. We'll see what happens.

Drive-by blogging

Another busy day (I had a meeting all morning that went an hour over time, three papers to write, two students needing recommendations, another student needing a paper critiqued, two proposals to write -- you get the idea). Anyway, a couple of links to commend to your attention.

Sense about Science is one of those most excellent UK projects that the U.S. is just too good for. They do their best to make scientific issues of public interest and of relevance to public controversies accessible. For example, here's their backgrounder on population screening for cancer and other diseases. If you want a reasonably in-depth but also accessible primer on some of the issues I often discuss here, this is a great resource.

Then of course there is the U.S. health care system, "The Greatest In All The World," sayeth the GOP, and if you don't agree you must look French and wear treasonous Birckenstocks.

Why then, when the Commonwealth Fund (Commonwealth, eh? Sounds socialistic to me) surveys primary care physicians in 11 countries, the U.S. comes in last on:

* Electronic health information capacity (yep, we're the lowest tech around);
* After-hours access to care without going to the ER;
* Percentage of patients who have difficulty paying for medications;
* Amount of time doctors spend trying to get access to treatment because patients aren't covered for it.

The U.S. also ranks low, though not last, on performance incentives, use of patient-centered chronic care models, and other innovations to make medical care more efficient, effective, and better at meeting people's needs and preventing serious consequences of chronic disease. It's the same old story -- we're still spending the most, and getting the least. We're losers. We're the pits. And we seem to be proud of it.

Okay, people have been asking

Why don't you write more about your own research? So say the masses. Well, partly it's because of the weird rules about discussing stuff that hasn't been published yet. So, while this may not be the greatest thing since The Revolutions of the Heavenly Bodies, it has been published, and best of all, it's open access. (It's kind of hard to explain, but being listed last is a funny privilege I don't quite deserve in this case. The main thing you should know is that Doug and Tim started the project and I came in to deal with the Spanish language material and participate in the interpretation and writing.)

Most of the work I'm doing now is more wonky and quantitative than this, but I also do keep up with the qualitative work. The major takeaway from these focus groups, for me, is that there is a big difference in the way physicians and patients experience their shared interactions. Physicians, health care researchers, and the NIH that funds these studies mostly view communication as instrumental. They're worried about whether patients understand the facts, concepts, guidance and instructions they get from their doctors, and whether doctors are getting an accurate understanding of the history and symptoms patients relate to them. And indeed, studies have found that immediately after a medical visit, people do not remember or cannot accurately report half of what the doctor said to them.

But as patients, most people don't know what they don't know. (Donald Rumsfeld had a point there, although what he didn't know was everything, and he didn't know that.) If they hear doctors saying "Magamamagama anamanapuna" they'll just nod and say okay. They will tend to fill in the blanks of their understanding. They are much more likely to be annoyed by the way they are treated -- that they don't feel respected, listened to, cared about. They may well perceive that the doctor didn't bother to give them some important piece of information at all, or would not accept what they were saying. This may be true, or it may be that the doctor did say something that they just didn't absorb, or heard them but placed a different interpretation on the information that she or he did not clearly and respectfully negotiate with the patient. But as patients, people just don't disentangle instrumental aspects of communication from the total experience of health care.

People just aren't going to say, "I don't think I understood that," or "I hear you but I don't believe you," or "I'm not going to do what you advise for reasons that I'm not going to tell you because I don't think you want to hear them." They'll nod and say okay and then go home and get on with their lives, however they are going to do it. These interactions are much more likely to be successful instrumentally -- as effective exchange of information and motivation of health promoting behavior -- if they are successful as interpersonal relationships. For that to happen, we need to find ways of narrowing the gap of experience and culture between physicians and patients, and achieving a more symmetrical relationship that nevertheless honors professional boundaries and the differential expertise between the parties.

So that's what a lot of my work is about. I'll try to incorporate more of it here.

BTW: Unusual for me to miss yesterday. I often generate my Wednesday post by riffing on something in JAMA, but the entire issue was about %$^&* flu. Feh.

Why we really, really need to stop talking about the #&*!@ flu.

