Map of life expectancy at birth from Global Education Project.

Monday, March 31, 2008

There are two sources of BS

There's been plenty of coverage of the results of the so-called ENHANCE study that casts doubt on the effectiveness of Vytorin in preventing atherosclerosis, but very little of it, as far as I can tell, casts much light on the public health policy issues behind this latest debacle. (Vytorin is a combination of a statin, the traditional cholesterol-lowering agents, and ezetimibe, a chemical that blocks absorption of cholesterol from food.) In fact, the stories tend to appear in the business section, where the emphasis is on what's going to happen to Schering-Plough stock. Here are a few things the corporate media isn't telling you.

First of all, if you have watched television for even one hour in the past year, you have probably failed to escape the advertisements for Vytorin, one of the drugs most heavily marketed to consumers in all history. Those are the ads with people dressed up to look like food, and the line that "There are two sources of cholesterol: the food you eat, and that produced by your body based on family history." You are urged to take Vytorin because it addresses both of these sources.

Okay, aside from the observation that there is no reason why looking at pictures of people dressed up to look like lasagna and chocolate cake should cause you to take a pill, you need to know that the information in the advertisement is false. It is true that your body produces cholesterol, and that you do get some cholesterol from the food you eat. However, it is not true that the cholesterol produced by your body is "based on family history." You do have a genetic predisposition to produce more or less LDL (the "bad" cholesterol), but that is not "based on family history."

Family history has some correlation with your blood lipid profile, but it does not determine it. First of all, you may or may not have inherited any of the particular genes that your mother or father had that influence cholesterol levels. Family history may give some indication of your likely genetic profile, but it is not identical with it. Second, and more important, your genes don't determine your LDL cholesterol level or anything else about you for that matter, they interact with your environment to make you what you are. Diet is an important determinant of your blood lipid profile, but it is not, in fact, ingestion of cholesterol that is the most important factor. Rather, it's the kinds of ordinary fats that you eat, which influence production of LDL and HDL cholesterol in the liver.

In case you didn't already know -- and most readers of this blog do know, I'm sure, not least because I've written about it a lot -- the more saturated fat you eat, and even worse, the more trans-unsaturated fat you eat, the worse off you will be. That means mostly animal fat from meat and dairy, and artificially hydrogenated vegetable oils. Unsaturated vegetable oils, and particularly mono-unsaturated oils such as olive oil, are the good fats. Dietary cholesterol is most likely to come from eggs, by the way, but it's less important in raising LDL cholesterol than saturated and trans fats.

So, the ads are misleading because they are trying to make you think that by taking Vytorin, you are eliminating the influence of diet on your cholesterol levels and making it okay after all to eat stuff your doctor told you to cut down on. To put it another way, they are lying to you, in order to sell you a product, and the result may very well be to influence your behavior to your detriment, specifically with the effect of causing you to have a heart attack or a stroke. That's kind of evil, don't you think? And don't you think the FDA should have said something to Schering-Plough about those misleading ads?

Then there's the question of why this drug was approved in the first place. It was approved based on a 12 week trial with fewer than 4,000 patients. There has never been any evidence whatever that ezetimibe (Zetia), the stuff that blocks cholesterol absorption from the gut, has any health benefit whatsoever. The trial showed that combined with a statin, it does produce an additional reduction in LDL cholesterol, and that was enough for the FDA. The ENHANCE trial, however, shows that it does not produce a concomintant slowing of the progression of atherosclerosis. (Actually, there's a trend toward making it worse, but it is considered not statistically significant.) We'll have to await even longer-term studies to learn if it has any benefit on heart disease and stroke outcomes, but at this point, there's no reason to believe that it will.

Now here's the bottom line -- the stuff costs a whole lot of money, all of which, it now appears, has been wasted. NEJM, which I am coming to like more and more as they are changing their evil ways and showing a genuine commitment to the public welfare, makes this important study available free to you, the great unwashed. Dr. Jackevicius and her colleagues find that by 2006, 3.4% of prescriptions for lipid lowering agents in Canada were for Ezetimibe, while more than 15% of prescriptions in the U.S. were for Ezetimibe. In the U.S., prescriptions for statins actually fell since the introduction of Ezetimibe. And, we spent 4 times as much per capita on this apparently useless or even dangerous potion than did the Canadians -- a total of more than $260 million a month.

So why did the hoseheads of the Great White North escape our fate? Well, for one thing, Direct to Consumer advertising of prescription drugs is forbidden in Canada. They spent $200 million a year on those ads here in the land of the free, which obviously paid off big time. Second, as you may have heard, Canada has single payer health care and Vytorin and eztemibe were approved for use in most Canadian provinces only as a last resort, because data on outcomes were not available. Unlike doctors here, Canadian docs can't just write prescriptions because the customer saw it on TV -- they have to follow guidelines.

So maybe we are the Greatest Country on Earth, and maybe Canada smacks of creeping socialism, but they are just maybe smarter than we are.

Friday, March 28, 2008

Friggin' Nuts

What is the DSM-IV diagnosis for this?

WASHINGTON — President Bush, saying that "normalcy is returning back to Iraq," argued Thursday that last year's U.S. troop "surge" has improved Iraq's security to the point where political and economic progress are blossoming as well.

Bush coupled his description of the situation in Iraq, meant to lay the groundwork for next month's report to Congress by U.S. military and diplomatic chiefs, with a forceful slap at war critics.

"Some ... seem unwilling to acknowledge that progress is taking place," Bush said in a speech at the U.S. Air Force Museum in Dayton, Ohio. He accused war opponents of constantly shifting their critique, adding: "No matter what shortcomings these critics diagnose, their prescription is always the same — retreat."

In touting progress in Iraq, however, the president appeared to gloss over developments that most would characterize as a far cry from "normalcy," even by Iraqi standards.

Gee, d'ya think? For example, there's this: Hospitals in the unrest-stricken city of Basra received more than 60 bodies and 300 others wounded until Thursday evening in clashes flaring up in southern Iraq, a medic said. "There are many casualties that are not received by the hospitals for inability to reach them," he said. Sure, that's perfectly normal, happens in Boston every Thursday. Or this: Thirty-nine people were killed and 389 others wounded in the clashes that erupted on Tuesday in Sadr City, eastern Baghdad, a medic said on Friday.

I mean, if you can kill 39 people in just one neighborhood of the capital city in two days, that's got to be progress! And believe me, there was a lot more progress than that -- people all over the capital city were killed by mortars and bombs, not to mention the as yet unnamed U.S. diplomat -- or possibly CIA agent -- who was killed by a mortar attack on the "embassy," and the guy who died in the mortar attack on the Iraqi Vice President's office. And you absolutely know your security plan is working when gunmen kidnap its chief spokesman and burn down his house. As soon as that happens to Dana Perino, I'll know that Bush is all the way back! And when the artillery starts falling on Dick Cheney's office, then hey, the New American Century is here!

I'll tell you what, it's not quite a perfect fit, but there's Schizophrenia, paranoid type: "A type of Schizophrenia in which the following criteria are met: A. Preoccupation with one or more delusions or frequent auditory hallucinations. B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect." Is the disorganized speech too prominent to allow this diagnosis? And the affect, while not flat, seems inappropriately joyful, especially when discussing the people he has killed or tortured. He does claim to hear the voices, so that part fits.

