Saturday, December 15, 2012

The Epidemiology of Senseless Agony

Like millions of other Americans did yesterday, I listened to the news of the tragedy in the Sandy Hook neighborhood of Newtown, Connecticut while my emotions rapidly oscillated between fear, anxiety and outrage. I spent most of the day seeing patients in the hospital and so was only vaguely aware that something terrible had happened. I got into my car in the early evening and soaked in what details were known as I made my way on the hour long commute into Boston where we were having dinner with some friends. I walked into the door, found my child, and held him while I wept.

Surely that scene must have played out in countless homes across the United States yesterday--private moments of utter grief as we contemplate the suffering that must be taking place for the families of those children and teachers in Connecticut. So too are the numerous public expressions of shock and horror that could be found on Facebook or Twitter. Everyone wants to express something of the peculiar emotional state in which we find ourselves after yet another mass killing of people whom we do not know but whose lives very much resemble our own. And so we have, and it is very nearly unbearable to read a Facebook news feed today.

I am no different in wanting to say something to help process my own sorrow, and the words I can summon have already been used by tens of thousands of others: unspeakable and unthinkable and horrific and on and on. But Sandy Hook can also be described in different terms besides moral outrage, and one term in particular leapt to mind because I am a physician and because I treat infectious diseases.

Sandy Hook is part of an ongoing epidemic.

It is an epidemic in every traditional sense of the term: it affects "many persons at the same time, and spreads from person to person in a locality where the disease is not prevalent", as describes it. It is prevalent, and it is widespread. It is, in a very meaningful way, a disease that continues to afflict our country, and will continue to reach new communities unless it is stopped.

For Sandy Hook is, as everyone knows, not an isolated incident, but rather simply the latest in a string of horrors that began its modern phase with the Columbine massacre in 1999 and has included the Virginia Tech massacre in 2007 and this year's repeat performance in Colorado at a movie theater in Aurora. Like, say, HIV, where strange isolated cases cropped up decades before the full-scale epidemic began in the 1980s, almost serving as a warning of things to come, mass shootings also have much earlier precedents, the most famous being the University of Texas shootings in 1966 and, more obscurely, the Bath School incident in 1927 (which was for the most part a bombing rather than a shooting). Since Columbine, however, we've witnessed a steady stream of mass death.

Against the backdrop of these earthquakes of violence are what might be thought of as tremors of shooting--dozens of one- or two-person killing events that would hardly garner a blip on national news coverage today, so desensitized have we become to gun violence that mere individual shootings do not merit our attention or alarm. (The Wikipedia link only deals with school shootings: actual gun violence in the United States currently accounts for over 30,000 deaths per year, which is roughly the same number of people that die of influenza on average in any given year.)

From an epidemiologic perspective, gun violence precisely resembles any number of lethal infectious diseases. And like other infectious diseases, it will not abate simply of its own volition, our expressions of rage and grief notwithstanding. No amount of candlelight vigils or eloquent statements from public officials will put a dent in this problem. We'll see another Sandy Hook, and we'll probably see it again within the next year or two if this behaves like any other uncontrolled epidemic.

So what will make a difference?

I think it's helpful again to look at how we treat infectious epidemics. Over the past several months there has been a very deadly multistate meningitis outbreak; 37 people--almost exactly the number of the Aurora and Sandy Hook casualties combined--have died thus far. And the response of our government has been swift and definitive. The company which was the source of the outbreak was quickly investigated and shut down, as were other pharmacies who were immediately inspected as well. The FDA, CDC and various state health authorities worked in close coordination. And as a consequence of a government that functions to protect its citizens, the outbreak appears to be under control. Should we expect less of our government to address the problem that led to Sandy Hook?

Yet the epidemic of gun violence, which is a far more serious and prevalent problem in the United States, remains "untreated". Indeed, even initiating a discussion about how such a treatment should be administered can cause fierce recriminations. Only a week ago, sports journalist Bob Costas opined in his typically erudite fashion that the Jovan Belcher tragedy might not have happened at all had it not been for Belcher's possession of a gun; the roar of the right wing could be heard immediately. Even the President's statement about Sandy Hook, while unquestionably tactful, was extremely cautious on the subject of gun access. No such caution would have been in evidence had he been speaking about a case of Ebola.