I have written quite a lot about how inappropriate and misleading is the massive media obsession with the "novel" (not really) H1N1 influenza strain that's going around. It's misleading because influenza, even if we are having a somewhat worse flu season than average, is just not a very important cause of morbidity and mortality in the United States; but it's even more misleading and damaging to the political discourse because it drives out discussion of what is really important in public health, which is inequality, poverty, and political power. Flu is largely apolitical, and the more we talk about it, the less we talk about issues that really matter.

Regarding morbidity and mortality, the vast majority of people who get the flu get over it in a few days and then they are perfectly fine. The National Center for Vital and Health Statistics attributes around 36,000 deaths each year to influenza, which is way down the list of causes; and that will be true even if the absolutely worst case predictions come true this year (which at this point it is clear they will not) and we have 3 times the usual number. And most of those attributions are questionable anyway. What's more this will be over in a few months, whereas our other problems are still with us.

Approximately 6,650 Americans die every day. More than 1,700 of those deaths are attributed to heart disease, the number one cause, with cancer not far behind. About 122,000 Americans die of unintentional injuries every year. But in fact the actual, underlying causes of these deaths are largely social determinants subject to political responses: tobacco marketing, poverty, environmental contaminants, social stress, inadequate mass transit, you name it.

For example, there is the epidemic of obesity, which is associated with all sorts of major chronic illness and disability including diabetes, heart disease, cancer, blindness, loss of limbs, and kidney failure. And yes, it's affecting children more and more. And it's a political issue. The average child in the United States sees 15 television food ads every day, that is 5,500 per year. Food companies also market their products in schools and on the Internet, and they place products in TV shows, movies, video games and music. More than 98% of TV food ads seen by children are for high-calorie, low nutrition foods -- full of fat and sugar. There is consistent, direct evidence that TV food advertising causes kids to eat the advertised foods. Our agricultural policy, that subsidizes corn and its sugar that find its way into most of that junk food, either directly or by fattening up chickens and cattle, makes toxic junk food cheap compared to fruits and vegetables. This is not a failure of personal responsibility or even a cultural failing. It is a political issue. It is a public health crisis caused by corporate greed.

In fact, social inequality is by far the leading cause of premature death and disability. If death rates were equalized between Black and white Americans, there would be almost 84,000 fewer deaths in the United States each year. That's far more than influenza will ever cause. And yes, these premature, preventable, politically and socially determined deaths include more deaths of children than influenza will ever cause -- children are far more likely to be murdered than they are to die of the novel H1N1 influenza.

And of course, taking a global perspective, it's even less important. While we have been obsessing about influenza, pneumonia unrelated to flu has been killing a little kid every fifteen seconds. The new issue of Health Affairs gives us lots of information about the real burden of infectious disease in the world -- and no, it doesn't even mention influenza. There's HIV (sorry, abstract only to non-subscribers) which today infects more than 30 million people, with 4.1 million new infections every year, and only 1.3 million more people getting treatment -- in other words, we're falling farther and farther behind. And there are innumerable infectious diseases you probably never heard of -- 50 million people get dengue fever every year, 12 million are currently living with Leishmaniasis, 128 million people have lymphatic filariasis, 807 million have ascariasis, 37 million people are infected with onchocerciasis and nearly a million are totally blind or visually impaired as a result. I could go on and on but you get the idea.

And these diseases are not limited to poor countries. They are right here in the U.S. The prevalence of HIV in the District of Columbia -- yes, the capital city of the United States, in the shadow of our greatest symbols of national power -- is more than 3% among adults -- comparable to Nigeria and Angola. And the prevalence in black men is more than 6%. Poor people -- Black and Latino and rural white -- in the United States, are infected with some of those diseases you never heard of. As many as 4 million people, mostly African Americans in the south, are infected with ascariasis, which causes stunted growth and cognitive impairment. Toxocariasis may infect as many as 2.8 million Americans, again mostly African Americans. Latinos are subject to Cysticercosis, Chagas disease, and Dengue fever.

So why do we hear about nothing but the flu? Because it can affect rich white people, that's why. Because it has nothing to do with justice, or inequality, or politics. Because it's a convenient diversion to stop anybody from talking or thinking or doing anything about issues that really matter.

Time for it to stop.