There's also Delusional Disorder, grandiose type, which sounds good but may have some criteria that rule it out: "This psychotic mental disorder is diagnosed when prominent nonbizarre delusions are present for at least one month and the symptom criteria for Schizophrenia have never been met. Hallucinations may be present, but auditory or visual hallucinations cannot be prominent. Olfactory or tactile hallucinations may be prominent, but only if they are related to the content of the delusion. Psychosocial functioning may not be impaired and any co-occurring mood episodes must be of relatively brief duration." The grandiose part is "delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person."

That certainly fits in some ways, but the issue for me is whether the delusions are "non-bizarre." And is "psycho-social functioning" impaired? I would say that being responsible for the deaths of a million people is suggestive of impaired psychosocial functioning but I'm not a trained diagnostician.

Thursday, March 27, 2008

Putting Descartes before the horse

I suspect that most of the people here would agree with me, although it hasn't exactly come up in an overt way: the majority of kids who come to the attention of adults because of their alcohol or drug using behavior don't, fundamentally, have a drug problem. If kids are smoking pot before class, they have a school problem. If they are drinking six beers at a party and then driving home, they might have a social problem and they certainly have a judgment problem, as most adolescents do. Kids in poor neighborhoods who end up involved with criminal drug dealing gangs likely have an economic problem.

But the basic issue is not that there are bad chemicals out there and we need to sit down and talk with them about chemicals. There might be something we need to talk with them about, or really, there might not be a problem at all -- they might just be experimenting because kids like to try new things. The vast majority who do so do not end up getting into any kind of trouble at all, except for the trouble that overreacting adults make for them.

Now, there are exceptions. Some people, after using heroin or meth or cocaine, or perhaps alcohol -- certainly nicotine, which is probably the most powerfully addictive substance -- for long enough, end up with dopamine pathways in their brains rewired so that they have a powerful compulsion to consume the drug, which becomes a fundamental behavioral drive. That's absolutely a real phenomenon, and it's a hard one to beat. But few adolescents are there yet, with the exception of nicotine. Of course, it's important that they not get there, and we need to learn to recognize and deal with the real problems of adolescence effectively. But if we define the problem as the drug, we're missing the point.

Now, as for my overly subtle title. A few weeks back I did a series on the error of Cartesian dualism. The mind is not a separate entity that exists outside of the body it inhabits, it is a manifestation of the body. With psychoactive chemicals, this works in both directions. That we can take a pill or a potion and find our minds radically changed proves that the mind is inseparable from its physical substrate in the brain. That people, in turn, can come to organize their lives around obtaining psychoactive chemicals proves the same, that free will is an illusion and chemicals moving across microscopic synapses make us think and feel and do. But the whole thing is embedded in a larger social and physical environment. That's where we always have to start.

Wednesday, March 26, 2008

Senator: Enough!

Hillary Clinton is evidently running for the Republican nomination for president. Monday, she met with Richard Mellon Scaife -- yes, the very architect and financier of the Vast Rightwing Conspiracy, the man behind the Whitewater hoax, the man who spent millions of dollars promoting the story that Hillary Rodham Clinton had Vince Foster murdered -- now the publisher of a commercially non-viable far right-wing vanity newspaper, and used the occasion to denounce Barack Obama for being a member of Jermiah Wright's church.

Today, I read this in the Washington Post: "[Like John McCain] Sen. Hillary Rodham Clinton's campaign has also started slapping the L-word on Obama, warning that his appeal among moderate voters will diminish as they become more aware of liberal positions he has taken in the past, such as calling for single-payer health care . . . ."

It's not very surprising that a recent poll finds that 28% of Clinton supporters would vote for John McCain if Obama is the nominee, since it has been the Clinton strategy for several weeks now to endorse John McCain over Obama.

This crosses the line. Clinton is betraying the Democratic Party, and the country, in what is now revealed as her utterly selfish, megalomaniacal pursuit of power for its own sake. She is a disciple of Karl Rove. The party leadership must make it clear, right now, that these tactics are intolerable, and that she will become a pariah within the party if this does not stop, now.

If you got the time . . .

This morning we heard from Dr. Kelly Kelleher about how it's a great idea for primary care doctors to screen for alcohol and other drug abuse problems. There are, however, some difficulties.

Every disease advocacy organization in the world wants primary care doctors to be screening -- for asthma, diabetes risk, cancer, depression, domestic violence, you name it. In fact there are something like 700 questions that primary care docs are supposed to be asking their patients. However, they generally see 4 or 5 patients an hour. Since the patients are presumably there for some reason other than to be asked the first 30 or so of 700 questions, it's unlikely we're going to get very far with that.

And then, suppose the doc identifies an adolescent with a so-called "substance" abuse problem? ("Substances"? Puhleeze. The reason for this bizarre locution is that we aren't allowed to call alcohol a drug of abuse. Because they have a lobby.) What to do? Generally, no idea. The primary care doc does not get paid to do any counseling about this herself, if she has any idea how to do it in the first place. And no, they don't teach that in medical school, or in your residency. Referrals? Maybe something is available, maybe not, but then do you have to tell the parents? What if the kid doesn't want you to? If you do refer the kid, will he go? Answer: no.

So, they're trying all sorts of high tech solutions with computer-based screening tools that upload data to central registries that dispatch social workers whenever the light blinks red. Who's going to pay for that when the study grant runs out? Answer: nobody.

Here's the bottom line, for me. Primary care physicians have a lot of important jobs to do, that they aren't paid to do, and therefore they don't get done. If insurers started reimbursing primary care physicians to spend time talking with patients -- and it could be very structured, so that specific, well defined, evidence-based screening and counseling services are being delivered and evaluated, and the docs are trained to do them -- we'd have more people going into the primary care specialties, they'd be happier in their jobs, they'd have more prestige, they'd spend more time with patients, and we'd have a healthier population. We'd also need to reimburse primary care practices for important ancillary services such as case management and disease management programs. All this makes tremendous sense in long-term social cost-effectiveness as well. So why doesn't it happen?

Because it doesn't make sense in terms of short-term cost effectiveness for the individual payer. If a health plan starts paying its primary care docs to identify more patients who need services that cost money, it's out of pocket for now. Even though it's relatively little money, and it's going to prevent much more expensive problems later on, by the time those expensive problems emerge, the person is probably not going to be a member of the same health plan any more. So somebody else will have to pay for it.

If we want to do all these great, progressive, sensible reforms of the way we deliver health care, we need:

Universal, Comprehensive, Single Payer National Health Care.

That's the only way.

Tuesday, March 25, 2008

Like I said the other day . . .

Your God-given right to be an irresponsible idiot.

Moral Values

This morning we heard from representatives of the Children's Defense Fund, who discussed the Fund's report and campaign called Cradle to Prison Pipeline. Using what a take to be the method called Life Table Analysis (although they didn't actually say so), CDF has figured out that a Black boy born today has a 1 out of 3 chance of going to prison during his lifetime, and a Hispanic boy a 1 out of 6 chance, compared to 1 out of 17 for a white boy. Ratios for girls are similarly disproportionate, although the absolute chances are lower.

