Map of life expectancy at birth from Global Education Project.

Wednesday, July 23, 2014

Reality Bites Denialists


That's the trouble with cynical denial of facts you know to be true, which is what the Koch brothers and their political allies are mostly doing with global climate change denial. We know it's cynically dishonest because they keep changing their premises: it isn't happening, maybe it's happening but people aren't causing it, maybe people are contributing to it but it isn't really bad, maybe it's a little bit bad but it isn't worth doing anything about it . . .

A recent arrow in the denialist quiver has been the claim that the planet has not been warming for 15 years. Either this means the whole claim about climate change is too a hoax, nah nah nah nah nah, or else it means the problem isn't really urgent so we'll just wait for the technology fairy to save us.

More sophisticated climate scientists have been saying all along that this is not true, the global surface temperature has been on a bit of a pause but that's because the heat is going into the oceans. This is kinda wonky, but a new analysis sets us straight. Climate models based on straightforward computation of how heat is trapped by greenhouse gases have tended to overestimate recent increases in global surface temperatures, i.e. they have failed to predict the recent slowdown. This has caused denialists to claim that climate models are worthless. Not so.

All you have to do is add the El Niño/Southern Oscillation phenomenon to the models and they fit reality just fine. In other words, for the past decade we've tended to have more La Niñas -- episodes of cool southern Pacific water -- than El Niños. Add that info to the models and they do predict recent surface temperature history. But now that's changing, with an El Niño predicted for later this summer or fall and guess what? We'll have an apparent acceleration in warming. It's already started, seemingly, with the warmest three months on record. Add to that the sparse coverage of the Arctic by weather stations, the Arctic being the region that has warmed the most, and we find the planet is even warmer than we thought. Already.

We're headed for a really obvious hot spell, folks, and the oceans will continue to rise, faster than before, the arctic sea ice to disappear, and the southwest U.S. to parch and bake until cities become uninhabitable. Yes. Then Sen. Inhofe and the Koch brothers will have to eat shit.

Monday, July 21, 2014

AIDS 2014


I'm not there this year, and of course, neither is Joep Lange. The linked remembrance by Laurie Garrett explains why the International AIDS Conferences are really unique. There is a lot of science presented there -- you get the usual PowerPoint presentations with socially awkward biologists droning on about viral lineages and the blood-brain barrier, as well as social science and program evaluations and every other possibly relevant discipline.

But only about half the people there are researchers. The rest are activists and practitioners of one kind or another. And the presentations in the big hall sometimes feature science, (usually in a fairly popularized form), but are just as often political speeches, and even rallies and demonstrations.

Outside of the lecture halls and workshops, the corridors and exhibition halls are constantly enlivened with political theater, music and dance, and mobile polemical exhibitions. The conferences are an immersion into a special universe in which science, morality, and passion all collide, shattering and recombining unpredictably.

HIV is not like other diseases in being so freighted with culture, politics and morality. And Dr. Lange's career exemplifies that complexity. He was a scientist who was also compelled to be an activist and a campaigner. Of course his loss is no more egregious than the death of any other victim of war. As I said last time, I perhaps take it a bit more personally. But as a species, we just can't afford to keep fighting over tribalism. We have urgent work to do. 

Friday, July 18, 2014

MH17 and me, and us

As you likely have already heard, something like 100 of the passengers on MH17 were on their way to the International AIDS Conference in Melbourne. Of the names so far made public, I don't know any of them personally. However, I have attended two past International AIDS conferences, in Mexico City and Washington, D.C., and live-blogged them here. It certainly would not be surprising if some of the victims are people I have spoken with, or heard speak, or who have attended presentations of mine. Certainly they would have similar kinds of education, interests, and political and social commitments.

I don't have enough insight to say how this affects my feelings about the incident. I like to think of myself as a universalist humanist and want to claim that the degree of personal affinity I have for the deceased and their colleagues, friends and loved ones is beside the point in how I evaluate this atrocity. We don't yet know all of the facts, so I'll hold off the rant I have saved up for Vladimir Putin and the thuggish morons he is sponsoring in Ukraine. But I will say this.