Update: Just for the heck of it:

[I]t can't be denied that in most cases, the infection has run an astonishingly mild course. And the question of whether the WHO overreacted will only become more pressing. Some experts expressed criticism early on, saying that before declaring phase six, the WHO quickly modified its own definition of a pandemic. The organization simply disregarded the criterion that stipulates a very high mortality rate must first be present, and changed passages accordingly in the pandemic definition on its Web site. If the virus turns out not to be nearly as new as first believed, that begs a further question -- what, then, actually makes swine flu a true pandemic?

Some virologists already had doubts when the WHO first announced the existence of a new flu in late April. Top health officials were indeed talking about a "new subtype" of the influenza virus, one feature required by the US Centers for Disease Control and Prevention to meet its definition of a pandemic. But "new subtype," it turns out, was an inaccurate description -- the pathogen behind swine flu is in truth only a new strain of an old subtype. And as influenza expert Hans-Dieter Klenk at Marburg University's Virology Institute explains, "such strains are more closely related to each other than subtypes are." . . .

No one knows how swine flu's course will run. But in the end, British molecular biologist Derek Gatherer may prove to have been right all along. Gatherer declared his suspicions back in the beginning of July, that humankind is facing only a "pseudo-pandemic," one that "may be insufficiently virulent ultimately to enter the annals of major pandemics."

Chicken Little, anyone?

The proper goals of health care reform . . .

I'm too busy for a decent post today, so I'm just going to blow some smoke.

It is now fairly clear that any health care reform legislation Mr. Obama signs this year will be, to use a technical term from political science, crappy. It won't get us anything that we need. But, just maybe it will provide raw material out of which something better can be made next year. Meanwhile, here's some of what's wrong with health care in the U.S., none of which we are even talking about fixing.

It costs far too much. We don't get what we pay for. Every dollar we waste on health care -- and the waste is something like 6% of GDP -- is a dollar we don't spend on making people's lives better and securing our future.

We overtreat and often do more harm than good. When people are systematically given information and decision aids so that they fully understand the potential harms from common procedures such as prostatectomy, joint replacement surgery, coronary artery bypass grafts, etc., the proportion of people wanting such surgery declines dramatically. But right now, doctors get paid for doing stuff, so stuff they do.

Half of the drugs on the market are either basically useless and dangerous, or no better than much less expensive alternatives. Drug research and utilization are driven by commerce and marketing, not by what makes people healthier and feel better.

The system is fragmented. People have to negotiate multiple specialists who don't know them, are thinking only about the organ or disease they specialize in and aren't interested in people's lives, and they get multiple and conflicting prescriptions, advice and treatments, much of which is counterproductive.

We aren't investing in public health and improving the social and physical environment. We spend hundreds of billions every year trying to fix problems we could have prevented for five cents on the dollar, and usually we can't really fix them.

People are dying horrible deaths in sterile cells hooked up to machines while their friends and family are tortured with false hopes and pointless choices.

Primary care -- the key to an effective and humane medical institution -- is underfunded and despised. Primary care doctors don't have enough time for their patients, don't have awareness and can't manage the overall care of their patients with complex medical problems, they are overworked and underpaid, and they don't get respect within the profession. That means that as patients we don't have a medical home and we don't have a personal connection with the system that can make it work for us.

Yes, we need to cover everybody, but not at the expense of making them pay money they don't have. Universal coverage is only a progressive step if it is linked to progressive financing and reorientation of medicine away from profit and sickness care to taking care of people and actually doing health care. Without that, it's just one more way of stealing from the poor and giving to the rich. And yes Sen. Lieberman, I'm talking to you, you schmuck.

Yes, I have been reticent

Perhaps people have expected me to say more about the goings on in Congress lately. I have largely abstained because I don't have time to read 1,200 page draft bills, which means I have to depend on what other people say about them, which is inevitably tendentious, and you can read those folks as well as I can.

Also, my own position could not be more clear. Whatever comes out of this legislative session is barely going to begin to solve our problems, at best. While it's a worthy objective to get more people covered by health insurance, and the general idea of enforcing community rating and everybody into the pool is part of what a decent system will have to include, by itself it's not enough to be good or bad. It all depends on other pieces, which for the most part are not there.

We need a radical reorganization of the way in which health care is delivered, and radical changes in financing are required to make that happen. Nobody is even willing to touch that right now, because the power of vested interests -- drug and device manufacturers, medical specialists, insurance companies, big institutional providers -- especially the for-profit hospitals and nursing homes but non-profit academic medical centers as well -- are not going to allow it. They own enough politicians and they are ruthless enough to promulgate sufficiently outrageous lies that we can't even have the discussion we need to be having.