The CDF points out that 1 out of 6 children in the U.S. are living in poverty, and that the numbers living in poverty, and the poverty rate has increased during the reign of the current Christian moral values administration -- most dramatically among the very poor. Poverty is of course associated with all sorts of problems for children -- failure in school being the most pervasive. The CDF goes on to talk about all the other ills that afflict poor children, and disproportionately afflict poor and minority children, but I want to get to the bottom line.

The essence of this problem is that our society responds to children in trouble with punishment -- if they are black or Hispanic. The presenter -- Natacha Blain -- told some astonishing stories of police being called to arrest children as young as four or five for such crimes as refusing to take a nap or having a temper tantrum. Thirty-nine percent of the youth population are minority group members, but they represent 60% of youth who are incarcerated. Mostly, they are committed for drug related offenses. Once you are in Juvi, you're well on your way to prison.

But guess what? The CDF for some reason doesn't point this out, but all the available information shows that Black and Hispanic youth are less likely than white youth to use illicit drugs. The difference is the response -- white kids from affluent families aren't prosecuted for using or even distributing drugs. There probably won't be any law enforcement response at all, in fact, but if there is, they will be "diverted" into mandated counseling, not prosecuted. Poor black and Hispanic kids face a lot of disadvantages that add up to the likelihood of a grim future -- lack of adequate health care, including mental health treatment if they need it, damaging neighborhood environments, greater likelihood of exposure to violence, poor schools, low expectations, you name it. But the worst problem they face is that when they need help, they aren't treated like children in need, but like criminals.

That, of course, is the philosophy of the Christian leadership of our country. I thought that Jesus said something like, whatever you do to the least of these, you do to me; but apparently he really said, fear and hate the least of these, then lock them away.

Sunday, March 23, 2008

On the Road Again

Monday morning I continue my jet setting lifestyle by flying off to DC for the Joint Meeting on Adolescent Treatment Effectiveness. That refers to substance abuse treatment.

Now, like a lot of you, the way I remember my adolescence the biggest drug problem we had was insufficient supply. However, the problem we have today is entirely different. There is a major epidemic of adolescent opioid addiction in the U.S. right now, including 16 and 18 year old kids who inject heroin. When I was a youth the idea of going anywhere near heroin was absolutely appalling. I never knew anyone who would even consider it. Ditto with meth. Yes, people got into that stuff but usually not so young, and it was largely limited to poor communities. Scholars of addiction could honestly say that the problem was not drugs, but lack of life prospects, or psychological damage. People with jobs to go to and education to pursue could get high on weekends but they would show up on Monday because they had a reason to, and they did not become addicted.

It's not that simple any more. We have a growing heroin problem among kids from affluent or at least stable and economically adequate families, with access to decent education and what ought to be reasonable expectations. Availability has something to do with this -- prescription opioids are the usual starting point and they are flooding the market right now, including very powerful drugs like oxycodone and fentanyl. Kids in the burbs are taking them like M&Ms. I mean, how dangerous could they be, they're medicine?

But they're hard to get in the quantities that an addict needs and their street price is high. Heroin, however, is plentiful and cheap, thanks to the failed state in Afghanistan and the many warlord fiefdoms there which are flooding the world with high quality junk. Yup, it all goes together.

So we aren't talking about firing up a Dooby on a Friday night here. I'll report anything interesting from the conference. I may have trouble getting up a post tomorrow, since I'll be traveling in the morning and meeting in the afternoon, but I'll do my best.

Friday, March 21, 2008


NEJM continues to rack up the Cervantes points by making material of importance to public policy available to you common rabble. This week, Dr. Wintemute discusses your God-given right not only to carry a concealed weapon into the church and shopping mall, but to kill people with it if they look at you sideways. Think I'm exagerating? Not at all. Wintemute tells the tale of a Louisiana homeowner who shot and killed a teenage boy who mistakenly knocked on his door, looking for a party. A jury acquitted the man after three hours deliberation, based on the defense attorney's assertion that "You have the legal right to answer everybody that comes to your door with a gun." In Louisiana, you indeed have the legal right to kill somebody if they refuse to leave your business or dwelling.

In the southeast generally, and in Michigan and North Dakota, legislators have eliminated any duty to try to avoid deadly confrontation by retreating. In other words, all you have to do is murder somebody, and then claim you felt threatened. You're innocent -- and you also are not liable for any injuries to bystanders, in many cases. Thirty-five states require that anybody who isn't disqualified from gun ownership by a criminal record or mental illness must be issued a permit to carry a concealed weapon.

I was at the American Public Health Association meeting in Indianapolis a few years back. Two of my fellow convention goers were in the local Planet Hollywood when a man dropped a cigarette, bent over to pick it up, and his loaded gun fell out of his shirt pocket, hit the floor, and discharged. The bullet went through one woman's wrist and struck the other in the side.

The police announced that no charges would be filed because the man had a permit to carry the gun. That would also be a permit to be an irresponsible idiot, but maybe the good people of Indiana want us to think that's the norm out there. Is that what you all want?

Now, in thinking about public health we frequently confront tensions between reducing death and injury, and what at least initially appears to be the individual liberty interest. Many conservatives, and libertarians who don't necessarily accept the "conservative" label, tend to oppose regulations to improve public health, such as restrictions on smoking, motorcycle helmet laws, and of course gun control, on liberty grounds. (Strange how conservatives are especially zealous about restricting some other categories of personal behavior, such as illicit drug use, but we'll leave that as an aside for now.)

However passionately you may reject the notion of government paternalism, we should at least base the debate on the facts. As Wintemute points out, the relationship between gun ownership and personal safety is clear -- owning and carrying a gun makes an individual far less safe. Having a gun in the house increases your chance of being murdered by something like 100%, and your chance of killing yourself by a far greater amount. Increased gun ownership is associated with increased, not decreased, crime rates, and defensive gun use is far less common than widely believed, so that if you own a gun, you are far less likely to ever use it in self defense than you are to see it used to kill a loved one, by suicide, accident, or impulse.

The National Rifle Association purports to be a grassroots organization of citizens, but it is principally financed by gun manufacturers and it is their interests which it represents. I have written about my friend Festus, the farmer, who uses a rifle to protect his crops from deer and woodchucks, and I would like to see a lot more deer hunting in New England, frankly, because there are too many of the antlered rats and they are terrible pests. I understand very well that in many areas, guns are basic tools for some people and they are a part of the culture. That's fine. So are automobiles, but we license drivers, register vehicles, and ticket or even prosecute people who operate vehicles in an unsafe manner.

It seems to me as obvious as Monday morning that we ought to treat firearms the same way: require people to demonstrate that they understand and are capable of safe possession and operation; require that the devices have safety features; register them so that they can be identified when they are misused and confiscated if the owner proves irresponsible; and require safe use and fine people who don't follow the rules, or revoke their licenses if it comes to that. Objecting to that strikes me as insane.

Thursday, March 20, 2008

GW Bush: Delusional idiot, or psychopathic liar?

I realize they aren't mutually exclusive, but I'm leaning toward more of the latter than the former. The point is, I don't know for sure whether he believes in the alternate universe represented in his public pronouncements -- most recently his triumphalist crowing on the fifth anniversary of his world historic crime of invading Iraq -- or whether he knows it's all fantasy and he just figures that when George W. Bush lies, it's not a sin, because he's God's anointed.