As a species, we have only a very short time left to grow up, before we do ourselves in. We are now recognizing the 100th anniversary of World War I. Europe blundered into catastrophe due to exactly the kinds of tribalism, instinctive reliance on military technology and prowess, and the view of global affairs as fundamentally and properly a competition among nation states for power and primacy. The catastrophe this time would be incalculably worse.

So, remember that in 1988 a U.S. naval vessel shot down an Iranian civilian jet liner, while St. Ronald Reagan was president. That was just as awful, but unlike John McCain today, nobody started calling for World War III. 

Update: It turns out that 6, not 100 of the passengers were on their way to AIDS 2014. Doesn't affect my point, but for the record. 

Monday, July 14, 2014

Black Hole in the East River

The New York Times, for all it's flaws, is still indispensable as one of the last redoubts of journalism. This should make your blood boil. According to an internal study, which the New York City Department of Health and Mental Hygiene tried to keep secret, prison guards at Rikers Island assaulted and seriously injured 129 inmates over an 11 month period. That's "serious injuries" only, which means they were too severe to be treated in the prison clinics. More than 3/4 of the victims have mental illness diagnoses.

There have been a couple of recent incidents of mentally ill Rikers Island inmates dying from neglect. One guy cooked to death in an overheated jail cell, another died after ingesting detergent and then being ignored as he begged for medical help. But this is different -- this is guards beating the crap out of people, sometimes in revenge for having urine thrown at them or the like, sometimes to control people who are acting out, sometimes apparently just for fun.

So yeah, impunity for corrections officers, as well as terrible conditions in the jail and terrible working conditions for the officers, is intolerable. But here's the worse problem -- about 4,000 out of 11,000 Rikers inmates are diagnosed with mental illnesses, which exceeds the entire census of psychiatric inpatients in the state. Jail is where we send mentally ill people today.

And this has been building for a long time. Back in grad school I took a course called something like Social Control of Deviance Through the Courts, which was taught by a judge. We took a field trip to the Massachusetts high security prison, and we met with a group of lifers. Most of them were career criminals who had been in and out of jail for much of their lives until they finally got the big ticket. And they told us they had seen the change. You would know the guys, back in the day, one of them said,  but now half of these guys belong in the Pine Street Inn. That's Boston's big homeless shelter.

The judge explained what was happening: mandatory sentencing laws. It used to be he had discretion. Mentally ill people sometimes do things like trespassing, random destruction of property, aggressive panhandling, subsistence theft, inappropriate sexual expression, which gets them arrested. The judge could commit these people to treatment. Now he can't, he has to send them to jail. And that is obviously the worst possible place for a mentally ill person to be. Yeah yeah, criminals get a tautological diagnosis of sociopathy but that's not what we're talking about here. We're talking about psychosis, bipolar disorder, and the like, combined with social marginalization and deprivation.

It's a crime against humanity.

Thursday, July 10, 2014

A couple of modest observations


My colleagues and I analyzed a whole lot of medical visits by people with HIV and we did find some differences depending on patients' race and ethnicity. (Click on the link and you also get to see an unflattering picture of me, engaged in the bizarre practice of neck binding.)

Black patients tend to talk less than do other patients in physician visits -- this has been observed before. And doctors talk to Black and Hispanic patients about medication adherence more than they do with other patients, regardless of whether there are any indications that the patient is non-adherent (which is the fancy term for not taking the pills on schedule). These docs are all white or Asian, BTW, except for two African American women at one site. So we can't sort out any effect of physician ethnicity or provider-patient concordance from this data. But on the other hand, that's the real world. There just aren't a lot of Black or Latino physicians.

Not sure what this means or whether these disparate communication patterns are a big problem -- just  worth noting that ethnicity still matters. The call for a "race blind" society is fallacious. We aren't race blind and we won't be any time soon, so pretending we are just evades the issue.

Tuesday, July 08, 2014

Ho Lee Crap


While cleaning out an old storage room, NIH found at least six vials of smallpox virus. Unsecured. Just sitting there. With no accompanying documentation.