I'm off to Connecticut now, so I'll just leave it at that and say more about it later. But the bottom line is, we have to stop health care from eating the economy. We need to take commerce and greed out of it, and create a new, cost-effective, just and humane, and oh yeah, much cheaper and humbler way of doing this.

And oh yeah. We need universal, comprehensive, single payer national health care. Nothing less.

The thing speaks for itself . . .

Picked this up from Balloon Juice, it must be shouted far and wide:

Evan Bayh, the junior senator from Indiana, is in the middle of a heated debate in the Senate on whether a public option should be included as part of President Obama's health care reforms. An organizer of a group of so-called Senate Blue Dog Democrats, to date, Bayh's been a staunch opponent of any changes to the status quo in this debate. He's worried aloud that any public option would be a nod to socialism and counter to his principles as a fiscal conservative. . . .

His wife, Susan Bayh, sits on the board of WellPoint(WLP Quote) in her hometown of Indianapolis. Over the last six years, Susan Bayh has received at least $2 million in compensation from WellPoint alone for serving on its board.

Now that's fiscally conservative.

There are pills that make you large . . .

but the pills the FDA approves don't do anything at all. Schwartz and Woloshin have a kvetch, that a lot of information the FDA has about the drugs it approves don't make it onto the "label" -- actually a many-page document which is supposed to discuss the risks, benefits, indications and counterindications. The drug companies write these labels themselves, and the FDA just approves them. So, no big surprise, they tend to overstate the benefits and underplay the downside.

However, I take a further lesson from the cases they discuss, which is that some of these drugs never should have been approved in the first place, because they don't actually work. And not surprisingly, these drugs that don't actually work are often among the most heavily marketed and the biggest sellers.

Take Lunesta. If you own a television, you have been exposed to countless visions of formerly sleepless, cranky people passing instantly into sweet oblivion and awaking as though dipped in the fountain of youth. But as it turns out:

Lunesta sales reached almost $800 million last year. Clinicians who are interested in the drug's efficacy cannot find efficacy information in the label: it states only that Lunesta is superior to placebo . . . The FDA's medical review provides efficacy data, albeit not until page 306 of the 403-page document. In the longest, largest phase 3 trial, patients in the Lunesta group reported falling asleep an average of 15 minutes faster and sleeping an average of 37 minutes longer than those in the placebo group. However, on average, Lunesta patients still met criteria for insomnia and reported no clinically meaningful improvement in next-day alertness or functioning.

Oh. So what are we spending the $800 million for?

Well, it's not the FDA's job to decide whether a drug is actually worth anything. It just has to be superior to placebo, not necessarily in any clinically significant way. And while risk of serious adverse effects could make a drug non-approvable in principle, there aren't any clear criteria for deciding when risks outweigh benefits to the extent that a drug should not be approved. Indeed, risks often emerge after approval but seldom lead to withdrawal.

But it has to be somebody's job to make the judgment that it just doesn't make sense to prescribe this drug. That's the agency we don't have here in the U.S. - and no, it's not in any of the Senate bills.

About the massive killer flu pandemic

From the CDC weekly report.



When I made this small enough to fit on the blog it got hard to read. (Click it for a larger view.) Each wave is one year -- the little spike above normal was in 2008. This year, nothing unusual is happening.

Res ipsa loquitur.

This must stop

It's been a while since I've ranted about the pandemic of antipsychotic poisoning in children, but Christoph Correll and colleagues have just reloaded my cartridge belt. Previous studies of the adverse effects of antipsychotic "medications" in children have been flawed because most of the kids had previous exposure to these toxins and were already damaged. That made the new damage seem less.

Correll et al find that when kids are first given these poisonous substances -- aripiprazole, olanzapine, quetiapine, or risperidone -- they very quickly gain weight. A lot of weight, up to 20 pounds in less than three months in the case of olanzapine; and they develop lipid and metabolic abnormalities putting them at risk for diabetes and heart disease. Less than a third of the kids who were prescribed these "drugs," by the way, were diagnosed with schizophrenia; almost half had "mood spectrum" disorders, and a fifth had behaviors that adults didn't like.