That is the lede to a rambling post today, and the reason you're getting this, and didn't get one yesterday, is because of traveler's burnout. Honestly, I don't know how the candidates do it, constantly changing time zones, eating too much or too little and usually badly, sleeping erratically, but having to keep working and stay alert through it all -- it's just too much for a hairless ape from the African savannah to endure.

Anyway, I don't do a lot of blogospheric meta-analysis, but one of the obvious differences between progressive and wingnut bloggers is that the portside doesn't jump all over stuff that isn't well established. For example, you might have thought that the Duke lacrosse team allegations would have wound up burning a lot of us with it's juicy low hanging fruit of apparent elitism, racism and sexism but in fact, most everybody steered clear of it, or discussed it only in the hypothetical, because we believe in the presumption of innocence. Good move. (BTW, this is the first time I have ever mentioned it.)

We all know how different it is over to starboard, where the leading ranters have repeatedly spewed firehoses of venom over stuff that turned out to be not actually true. Even when their material is discredited, they keep talking about it because what the hell, it should have been true. I'm sure you can think of plenty of examples -- Obama attended a fudamentalist Muslim madrassa in Indonesia, numerous instances in which they "found the Weapons of Mass Destruction™" in Iraq, Nancy Pelosi's trip to Syria was treasonous -- even though a Republican delegation had met with Assad two days earlier -- etc. and so on and so forth.

So, in case you're wondering why I haven't written about certain subjects you probably think are naturals here, it's because there just isn't enough information yet to say anything meaningful. But it occurs to me that the fact of lacking information is information, so let me comment on a couple of items in the news.

First there are those pharmaceuticals in the water supply. For better or for worse, we now have the ability to detect extremely low levels of chemicals in water -- a few parts per billion, even parts per trillion. What that means, basically, is that just about anything you can think of looking for, you will find. Whether the levels of Prozac and Zantac and Claritin-d the AP found in municipal water are of any biological significance whatsoever, to human or beast, is not absolutely certain but I would classify it as highly doubtful. We'll reserve judgment on this, but not lose sleep over it. In semi-contradiction to my assessment above, there are some environmentalists who get a bit trigger happy and over the top on stuff like this, the Natural Resources Defense Council being one example I can think of. I'd say that as far as environmental concerns are concerned, we've got bigger fish to deplete.

Next there's that allergenic heparin that might have something to do with bad oversight of raw material suppliers in China. It might. Or it might not. And if it does, it might be indicative of a more widespread problem or it might just be an oddity. So I'm again witholding judgment. I will say, however, that it's unlikely to be a sign of a big problem because pharmaceutical manufacturers are generally buying specific chemical compounds and assessing their purity. The contaminant in this case was very hard to detect, is also very hard to explain and nobody actually knows how it got into the heparin. So we still don't know what happened or whether it had anything to do with China at all.

If there's any larger point to all this it's that the latest news isn't necessarily very important, whereas stuff that's just still going on and therefore isn't big news might be very important. We have a bias against being concerned about problems that are familiar and of long standing, one that is powerfully reinforced by the habits of the corporate media. We need to resist that.

Tuesday, March 18, 2008

It Can't Happen Here

You know better. You don't have to go to Africa to find people living with HIV who have trouble feeding themselves. Dr. Sheri Weiser reports that about half of homeless people living with HIV in San Francisco report chronic food insecurity, and that, no surprise, they are sicker and more likely to die than people who don't. That doesn't mean they are starving in quite the same way Africans do. They can come up with the calories, usually, but they either have to do it in socially unacceptable ways or they have to eat stuff they'd really rather not. Think dumpster, for example.

Now your friendly neighborhood Republican will tell you that homeless hungry people with HIV are that way because they failed to take personal responsibility, so the Christian thing to do is to let the Free Market™ sort them out. I'm telling you that they got that way because they have a serious mental illness, or are suffering from the effects of serious trauma or abuse.

Dr. Daniel Kidder tells us that food or no food, being homeless isn't good for people with HIV, and also that people without insurance are sicker and die sooner. Another open door crashed through, to be sure, but the point is, there are people in those conditions in all of our cities. We don't have any problem coming up with $270 million a day for the military occupation of a far off country, or a few tens of billions to bail out an investment bank, so maybe we can throw some folks a good hot meal and a clean dry place to crash. I realize that's contrary to anything Jesus taught -- just ask the Christian party -- but I'm willing to blaspheme on this one. Even if some of those people are homosexuals.

Monday, March 17, 2008

Hierarchy of Need

The morning plenary was about HIV treatment in poor countries, mostly Africa. There is a lot I could tell you, but in the ten minutes I have between sessions I'll just mention this. It seems that one of the more common reasons that people in Africa don't take their meds as prescribed is because when they don't take the meds, they don't have any appetite, and if they don't have any food, they'd rather not be hungry.

If the clinics can get food from the World Food Program, the people will take their pills, gain weight, and stay healthy. Giving people food is also a good way to make sure they come in for their appointments. So here's a side effect of the rising global price and scarcity of food, which we are experiencing right now. Not only will people starve, they won't take their HIV meds, which means their viral loads will go up and they will become more contagious -- until they die, which will happen sooner, of course.

It's also a reminder that, while the various global funds are doing a a better job of getting medications to people, hunger is still a major problem in much of the world, and it's getting worse. It all goes together.

Friday, March 14, 2008

Jersey City, Jersey City here I come . . .

They got some pretty little women there and .. .

Oh, never mind. Anyway, my jet setting lifestyle continues as I will be in Jersey City Sunday through Wednesday for the Third International Conference on Antiretroviral Adherence. Sounds a little narrow, I know, but the subject actually is quite revealing as a test case for physician-patient relationships and communication and disease management and stuff in general.

Conference presentations aren't as strictly and paranoically embargoed as journal articles, so I will tell you that in general terms, my colleagues and I have found that if you give doctors a report about their patients' medication taking behavior, they will indeed talk about it more during the visit -- twice as much, on average, in fact. However, that does not result in the patients being more adherent to their medication regimens.

In fact, it has the opposite effect.

Why is this? Can't nail it down as a 100% certain lead pipe cinch, but the way it looks, what the doctors do is hector and scold people and threatent them with death if they don't take the pills on time, every time. Well that just doesn't work. The people already know what the doctor thinks they need to do, and they already aren't doing it. Our friend Dr. Showalter (see the Align Map blog in the sidebar) already knows this, I think, but there's nothing like getting a little scientific proof to wake up the profession.

Doctors just aren't taught how to be effective partners with their patients in disease care. That doesn't happen in medical school, and it doesn't happen in the residency. A few are good at it because that's just the kind of person they are, but most of them, let's face, are kind of, well, arrogant. So, we hope to make our next step an effort to teach docs how to be better motivators and problem solvers, instead of just yelling at people. Who knows, it might not be completely hopeless.

Thursday, March 13, 2008

Funny you should ask

The CDC has asked a colleague of mine to participate in a consultative group on HIV prevention for Latinos, and she asked me to contribute my thoughts on the four big questions they are asking. My pleasure, I do happen to have some opinions.

Based on your knowledge of HIV/AIDS among Hispanics in the United States;

1. Identify at least two community and two societal-level factors that place Hispanics/Latinos at disproportionate risk for acquiring HIV. How should CDC
address these factors?