Okay, so they've been found, and secured, and will be destroyed. By international agreement, the variola virus can be maintained at only two ultra-high security laboratories, one in Atlanta at the CDC, the other in southwestern Siberia. There has been considerable controversy about this and many people -- including  YT -- have argued that these samples should be destroyed. The problem is that since smallpox was eradicated in 1979, no-one has been exposed or vaccinated. And, there isn't a lot of vaccine available. If smallpox were to get loose in the world -- don't even think about it.

It is not necessary to retain samples for any conceivable reason. Vaccine is made from a related virus, cowpox (hence "vaccine," from the Latin for cow). The genome is obviously fully described. Nobody is doing any research with variola nor is there any research that one can imagine doing. The only possible use of variola is as a weapon.

This discovery is disturbing because it suggests that there could be other overlooked samples somewhere -- or possibly not overlooked at all, but just kept in secret by some government laboratory somewhere. eww.

Monday, July 07, 2014

Les Izmore, continued

Friday's BMJ features a discussion of the Choosing Wisely campaign, which I have referenced here a couple of times. The essential question is whether we can substantially reduce wasteful medical interventions simply by moral persuasion and cultural activism, even without changing economic incentives. Author Richard Hurley says that a survey finds a majority of doctors will order unnecessary tests if a patient insists, and goes on to write "Doctors order unnecessary interventions for a multitude of other reasons, including fear of malpractice suits, to appear to be doing something rather than nothing, to try to demonstrate thoroughness, and because of how they were taught."

Oddly, he doesn't mention what would seem to be another important reason, which is they get paid to do it.

Anyway, what's more interesting about this essay is the discussion of the political background. Physicians don't generally think they have responsibility to reduce health care costs, and in the U.S., at least, the general public thinks that these efforts constitute "rationing," which is evil from the pit of hell, and that any effort not to give some form of medical test or treatment to somebody is all about death panels and murdering people to save money.

What we have so far not gotten across to enough folks is that medical tests and treatments can do harm as well as good, or just be useless. Money wasted on a useless test, drugs or surgery is money that can't be spent on something beneficial, and meanwhile people are directly harmed. But the cultural authority of medicine in the U.S., and the God-like status of physicians, prevents people from understanding or believing this. So the Choosing Wisely campaign has to go beyond targeting health care providers and effectively target the general public. Is anyone prepared to do that?

Thursday, July 03, 2014

Brain Dump

For reasons I won't go into I watched a regular network news broadcast last night and one third of the entire broadcast was about (now) hurricane Arthur. This storm is expected to brush the Outer Banks as a minimal hurricane then decay in the cold waters of the North Atlantic while turning out to sea, possibly giving part of New England a rainy day. It would be news, of course, if Cape Hatteras and environs got through a summer without a hurricane. Why is the teevee news so obsessed with ordinary, mildly unpleasant weather? Well, for one thing I suppose they don't have to think or do any work.

As I have occasionally confessed here, I am a long time Red Sox fan. Last year's epic season, culminating in the Championship that Healed The City, has been followed by . . . Feh. The team is so incompetent, so lifeless, you'd think they've been zombified. And that's actually the only explanation I can think of. Other than the defection of center fielder Jacoby Ellsbury to the forces of darkness in New York, it's the same team. They replaced Ellsbury with what was supposed to be the second coming of Willy Mays, Jackie Bradley Jr., who indeed has great speed, a great outfield arm and can, as they say, steal every base but first. He's been struggling with the Mendoza Line* all season, but even so, one less bat shouldn't turn the team from champs to dreck. The fact is nobody is hitting. El Papi tremendo, El Papi enorme, El Papi largo y anchoso, El Papi que ocupe mucho espacio, El Papi de gran vólumen, El Papi de maximo tamaño, i.e. Big Papi David Ortiz can still hit home runs, but otherwise his production is nil. He used to hit timely base hits and doubles to drive in runs, but now he's dinger or bust. The rest of them can't hit anything. So why do the Sox Sux? The moral is that for all we obsess, sports don't mean anything, it's just shit that happens.