The truth is that children are normally emotionally labile and it is not established in any way that there is any such thing as "bipolar" disorder in children; nor that the appropriate response to children whose mood swings or behavior is problematic for adults is to drug them. Most children with emotional and behavioral problems have been victims of some sort of trauma and that's what needs to be addressed, by getting them into a safe environment and providing them with trauma focused counseling which has been proven to work.

But more and more, we're just drugging them. In an accompanying editorial, Varley and McLellan note that in 2003-4, 1% of all pediatric outpatient visits resulted in the prescribing of an antipsychotic. This is a crime on a massive scale. The drug companies got these substances approved for use in adults, but most prescribing in children is still off-label. Nevertheless insidious marketing, much of it the work of physicians who take big payoffs from the companies, such as the distinctly odious Joseph Biederman of the World's Greatest University has produced this epidemic of poisoning.

What's motivating . . .

about listening to a war criminal talk about picking up dog poop? Only in America could a guy who ought to be in a prison cell in the Netherlands end up telling lame stories for 19 bucks a head. What a country!

However, George W. Bush is not the most loathsome politician in the United States. That distinction, without question, goes to His Holiness Joe Lieberman, of the Joe Lieberman Party, representing Aetna Insurance in the United States Senate. On behalf of his sole constituent, Holy Joe promises to join Republicans in a filibuster to prevent the majority of Senators from carrying out the wishes of the large majority of voters, because democracy is bad for Aetna.

Holy Joe says "We're trying to do too much at once. To put this government-created insurance company on top of everything else is just asking for trouble for the taxpayers, for the premium payers and for the national debt. I don’t think we need it now," and "even with an opt-out because it still creates a whole new government entitlement program for which taxpayers will be on the line."

I'm trying to remember the last time Holy Joe moved his lips without lying, but I'm not coming up with anything. All of the above is, of course, a lie. The government sponsored plan in the legislation is financed entirely by premiums, not taxes. It is not an entitlement, it's an insurance plan that people can buy. It does not add to the national debt, it reduces it, because it will be cheaper than what Aetna has to offer, and therefore will require less in the way of subsidies from the treasury for low-income people to buy it.

But Holy Joe knows he can lie all he wants to, however outrageously he wants to, and the corporate media will just reproduce what he says without bothering to point out that it is not true. As in the provided link.

It is, of course, his deep piety and love of G_d that gives him the moral authority to spew lies in the service of his corporate masters against justice and freedom. He's such a good and holy man.

Business News

A commenter asks who does own these Blue Cross/Blue Shield insurance companies? Originally, they were all non-profit, but a movement began in the '90s to convert them to for-profit corporations. As Jamie Robinson recounts here, being not-for-profit did not necessarily mean that they operated principally in the public interest. Cozy relationships with hospitals and specialists, limited or no competition, and indulgent regulation all meant that they weren't necessarily working for you.

However, for-profit insurers have investors who inevitably are going to come first, so it's not even an issue. The largest insurer in the U.S., WellPoint, owns the Blue Cross/Blue Shield brand in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Virginia, Wisconsin, George, New York and California. It is a public corporation. You can buy stock -- it's going for about $45 a share right now, and the share price is prominently displayed at the top of their web site, next to a tab leading to investor info. Some other states' plans are private corporations, but I don't have easy access to a list of which are private for-profit and which remain non-profit.

There were a lot of issues in these conversions about what should happen to the "social assets" embodied in the not-for-profit corporation. In California the conversion was accompanied by a big contribution -- about $6 billion IIRC -- to a foundation called the California Endowment which basically funds projects aimed at health equity. That sounds good, but $6 billion doesn't go far at all in California; as is obvious right now, the good offices of the California Endowment are a fart in a whirlwind compared to the unmet health care needs of Californians.

The main issue, as far as I'm concerned, is that this created a powerful vested interest, with very deep pockets to spend on lobbying and lying to the public in advertisements, which is standing in the way of reform in a way that non-profit corporations would have been much less motivated to do. That was the biggest mistake.

I got nothin',

basically, so go check out TPM's report on BC/BS of North Carolina pressuring Sen. Kay Hagan to vote against any "public option." Their rationale?

Public option?
Government Cooperatives?
Community plan?
Single payer?

No matter what you call it, if the federal government intervenes in the private health insurance market, it's a slippery slope to a single payer system.