Much of the disproportionate risk for HIV among Latinos in the northeast is related to injection drug use. While primary prevention is certainly what we would most want to achieve, unfortunately the evidence base for primary prevention is limited. (See below.) We do know that treatment can be effective, and furthermore, as IDU must be transmitted from users to non-users, treatment of current users does constitute a form of primary prevention as well. (Think of it as analagous to infectious disease control. Current users are infectious; get them into recovery, and you stop transmission.)

Right now, we do not have treatment on demand for anybody, but the availability of culturally and linguistically competent treatment for Latinos is even more limited. Furthermore, the courts are much more likely to deal with Latino drug abusers punitively than they are people of other ethnicities. Here in Massachusetts, Latinos are highly disproportionately incarcerated but the disproportion is entirely due to drug offenses. Drug addicts should not, in general, be incarcerated, they should be in treatment, but that is not happening.

Latina women are sometimes at risk due to injection drug use or MSM behavior by their spouses or partners. Sometimes they are truly unaware of these behaviors, in other cases they are unaware by choice, as it were, or choose not to address the risk behaviors. This has to do with gender role norms, stigmatization of homosexuality, and norms about privacy. The prevalence of HIV among Latina women in our region is even more disproportionate than the prevalence among men, and this is largely accounted for by IDU, IDU by sexual partners, and what CDC classifies as "unknown" risk but Mass DPH generally classifies as probable heterosexual transmission.

2. Identify at least two gaps in HIV prevention services and research targeting Hispanic/Latinos in the United States and Puerto Rico. How should CDC address these gaps?

Primary prevention of IDU among Latinos. Difficult to study, we should start with more ethnographic and qualitative research to better understand the process of induction into IDU.

Better understanding of norms and behaviors related to MSM among Latinos and culturally competent approaches to risk reduction.

The way to address these gaps is to put up some money for scientifically sound investigation by culturally competent investigators. Get over the fetish for quantification.

Note that the focus needs to include positive prevention. Latinos living with HIV frequently face substantial obstacles to disclosure to family members and others in the community. The difficulty of mobilizing natural supports and the burden of stigma are obstacles to positive prevention. This means that counseling approaches cannot be rigidly standardized, the time required and the process required to achieve disclosure and manage its consequences has to be variable and specific to the individual and his or her family and community context. Proposal reviewers have a rigid and counterproductive concept of what constitutes a "scientifically" valid trial. Effective interventions have to be highly flexible and responsive to individual circumstances, and evaluation studies must allow for this.

3. Which prevention research approaches and program resources are currently available to address HIV/AIDS among Hispanic/Latinos but not supported by CDC? Identify two prevention research approaches and two program resources that CDC should use.

The approach to IDU must be informed by the harm reduction philosophy. The current policy of the federal government is based on an extremist ideology which purports to be morally superior but in fact is uncompassionate and murderous. People with addiction problems do not deserve to die because of their behavior, regardless of what some morally self-righteous people seem to believe. The federal government must support harm reduction approaches including needle exchange. We must end the policy of incarcerating millions of people who have substance abuse disorders, which is counterproductive. We must provide treatment on demand, and understand that addiction is a relapsing-remitting condition which often requires multiple attempts to achieve stable recovery.

4. How should CDC, Hispanic/Latino leaders and other external partners work together to implement HIV prevention activities? What are the expected outcomes of this proposed partnership?

We need to take an approach to HIV prevention which is based on reality, not faith. The moralistic and punitive approach currently underlying much of federal and state policy to the problems underlying the HIV epidemic is neither effective, nor truly moral. A moral approach to HIV must have the objective of preventing HIV transmission, and that means encouraging condom use, comprehensive sexuality education, and harm reduction approaches to substance abuse. I haven't discussed it previously, but the "abstinence only" sexuality education project is a hoax, an expensive and cruel fraud perpetrated on the taxpayers and on our youth. It absolutely does not work and it has contributed to the growing epidemic of STDs among young people. We also have a serious and growing epidemic of heroin and prescription opioid abuse in this country. The entire philosophy and approach of the past 7 1/2 years has been a manifest failure.

What I would expect from any partnership for HIV prevention is a return to reality based public health policy.

Wednesday, March 12, 2008

We report . . .

. . . you decide.

Which one of these people is more fucking nuts? This woman?

Authorities are considering charges in the bizarre case of a woman who sat on her boyfriend's toilet for two years -- so long that her body was stuck to the seat by the time the boyfriend finally called police. Ness County Sheriff Bryan Whipple said it appeared the 35-year-old Ness City woman's skin had grown around the seat. She initially refused emergency medical services but was finally convinced by responders and her boyfriend that she needed to be checked out at a hospital.

"She was not glued. She was not tied. She was just physically stuck by her body," Whipple said. "It is hard to imagine. ... I still have a hard time imagining it myself." He told investigators he brought his girlfriend food and water, and asked her every day to come out of the bathroom. "And her reply would be, `Maybe tomorrow,'" Whipple said. "According to him, she did not want to leave the bathroom."

Or this man?

President Bush delivered a rousing defense of the wars in Iraq and Afghanistan on Tuesday, mixing faith and foreign policy as he told a group of Christian broadcasters that his policies in the region were predicated on the beliefs that freedom was a God-given right and “every human being bears the image of our maker.”

“The decision to remove Saddam Hussein was the right decision early in my presidency,” Mr. Bush said, to a standing ovation. “It is the right decision at this point in my presidency, and it will forever be the right decision.” “The effects of a free Iraq and a free Afghanistan will reach beyond the borders of those two countries,” Mr. Bush said. “It will show others what’s possible. And we undertake this work because we believe that every human being bears the image of our maker. That’s why we’re doing this. No one is fit to be a master, and no one deserves to be a slave.”

Tuesday, March 11, 2008

The Depths of Human Folly

I normally stay away from the headlines because what do I have to add to the din? But prostitution is obviously an issue of considerable public health importance, so I will say something. First, though, a bit of political commentary.

You can start an illegal war of agression based on a campaign of lies, causing the deaths of hundreds of thousands of people (at least) and squandering trillions of dollars; commit war crimes in the conduct of that war including rounding up thousands of young men at random and brutally torturing them; systematically violate laws intended to protect the constitutional rights of Americans, and claim that the president is not bound by the law or the constitution and has the absolute right to do anything he wants, including making people, including U.S. citizens, disappear forever into a network of secret dungeons, merely on his whim; and turn the federal justice system into a political hit squad, conducting malicious prosecutions to consolidate power. That's just for starters. And impeachment is off the table.

Or, you can call up for a little nooky while you're out of town. You're gone. What a country.

Now, the enterprise patronized by Client 9 -- widely reported to be Gov. Spitzer -- was not typical of the prostitution industry. The worker who serviced Client 9 appears to have been well compensated. She was treated with respect by the representative of management with whom she interacted, and there is no indication that she was coerced or exploited in any way. The company evidently had a condom use policy, and management was concerned that Client 9 had previously wanted to violate it. Not to worry, said the worker, she knew how to insist on it. It must have taken her more than an 8 hour day to go to DC on the train, spend two hours boinking the governor, and then ride back, but I'm guessing she spent the train rides studying up for her Ph.D. in early Sanskrit literature, or otherwise used the time productively.

So, why bother to prosecute this? The company's activities are totally discreet -- nobody's neighborhood is being degraded by street walking and cruising and open and gross lewdness. Nobody is enslaved, nobody has 90% of her earnings confiscated by pimps, HIV and STDs are not being spread, the workers are in little, if any, danger from psychopathic serial killers. But you see the implication here -- this is atypical prostitution.