And yes, Tim Howard put on an astonishing performance in the World Cup, especially against Belgium, but that just covers up the main truth which is that otherwise, the team sucked a moose. The score should have been Belgium 10, U.S.A. 0.

I bought a tractor with an excavator so I can dig out stumps and otherwise landscape and make beautiful gardens. I expect to find it delivered when I get home today. I'll have fun! Other guys get BMWs and hair transplants to soothe their mortal angst, I got a backhoe.

I'll have a few things to say about health and health care in coming days. I mean it. Stay tuned. 

Tuesday, July 01, 2014

Mission Creep, Shmeep


Okay, so first Obama sent 300 special forces to advise the Iraqi military. Their mission was to make helpful suggestions such as "Don't abandon your weapons and flee." (I've always felt that's a good principle of military doctrine.) Apparently that advice was insufficient so Obama announced he was sending another 300 Marines to guard the Baghdad airport and the U.S. embassy, and the road between. Hmm, what contingency might make that a priority?

Reuters gives a good overview of the current situation. Notably, the Kurdish and Sunni Arab members of parliament walked out before a government could be formed; parliament will not meet again for a week. Meanwhile, government forces have been unable to regain any territory, violence is rising in Baghdad and to the south of city, which is now essentially surrounded by insurgents on three sides; Kurdistan has announced that it will hold a referendum on independence in three months; and mortar shells have fallen on the Golden Mosque in Samarra, the Shiite shrine which was destroyed in 2005 sparking the horrific civil war.

Iraq is irretrievable. It is no longer a viable nation. That is not, however, a defeat for the United States or a failure of the Obama administration. It is history. Once the hubris and incompetence of Dick Cheney and Donald Rumsfeld blew the country up, there was no turning back. The international borders of the Middle East, drawn in secret by France and Britain following World War I, are dissolving. The issue is not the Islamic State, which certainly cannot survive for the long term. It is only the immediate instrument of chaos.

The issue is that Iraq and Syria were never viable nation states to begin with. Our responsibility is to do what we can to limit the humanitarian catastrophe, and ultimately to contribute what we can to a settlement among the bewildering array of parties and guaranteeing the security of new boundaries. But the United States does not, and cannot, control events and there is no reason why the U.S. should try. The news is very bad for the people who live there but for now, it is what it is. Pushing in more weapons and more combatants means more people get shot and blown up. So let's not do it.

Monday, June 30, 2014

The Omega Man?


I wrote recently that I was losing no more than an hour of sleep each night over the prospect of a horrific global pandemic, mostly because we supposedly know what we are doing more so than the medieval folks who were decimated by the Black Death.

Well, maybe, but three essays in the new BMJ should give us pause. The problem is that scientific understanding of infectious disease isn't enough if we don't have global mechanisms for putting that knowledge to work in an emergency. I think you'll only get the first paragraphs, but it isn't hard for me to hit the high points for you.

First, Ilona Kickbusch (yeah yeah) and Mathias Bonk (also too), went to the World Health Assembly in May and they didn't have such a great time. That's the annual meeting of the WHO, involving all 194 member states. It seems that the delegations from some of the poor states didn't have high quality presentations to offer, the communications and AV technology was poor, and there were too many people there and a lot of blather. Okay, well you have to take the thick with the thin.

Journalist Sophie Arie then asks if current arrangements are good enough to prevent The Big One. Following the SARS scare, global agreements were revised in 2007. All 194 countries signed on, pledging to report outbreaks to WHO immediately and to set up monitoring systems and designating "disease free" (i.e. vermin free) entry points where travelers can be checked. But a lot of countries haven't done this yet, mostly because they can't afford it, and just don't have the means to comply.