As someone who knows something about how infections and epidemics behave, I'm confident that if we don't change the way we understand an unregulated gun culture, Sandy Hook won't be the last victims this disease will claim.

Tuesday, December 4, 2012

Pure Paul Krugman: Healthcare Costs

"The point is that if you want to control Medicare costs, you can’t do it by kicking a small number of relatively young seniors off the program; to control costs, you have to, you know, control costs...The key is having a health insurance system that can say no — no, we won’t pay premium prices for drugs that are little if any better, we won’t pay for medical procedures that yield little or no benefit."

This from his blog. I'd only add that we also need to figure out a way to say "no" to the needless prolongation of life in ICUs in people who have virtually zero chance of recovery. It accounts for an enormous amount of our expenditures, although I don't have the references on that at my fingertips.

Sunday, November 25, 2012

Write Shallow, Narcissistic Prose, Become a Published Author in the Times!

With our limited audience at the Billy Rubin Blog, we pine for the kind of attention that Lori Gottlieb has received throughout her professional career. Dating back to her days as a post-bac premed student, she was earning a name for herself in national publications: here, for instance, she dished up the skinny in Salon on interviews with mean people at Harvard Medical School back in 1999. Since then she has undertaken a rather dizzying set of career changes (for instance, she dropped out of med school after two and a half months because "she didn't like being around sick people"--even though the first two years of med school involve almost zero exposure to sick patients) but all the while pumping out essays and eventually, books, mostly memoirish accounts of her various professional adventures and misadventures. Today she has the kind of legitimate following that would make us pee our pants out of delight. Our envy is unadorned.

That said, much though we covet her following--or at least the idea of a following, though not so much hers in particular--we'd never stoop to the type of writing in which Ms. Gottlieb engages. Key recent examples include last year's offering in The Atlantic, "How to Land Your Kid in Therapy", as well as this week's remarkable meditation on the decline in psychotherapy, "What Brand is Your Therapist?", which appeared in the Friday edition of the Paper Of Record. "Remarkable" in that it really isn't an analysis at all of the profession and the challenges it faces, although it does provide some verbal window dressing in the first few grafs to make it seem so. Instead, it's the kind of piece for which Gottlieb is justly renowned: a me-me-me account of her experiences trying to start up her practice. Fully, three out of the 39 paragraphs do not contain the words "I", "me", or "my"--and the remaining 36 typically feature one of those three words in the first or second sentence. You may think you're reading about the modern state of psychotherapy; actually, you're reading about--may we use her first name?--Lori.

Here at the Billy Rubin Blog we have no qualms with the memoir, nor with centering a narrative around the concept of me. We are huge fans of Hunter Thompson, Ruth Reichl, PJ O'Rourke, Bill Bryson, Joan Didion, and Calvin Trillin--all fine writers whose central subject is often (sometimes only) the first person. But Gottlieb is playing at something else entirely: she's posing as a serious analyst about serious issues when in fact she is, at best, a shoddier version of the above masters of the craft. "How to Land Your Kid in Therapy" is in essence the uninformed musings of a trainee. She displays no evidence of having spent any serious time studying such an important topic or having considered what the research might have to say about parenting styles. Basically, she used her media persona to spin a couple of therapist-patient sessions (while a greenhorn, no less) into a full-fledged theory of childhood emotional development. Was The Atlantic doing anyone any favors by publishing this? Is the New York Times doing the same this week?

We think not, so waste not your time when you see her name in print, unless you, like us, can't avert your eyes from disaster in the same manner as watching the aftermath of a car accident. Which is, in summary, an apt description of her oeuvre.

Monday, November 5, 2012

One Offs: MA Question Two and Nate Silver F/U

Normally at the Billy Rubin Blog we like giving a good 12 paragraphs to explore the intricacies of an idea, but no time for that today. Before the election, though we want to follow-up on two themes about which we have been writing this year: Physician-Assisted Suicide and, more recently, the phenomenon of Nate Silver.

In Massachusetts this year, Question Two on the ballot proposes a legalization of PAS. It is often described as a "liberal" issue. I don't think it is, and I'm voting No--as emphatically as one can, given that voting consists of coloring an oval black, but there you have it.

The reasons to oppose PAS, especially from a lefty point of view, are twofold:

a. Hospice is wildly underutilized; and
b. PAS should only be practiced in a place in which all citizens have equal access to good health care, and even with the Affordable Care Act we are still a long way from that.