So the issue arises perennially. Wouldn't it be better to legalize it, and regulate it, so as to get all that bad stuff out of the business? Competition from legal, ethically run businesses (if you consider that possible given the nature of the product) would largely drive the traffickers and the streetwalkers out of business, at least that's the hope. Decent pay, relatively dignified working conditions, and safety could be guaranteed, condom use enforced, and the interests of communities respected. Workers with drug problems could be identified, referred for treatment, and their licenses revoked. Of course they might respond by going back to the illegal market, but at least we tried.

Various countries, and one U.S. state, have experimented with forms of carefully limited legalization, with arguably okay results. The legal businesses have not driven out the exploitive, dangerous and offensive forms of prostitution, but perhaps it's because they haven't been permitted on a large enough scale. On the other hand, the legal businesses haven't always been paragons themselves, but maybe the authorities need more experience and a more aggressive and capable regulatory authority.

The principal objection to these proposals is that prostitution is immoral and society should not sanction it. Some feminists believe that it is inherently degrading to women, although not all prostitutes agree. Some argue that they should have a right to pursue their trade with safety and dignity.

Personally, I can't even remotely understand why somebody would want this particular service, but obviously a lot of people -- principally men -- do, always have, and always will. It is never going to go away. So I think we might as well try legalizing it.

What do you think?

Monday, March 10, 2008

You don't have to take it from me

Barbara Burke in the new JAMA reviews Bipolar Children: Cutting Edge Controversy, Insights, and Research, Edited by Sharna Olfman. Unfortunately, it's subscription only, but I'll give you a fair-use quote:

IN EUROPE AND ACROSS THE GLOBE, MANIC DEPRESSION IS rarely diagnosed in the pediatric population. In the United States, on the other hand, the American Academy of Child and Adolescent Psychiatry (AACAP) suggests that it may exist in up to 13% of children.1 Prescriptions of sedating drugs (anticonvulsants, -agonists, and atypical antipsychotics) have increased up to 3-fold in the last decade.2 Both of these anomalous trends, poorly substantiated by quality research, have occurred during a time of dramatic economic change in the health care industry. Meanwhile, US children appear to be getting less mentally healthy, not more, with diagnoses of “mood disorders” and “pediatric bipolar” (PBD) topping the list. This is clearly crazy, but where does the madness lie? In the children, the prescribers, or society as a whole?

In this provocative, highly readable book, psychologist Sharna Olfman . . . presents 9 essays that collectively answer “all of the above,” with generally good success. In her introductory chapter, Olfman places the blame on the close ties between academic medicine and the pharmaceutical industry and on dwindling societal support for families. She highlights the weakness in the concept of PBD promoted by the AACAP, noting there is no proven continuity between PBD (especially PBD not otherwise specified, or “subsyndromal PBD”) and adult manic depression, strongly suggesting that children with this diagnosis have some other emotional disturbance. Olfman also points out that the current biomedical model of mental illness in children, which relies on symptom checklists to diagnose mental illness, is inadequate: While it pays lip service to psychosocial context, in practice it eliminates from diagnosis and treatment such factors as parent-child relations, history of maltreatment and loss, current and past stressors—in fact, all those external factors known to cause natural, reactive disturbance in children. Finally, Olfman points out that the practice of reducing children’s natural reactions to stress by treating them with medications is practically mandated by current economic forces in health care, especially managed care models of treatment. Soaring rates of prescriptions of anticonvulsants and atypical antipsychotics have delivered enormous profits to the pharmaceutical manufacturers in the absence of long-term follow up studies demonstrating their safety in children and despite the fact that these drugs have serious, known adverse effects, including toxicity and metabolic disturbances.

Like I just told you. Unfortunately, psychiatry is so deep in the tank to the drug companies that the idea that we should be slapping millions of kids with disease labels and drugging them, because they have trouble sitting still and shutting up in school, or they have temper tantrums or sulk or won't eat their carrots, is heavily promoted by leading academics, notably Joseph Biederman of Mass. General Hospital and Harvard Medical School, and the people who resist this movement are derided in all the higher circles of the psychiatric establishment as cranks.

When children show signs of emotional distress, there's usually a reason for it, and that reason is not bad chemicals. Somebody needs to ask what it is, and solve the problem.

Sunday, March 09, 2008

Healing Society

It has often been said that the family is the most violent institution in society. That probably is not true -- the prison system probably wins that competition -- but there is no doubt that the most likely assailant of a woman or child is a family member. Statistics on this point are not very reliable -- family violence happens in private, usually in secret, and usually does not come to the attention of the authorities. Advocacy groups have been known to exaggerate, but This fact sheet seems to offer a level-headed overview.

One can frame this problem in terms of gender role norms. Women are certainly capable of assaulting their spouses and children, but men are more likely to do so. (I'm steering clear of quantification here because it's not reliable.) We now understand that the phenomenon commonly called battering is not really about anger; it's a pattern of coercive control. Batterers are extremely possessive, jealous, and need to monopolize power in their intimate relationships. It's no surprise that they typically victimize children in their households as well as their spouses or partners.

What I want to focus on here is the etiology of family violence. Children who witness domestic violence, or who experience it directly, may overcome the trauma and become successful, and peaceful, adults, but some do not. Those with less intellectual resources and self efficacy, and who attract less support and affection from outside the family, are more likely to suffer lasting consequences. Among these are a greater likelihood of growing up to be violent or victimized adults, repeating the pattern of their families of origin as they assume the role of parent and spouse; or becoming more broadly antisocial.

While family violence is no doubt the most powerful and pervasive source of psychological trauma, children who experience non-family violence, natural disasters, and of course war, may also suffer long-term consequences, particularly if the trauma is repeated or continual. Think of the children of Iraq right now. And of course, even as adults we are vulnerable to psychological sequelae of violent trauma. Most Iraq war veterans are fine, of course, but they are at risk for manifestations of psychological trauma and may suffer from alcoholism, difficulty maintaining close relationships, or even violent behavior, similar to the problems people traumatized as children may experience.

Violence, then, spreads through society, ricocheting from one person to another, down through time and out through space. This suggests to me that it is analogous to an infectious disease, and that it may be reducible, or nearly eradicable, using analogous strategies. It is possible, through counseling interventions, to heal traumatized people so they no longer carry the violence virus. Perhaps it is possible to do a better job of early detection and intervention before families become highly destructive. Maybe we can boost people's immunity by the right kind of education and the sorts of messages that they hear from politicians and community leaders. Of course, we can choose not to go to war. There is a synergy of peace, just as there is a synergy of violence. Maybe we can tip the balance.

Thursday, March 06, 2008

Slacker Thursday

Ugh, I'm too tired for a decent post after this very looonnnnngg four day conference. More to say later no doubt.

Meanwhile, here is an exciting set of design proposals for the George W. Bush Presidential Library. I'm working on my design, which is based on the chicken coop at my friend Art's farm.

One thing I will say about the meeting, the people who do some of the toughest, and most important jobs, get scant recognition or compensation. In the current political climate, they may even be vilified. Just an observation.