So, Devi Sridhar and friends explain the real problem, which is that major funders -- excuse me, mostly one major funder, that is the United State government -- has drastically cut back on its core support for the WHO. Instead, the U.S. makes what it calls "voluntary contributions" which means it gets to designate how they are spent. Right now the biggest funders are U.S. and U.K. voluntary contributions, and the Gates Foundation. These don't cover core operations and they don't help poor countries set up surveillance and reporting systems. The U.S. adopted zero nominal growth -- that is, a guaranteed annual decline in real dollars -- in its contribution to the core budgets of UN agencies in 1999. Joe Biden's name is on the bill, next to Jesse Helms. So when we all die in the zombie apocalypse, you can thank Uncle Joe.

The fact is, we all live on one small, shrinking (metaphorically) planet. If we don't get over this sovereignty fetish, we're screwed.

Wednesday, June 25, 2014

Same as it ever was


Via Brad deLong, here is Amartya Sen taking down the essential conservative economic argument in 1982. Sen is responding to P.T. Bauer, who way back then was making the same Mitt Romney 47 percenter teabagger case we're still hearing about today. Bauer was a "serious" economist so he does not, as far as I know, reference Ayn Rand, but it's the same basic idea -- economic inequalities are "largely the result of people's capacities and motivations . . . . It is by no means obvious why it should be unjust that those who produce more should enjoy higher incomes."

There you have it: the Makers vs. the Takers. But as Sen goes on to show, it is evident, transparently obvious really, that people's incomes are not proportionate to their productivity. (Even if they were, one could still make a strong moral case for limiting inequality, but that isn't even necessary.) For one thing, this assertion requires that owning productive assets constitutes personal productivity. Even if it did, it is hard to see how inheritance constitutes moral entitlement.

For another, incomes vary for all sorts of reasons that do not correspond to whatever it is that an individual personally produces, which is very easy to show.

Yet these nonsensical claims made Bauer one of the most respected economists of his time, and continue to bring prestige to professors today such as Greg Mankiw. How anyone can pay deference to such ridiculous arguments may seem hard to explain but of course it is not: wealthy people endow chairs in economics, and wealthy people dominate public discourse.

Do read Sen's essay, and arm yourself for the struggle.

Monday, June 23, 2014

"End of the World" plague


I happened across this today and it inspired me to write a post I've been thinking about for a while. The link is to a story about the so-called Cyprian plague of the Third Century, possibly an outbreak of smallpox, which is said to have given a boost to Christianity.

A couple of decades back there was a virologist or epidemiologist, whose name I forget, who firmly predicted that at some time in the coming decades, an emerging infectious disease would explode and decimate the global population. He generated immense controversy in part because it kind of sounded like he was hoping for it, part of his premise being that there are too many of us. Unfortunately this story doesn't have parameters that make it easily researchable, so if anybody can remember who I'm talking about please let me know. Anyway . . .

The argument in favor of this scenario seems pretty convincing at first. There have been plenty of instances in the past in which infectious disease outbreaks have caused crashes in human populations, albeit limited geographically because not all populations were in contact. The Black Death is thought to have reduced the European population by50% or more late in the 14th Century. While it is not possible to prove historical causation, there is a compelling story that this event ultimately brought about the end of the Middle Ages and the emergence of modernity. A sudden shortage of labor, and the availability of twice as much land and fixed capital per person, raised the status of the peasantry and hastened the end of serfdom. The introduction of hitherto unknown diseases to the Americas, notably smallpox, caused the so-called Demographic Disaster which reduced the indigenous population by some 90% and made the European conquest complete.

HIV and the hemorrhagic fevers, SARS and MERS, although none of them turns out to be the apocalypse plague for various reasons, do prove that new human pathogens will continue to appear frequently. These particular viruses have limited transmissibility, which is why our global population continues to grow, but the point is, with every city on earth connected by air travel that can get an infectious person from Nairobi to New York in less than a day, when the new smallpox does arrive -- highly transmissible, highly lethal -- we're screwed, lassoed and tattooed.

Well, maybe. The most important difference is that today, we understand infectious disease. We'll know how to take effective action, both in the short term through isolation and quarantine, and in the longer term through understanding the pathogen and coming up with effective treatments and/or prophylaxis. We hope. But the deeper point is, you can't understand the future by extrapolation. Will there ever be 8 billion humans alive at one time? I wouldn't bet on it. This is only one reason.