Who wants that?

No comment necessary. What I do want to comment on, however, is the nature of Blue Cross/Blue Shield of North Carolina, and most of the other BC/BSs. If you got to their web site and read their annual report and all that you will see all sorts of frou frah about public service and making the world a better place for humanity and saving baby kittens, but in fact, Blue Cross/Blue Shield of North Carolina is a for-profit corporation that, despite posturing as Mother Teresa, exists to make money for its owners -- who, by the way, are conspicuously unmentioned anywhere in the web site or annual report.

Just so you know.

Oh yeah . . .

After a fairly miserable week, I finally feel like myself again -- and that actually feels better than feeling like myself. I think we really need to get sick once in a while to appreciate feeling well. Conversely, I'm more and more sold on Ivan Illich's idea of social iatrogenesis -- that as a culture, we've come to believe that perfect health and freedom from pain is some sort of a human right, and we're just going to keep going to doctors and guzzling pills and having ourselves sliced and diced until everything is perfect. That's one reason for all this influenza hoopla -- the idea that you might feel like shit for a few days is a major emergency.

Listen up buster. Life is tough. You're gonna get sick sometimes. Sometimes it's gonna hurt. Get over it.

Having gotten that off of my thorax, a couple of news flashes, one of them pretty disturbing. From Felix Salmon: "The length of time the average unemployed person has been without a job has been hitting new record highs for a while; it’s now managed to pass the 6-month mark. That’s much higher than any previous peak in this data series." And those folks are exhausting their unemployment benefits -- 7,000 a day hitting the end of the benefit period and now having zero income, last I heard. These people are almost all going to be wiped out -- they'll lose every material thing they've gained in their lifetimes -- financial assets, houses, furniture, cars. They're destitute. And their chances of ever getting it back are very small.

Now that really is pain worth worrying about, and if it continues and doesn't get a whole lot better pretty soon, it's going to put major strain on the social fabric. And it will be all over for the Obama presidency. We've read about people living in tent cities here and there, but the only reason we haven't had Hooverville scale phenomena is because of unemployment insurance, which didn't exist in the 1930s. But it might just be a delayed reaction. Watch out.

Now for something completely different, some investigators are saying that rats become addicted to junk food in pretty much the same way they do to heroin and cocaine. This hasn't been peer reviewed and what is more, people aren't rats (with some exceptions). Still, there may be something to it. Eating habits for many people do seem almost impossible to change. We'll keep watching.

The world turned upside down

Since people who are chronically ill presumably need health care even more than people who are not, one might hope that people who are not insured are disproportionately those who are young and healthy and just figure they don't need it. And indeed, that's what a lot of defenders of the status quo will say. Alas, it is not so.

As Pizer et al report, low income people with chronic health problems and disabilities have high rates of not being insured, even though one of the purposes of Medicaid is to provide access for that population. Indeed, they have considerably higher rates than the average among all Americans. This is yet another malignantly ridiculous situation in which common sense understanding of reality collides with policy to produce a massive explosion of inhumane idiocy.

The data for this analysis, from the Medical Expenditure Panel Survey, already moves us a step or two away from reality. MEPS asks about nine chronic conditions, but not, for example, cancer or chronic kidney disease, HIV, and others one might think are important. And it's definition of disability depends on functional categories, whereas the relevant category for policy is ability to work, since that's what determines Medicaid eligibility. Many people with disabilities, or course, do work, although bizarrely, many cannot only because they would lose their Medicaid if they took a job. (No joke.)

So already we're a bit askew. Nevertheless the results are instructive. Overall, the MIPS from 2000-2005 has 16.4% of adults under 65 uninsured. (It's more now, of course.) among moderate and higher income people, people with disabilities and chronic health conditions were somewhat less likely to be uninsured than those without; but among low income people, that is not the case. The disparity is most striking in the South, where more than half of people with incomes below 125% of poverty were uninsured, including 32.3% of people with chronic health conditions and 21.5% of people with disabilities.

Yup, the South rises again. The region where political resistance to health care reform is the strongest is the region where 1/3 of low income people with chronic health problems didn't have health care five years ago, and more don't have it today. And what happens when your diabetes is uncontrolled? Oh, not much. You might lose your legs, you might go blind, you might have kidney failure, you might drop dead. But the alternative would be socialism.