Wednesday, March 05, 2008

A View from the Helicopter

I'm not a clinician, I'm here as a project evaluator with the intention of getting sense of the what the field of mental health care for traumatized children is like these days -- at least for those community based agencies and academic experts who are fortunate enough to have support from SAMHSA as part of the National Child Traumatic Stress Network.

There's plenty of good news here -- then I'll give you the bad news.

Good news bulletin #1: I have heard scarcely a word about psych meds. The only way pills have come up is as a peripheral note that somebody who is part of a case scenario had been prescribed something. The NCTSN is not about drugging kids.

Bulletin #2: The DSM-IV is equally conspicuous by its absence. There is absolutely no interest in classifying kids' problems as diseases, tossing around disease categories, or using diagnostic labels to guide treatment.

Bulletin #3: The elaborate psychodynamic narratives that once dominated psychology are gone, at least from this group. The kinds of insights that are relevant to them are much more straightforward: the child feels guilty because he failed to protect his mother; the shadows falling across the bed remind the girl of her father entering the room with the light from the hallway behind him; the mother is encouraging the child's sleeplessness because she craves the child's company at night to ease her own loneliness.

The approaches to child trauma are pragmatic, focused on equipping children with knowledge, skills and strategies for overcoming their grief, fear, and pain and living successfully in the world in which they happen to be. There is a great deal of attention to cultural context, to children's experience and wishes, and to addressing practical needs for safety and effective nurturing.

Now the bad news: How many children who carry the scars of traumatic experience get this kind of attention? What percentage of kids who are disruptive in school just get slapped with a label of ADHD and given a vial of speed? What percentage of children who become aggressive, or addicted, or socially isolated, get any understanding and meaningful help from competent adults at all, and just end up in the juvenile justice system or go on to failed lives?

The fact is that the funding available from health insurance, public or private, just does not pay for these kinds of in-depth counseling and social work interventions. Even the most seriously disturbed children, who are involved in state child protection systems, are very lucky to get adequate help. The NCTSI right now is funding 33 programs in the entire United States, some of which do not even provide direct services. No doubt there is some other contract or grant funding from states or philanthropies here and there, but we all know what happens to the vast majority of children who suffer abuse or neglect, witness violence, experience catastrophes. And I just want to remind everyone that back when the putative president was still compassionately conservative, this was his signature issue. He was going to see to it that every child who needed help got it.

The president's budget for the new fiscal year phases out the NCTSI entirely. Its annual cost -- about 2 hours of war in Iraq.

Tuesday, March 04, 2008


C. and Kathy remind me that I probably gave short shrift to that morning panel of victims/survivors, and that readers are probably interested in their stories, and in particular what it means to go public. That was indeed a considerable focus of the panel.

One of the panelists was Barbara Feaster, who tells her story here. Apart from the very unusual detail that she was rescued because her father confessed to a clergyman that he was raping his daughter, this is an all too common story. The story after her rescue is unusual, however, both in that she was well served by the child welfare system, and her caseworker in particular; and that she has chosen to be publicly outspoken about her experience. For her, that is the ultimate victory: not only to transcend the damage done to her, but to devote her life to the cause of other children and to prove by speaking out that she has nothing to be ashamed of. Shame is the greatest burden that abused children have to bear, and clearly she has defeated it.

Another of the panelists whose story is available on the web was Michelle Renee, whose Internet presence is a bit less inspiring, in my view. She has turned her victimization into a business -- and now she's even picked up sponorship, like Tiger Woods, in this case from Jenny Craig. I must confess I don't remember this, but apparently in 2000 she was the victim of a spectacular crime that filled up CNN for a couple of news cycles, when she and her daughter were held hostage and wired with explosives by bank robbers. She was previously abused as a child, so now she is able to view trauma from the standpoint of child victim, mother, and adult crime victim. I certainly admire her courage and resiliency, although the way she has commercialized her fame may seem slightly off kilter to some.

As for why the panel consisted entirely of women, I would say that it is generally more difficult for men to admit that they have been abused, whether sexually or physically. Men are supposed to be strong, and dominant. Victimization doesn't go well with the gender role. One man who has very courageously broken this mold is professional hockey player Sheldon Kennedy, who was abused over a period of years by his junior hockey coach. How he found the courage to come forward in the macho culture of the NHL I'm not sure, but as far as anyone has reported publicly his teammates, and the fans, were supportive. Perhaps if more men did come forward they would find it is a path to healing, as Barbara Feaster has.

But I'm not a clinician and as a social scientist this is not an issue I have studied. Perhaps readers will have more to say about it than I do.

Cross of Gold

The Randomized Controlled Trial (RCT) is the so-called gold standard for determining what is and is not evidenced based therapy. When we talk about the clinical trials submitted to the FDA in new drug applications, that's what we're talking about. When people call for Evidence Based Medicine, they mostly want doctors to use interventions that have been "proven" through RCTs.

So it was refreshing to day to hear Malcolm Gordon, who is an official of the Center for Mental Health Services, tell us about many of the reasons why RCTs don't necessarily tell us what does and does not work when it comes to mental health services. For example, they are very expensive to do, so they seldom go on long enough or have large enough sample sizes to support adequate subgroup analysis. An intervention that works for some people might not work for others, but we just don't get the information we need from RCTs to understand that. Attrition is a big problem in trials, particularly of mental health treatments, and it can seriously mess up the statistics. A truly major problem is that interventions are developed, implemented and tested in highly specialized settings and circumstances that just don't correspond to anything that is likely to happen in the real world of the mental health system.

I'd like to offer another major problem with RCTs in the context of mental health, which expect Dr. Gordon wanted to get to but didn't have time. They depend on very highly specified, standardized interventions. But counseling interventions just aren't like that. You can't read people a script, you have to respond to specific needs, capacities, and wishes of the individual client. Some people need more of this and less of that, more or less time in therapy. Above all, a lot depends on the talent of the counselor and the fit between counselor and client. A counselor might help some people and not others -- even hurt some people and help some people -- and the same people, if they went to different counselors, would end up with different patterns of outcomes, even though everybody is implementing the "same" intervention.

What is more, these interventions are given in settings that have varying capacities for case management, flexibility with scheduling, providing supportive services; different language and cultural capabilities; different physical and social settings. All of this matters as much or more than the intervention manual.

That's why, in my view, the so-called evidence base for mental health consists mostly of cognitive behavioral therapy, and pills. Pills for the most part don't work all that well, but they're easy to standardize and test in RCTs. Of course, they're also very profitable so a lot of money is invested in getting them approved. CBT, among all the counseling interventions, is probably easiest to standardized, and it's also relatively short term, so it's cheaper to test and you have less trouble with attrition.

In other words, we're looking under the lamp post because that's where the light is. The first part of the morning consisted of listening to stories from survivors of trauma -- women who had been sexually abused as children, or victims of violent crime. They were convinced that they had benefited enormously from therapy -- that it had enabled them to put their lives back together. But I'm quite sure that none of the counseling they received has been subjected to any form of RCT.

Monday, March 03, 2008

A foray into the new media

Prof. Russell Korobkin of UCLA School of Law was kind enough to ask me to review his new book Stem Cell Century: Law and Policy for a Breakthrough Technology (with Stephen R. Munzer, Yale University Press, 2007). I haven't done book reviews here before, and come to think of it, I don't know that I've ever seen a book review per se on a blog. People say things about books, of course, but making fun of Jonah Goldberg is not the same as writing for the Sunday Times.