Friday, June 20, 2014

American Exceptionalism, once more . . .

This gets old, I know, but the Commonwealth Fund has once again released is report comparing U.S. health care to other wealthy countries and once again we are the pits. As in dead last, 11th out of 11. The competitors are western European countries and Canada.

Apparently its' good to be pinko. The United Kingdom, which is the only country on the list to have actual socialized medicine -- you know, government run health care, big gummint bureaucrats employing your doctor and telling her what to do -- is number 1. There isn't really a trend in that direction however. Switzerland, which has a version of Obamacare, is number 2.

Obviously, you can quarrel with the criteria. But the U.S. fares very badly on most of them, and that includes the bottom line -- the U.S. is dead last on "healthy lives," that is outcomes amenable to health care. The UK was not good on that one either, but they spend half as much as we do and still get slightly better results. And here is the main reason why we are for shit:

The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.
If it's really more important to your average moderate income voter that rich people not pay taxes than it is to solve this problem, then by all means vote Republican. They're on your side with that.


Tuesday, June 17, 2014

More on gun violence



Lawrence Gostin, writing for the JAMA forum, makes many of the same points I did recently about the framing of gun violence as a mental health issue. Sure, most mass shooters have diagnosable mental illness but a) most mentally ill people are not violent, b) most gun violence is not mass murder (in fact it's only a tiny fraction), and c) the only good predictor of future violence is past violence. To remind us:

Although most mass killers are mentally ill, only a small minority of persons with mental illness is violent. Overall, only about 4% to 5% of overall violent crime can be attributed to persons with mental illness. At the same time, it is exceedingly difficult to predict violence based on a psychiatric diagnosis: psychiatrists’ predictions of violence are no better than chance. It is true that mental illness can be a risk factor for violence, but often only with comorbidities, such as alcohol or drug abuse. The latter are far more powerful predictors of violence than the diagnosis of mental illness. Still more powerful is a history of violence, particularly threatening or using a lethal weapon such as a firearm.
Like I said. Nevertheless, Gostin still wants to tighten the background check system so that people who have been committed to a mental institution can't buy guns easily. I'm not even sure what he means by that -- if you've ever been committed, you should lose your rights for life? If you're currently committed, you can't buy a gun anyway. Anyway, civil commitment is a somewhat arbitrary process and there is no evidence, certainly none that Gostin provides, that it is predictive of violence. After all, if psychiatrists' predictions of violence are no better than chance, why should their decisions to have people committed as a danger to themselves or others get any respect? His proposal is transparently self-contradictory.

He goes on to propose that people with a history of violence be banned from gun ownership. That makes more sense, but I despair of it working. The country is so awash in firearms that it is easy to obtain them illegally, and people who have been convicted of violent crimes do not have a proclivity to obey the law.

The only hope, it seems to me, is cultural change. People need to understand that guns are dangerous; having them around makes you far more likely to kill yourself or inadvertently kill someone you wish you hadn't than it makes you likely to somehow defend yourself; and the more guns there are in the environment, the more violent death there will be. Make it the cultural norm, what the cool people do, that if you have some good reason to won a gun, keep it locked in a safe and only take it out when you want to hunt or shoot at paper cutouts of Barack Obama or Trayvon Martin. Require licensing of gun owners based on taking safety training and passing a test, and registration of guns, just like motor vehicles. But saying Joe is allowed to buy a gun and Fred is not, just isn't workable.



Monday, June 16, 2014

Why is marijuana illegal . . .

in most states, while chewing tobacco is not?

Tony Gwynn wasn't just a hall of fame baseball player, he was universally regarded as a really nice guy. He repeatedly eschewed the chance to make bigger bucks in order to stay with the Padres for his entire career. As baseball coach at San Diego State, his alma mater. A hometown guy who cared less about getting rich than he did about his community. Also, he leaves a wife and two kids. He was 54 years old.

And yes, it was cancer that started in his cheek, caused by tobacco. The people who market that stuff are murderers. The wrong guy died.