So how to do this seriously in the blogging form? Fortunately, Prof. Korobkin's book is divided into chapters which neatly address a number of discreet issues, rather than constituting a single arc of argument. That makes it particularly suitable for the format because I can make some overall comments here, then take on various of the chapters, each reasonably within the limits of a single post. Unlike a typical book review, of course, this one will be interactive to the extent that readers want to comment. What will be most exciting, of course, is if Prof. Korobkin cares to join us. I have no idea whether he will, but it's worth noting that in the Web Century, that is possible. So here goes.

Stem Cell Century looks at various problems in the domain of biomedical technology from the perspectives of ethics, law and public policy, with just enough science thrown in to clarify the substrate of these problems. Prof. Korobkin doesn't just mean to inform us, he means to convince us. The book may be described as a series of ethical or policy puzzles, through which he walks us to the solution. Each subsection concludes with a succinct QED sentence.

The casual news reader or viewer thinks of the controversy over human embryonic stem cells as being all about whether blastocysts -- the small ball of cells constituting an early stage embryo, from which HESCs are derived, at least until very recently -- have the moral status of human beings. Prof. Korobkin addresses this problem very cogently, but it turns out that's just the beginning. He uses the emerging research program and potential technology based on human stem cells (it starts to open up a bit whether they are necessarily embryonic stem cells) as a frame to discuss cloning (a partly separate issue), biotechnology patents (with collaborator Stephen Munzer), issues pertaining to public financing of biomedical research, the ethics of human subjects research, people's ownership stake (if any) in the products and pieces of their own bodies, and the regulation of innovative medical treatments. You may recognize some of these subjects from Stayin' Alive, so the book is most welcome here.

I would say that Stem Cell Century is written with the comparatively sophisticated and highly engaged lay reader in mind. Korobkin doesn't assume much prior knowledge on the reader's part, whether of science, law, ethics or policy, beyond what one would hope a decently informed citizen would have. The style is lucid and accessible to people without specialized training or pre-loaded storehouse of jargon, although you will need to deal with a considerable list of acronyms. Those who find themselves acronymically challenged might want to have a paper and pencil handy.

It seems likely that most readers will in fact have a substantial background in one or another of the relevant disciplines or problem areas, so some passages will be review of familiar information. That won't do you any harm. However, not everybody will find that every chapter gets the juices flowing. The section on patent law, in particular, gets pretty deep into the weeds of legal sophistry while the payoff for the concerned citizen could probably be summarized very succinctly.

Indeed, I expect that for most readers the first issue addressed in depth -- what is a human being and is an embryo an example -- is going to be the most compelling, and that the rest of the book may seem something of an anticlimax. As I said, that's what the loudest public controversy has been all about, and it's obviously about the most important ethical question there is. What respect is due to human beings, and what entities are worthy of that respect? Most people are already fairly passionately involved in that debate, and it has deep connections to other problems people care about, such as abortion and the end of life. Once Korobkin has walked us through that -- as he does very cogently and enlighteningly -- how much rooting interest do we have left for property rights and regulatory theory?

Well, that's too bad, because these other issues do matter, quite a lot, to us as taxpayers and to potential beneficiaries (or victims) of biomedical advances. Where Prof. Korobkin has perhaps done himself a disservice is in framing all of these discussions in terms of stem cell research and/or therapy. In fact, the ongoing biomedical revolution is considerably broader than that, and offers compelling examples from other domains -- such as gene therapy, monoclonal antibodies and other bioengineered "large molecule" therapies, neuroscience, etc. -- that could help liven up much of this discussion and connect it to other controversies with which people are already engaged. The stem cell frame seems arbitrary, once we get beyond the embryo problem, and even a bit misleading.

Fortunately, we'll be free to pull in some of these other areas of biotechnology in upcoming posts. Of course, it turns out that Prof. Korobkin doesn't succeed in selling me every one of his QEDs; I agree with him mostly, but not entirely. So we'll take on those points as well. I'm looking forward to it.

Sunday, March 02, 2008

A thought or two before jetting off

Flying is only slightly less unpleasant than being waterboarded, and I'm going to have to depart the east coast in the evening, to arrive in LA in what the people there think is the evening but is the middle of the night to me, and then find may way to a hotel 35 miles away. Should be a true test of character. Then I have to spend Monday in a meeting, presumably awake. So if I don't post tomorrow, you'll know why.

Today, I've been thinking -- inescapably -- about our corporate news media and the profound harm they do to our culture and our national interest. Lots of people in the blogosphere are on the case -- which is pretty much the only place we have to criticize them since they are incapable of insight or self-criticism, and do not allow substantial criticism from the outside to make it onto their letter pages, op-ed columns, or TV gab fests. Oh, you'll see some faux media criticism, but it's guaranteed to miss the target.

We all know many of their basic failings all too well -- from transcribing the he said/she said without bothering to point out that one of them is telling the truth and the other isn't, to unquestioning and uncritical transcription of military and government propaganda (often even ignoring the opposition's she said, which is usually timid anyway), to covering election campaigns as if they are high school popularity contests.

But what has struck me particularly lately is that by allowing the agenda to be driven by political actors rather than the real world, they completely fail to inform the public about the problems facing the nation. This isn't necessarily because of their own political biases -- it's really a function of laziness and ignorance. You don't actually have to know anything to be a reporter. And the politicians keep much of what matters off the agenda because it doesn't serve their own interests to talk about it.

In 1977 president Carter warned the nation, in a nationally televised address, of a "national catastrophe" if we didn't make a major effort to reduce our consumption of fossil fuels. You know what all that negativism got him -- no second term and a presidency widely characterized as "failed." Of course Carter was right. We spent the next 30 years in denial and now we're in profound trouble. The problems facing the United States right now are so complex, so difficult, and so threatening that any politician who dared to tell the truth would be writing his or her political obituary -- the American people don't want to hear it, they want uplifting rhetoric about Hope, and Morning in America, and Shining Cities on a Hill. They don't want to face up to bad news and they don't want to be told they are going to have to sacrifice and take on responsibilities that are inconvenient or unpleasant.

True, the Cheney administration has relied heavily on fear as its main political currency, but the reason it worked for them, for a while anyway, is because they also claimed that they alone would keep us safe and that we didn't actually have to make any sacrifices or suffer any unpleasantness if we just surrendered power to them. They offered a false choice of safety, and told us to go shopping.

Fear is good, after all. It's because of fear that I'm typing these words and you are reading them, because without fear, our ancestors would have been extinguished. The problem is not that Karl Rove tried to scare us, it's that he was lying about the true dangers we face, and lying just as egregiously about the solutions.

A politician who tells the truth will not be as likely to succeed, because, in the first place, there is no guarantee that we can find solutions that won't entail real reductions in our standard of living and an honest acknowledgment of failure and loss. In the second place, there are no solutions that won't require real commitment by people at all levels, individually and community, and changes in our way of life. You can scare the people, but that alone does not motivate changes in behavior and thinking. It's just as likely to drive people into denial.

Given that politicians can't afford to tell us the truth, somebody else has to do it. That obviously isn't going to be Tim Russert or Chris Matthews or Katie Couric, who owes her very job to her perkinesss. I'm really at something of a loss about what to do about this.