PAS has the feel of a hot-button issue--strong opinions on both sides with heated rhetoric and fierce stands based on core moral beliefs. But unlike, say, abortion, PAS is mostly a smoke-and-mirrors debate where there's very  little "there" there. Even in Oregon, the PAS pioneer, there have been only about 600 "prescribed" suicides in 18 years since legalization. But PAS has substituted for a more substantive discussion about how we will treat end-of-life issues in the US. At a time when we need to examine how we spend money on our health because we cannot sustain our current model (which isn't a good model anyway), that's lousy politics for the left, right, and center.

Onto Nate Silver.

We wrote that being "against" Nate Silver generally showed a contempt for science and mathematics, and we still stand by that claim. However it's important to note that Silver isn't a stand-in for Truth, and that if his success in political prediction matches that of his baseball analysis acumen, the Dems may be in for a very rocky night tomorrow and the Billy Rubin Blog staff will have one phenomenal hangover Wednesday morning. That is, Silver's statistical baby for baseball, named "PECOTA", hasn't performed significantly better than other models predicting player performance and has done so using a cranky, Rube Goldberg-like statistical contraption. Colby Cosh of Maclean's (a Canadian publication) heaps reams of skepticism on the Silver phenomenon here.

Cosh's writing is really good and provides some fresh insight from a guy who appears to be steeped in the numbers, although that said I think he's mostly missing the point. As can be found here and here (and talked about over here), there are number-crunchers who can provide plausible scenarios of why we might wake up trying to familiarize ourselves with the phrase "President Mitt Romney". But this is a question of "what is the underlying reality of the campaign, and how do we find data to help make an accurate prediction?" That question of late has frequently become morphed with "which guy do you want to win?", and Silver, who is almost completely a numbers geek with very few overt partisan leanings, has gotten pegged by conservatives as being in the tank for the Obama cause: right wing paranoia if ever there was any. This is why people have been giving pushback on Silver attacks.

Indeed, there were plenty of Dem-leaning commenters on the Cosh/Maclean's piece that welcomed the critique, because they endorsed the idea of data-driven analysis and not cult-of-personality devotion to Silver. Said one commenter: "I think Silver is a good thing for journalism, but it is misleading to call him a statistician or a scientist. He's something else entirely: a data journalist. He's a very bright guy to have spotted the gap in the market which opened up thanks to the easy availability of data, which mainstream journalists have no training or inclination to use." That sounds right to me, and is the best explanation of King Nate's popularity. Indeed, Silver's book Signal and the Noise is mostly a journalist's account, and it's a really good read.

We will wake up Wednesday morning and will know, given many Senate and House races in addition to the 50 state Presidential races, whether Rasmussen's polls, which have always favored Republicans by about 2 points this year, are more accurate than Quinnipiac's or anyone else's. If so they're probably doing something right and have a better model. Sure, some on the left have foolishly conflated support for Silver with support for liberal political issues, but crying foul against libs who Don't Get It is an exercise in false equivalence. The vast majority of the right wing screeching about Silver has not had to do with an opposition to Silver's possibly errant calculations, but rather with a resistance to any data that does not support one's ingrained assumptions.

More than anything else, this is why we find the Republican Party as currently constituted a menace to society, and until this problem is fixed, we have a very deep political problem in this country.

Saturday, November 3, 2012

What Being "Against" Nate Silver Really Means

Here's a prediction:

Barack Obama is going to win the Presidency.

Does that mean he's definitely going to win it? No.

Is he likely to win it? Yes, he is. He's got about a 3 in 4 chance of winning. It's not a coin flip. Romney has to have a lot of things break his way on Tuesday to capture the White House.

Why am I fairly--but not absolutely--confident that this will be the outcome? Because I've been following the polling for the past two months. There are a lot of sites that analyze various kinds of data and have a computer model to predict who is going to win, including, the Princeton Election Consortium, Votamatic, Real Clear Politics, and a host of others (see Votamatic's blogroll for the others). I have been keeping up with them, and for the most part, they're generally in agreement that Obama is the clear favorite.

The most famous of these predictors is a geeky stats guy named Nate Silver, whose blog back in 2008 became so popular that the New York Times incorporated it into their product. And as the campaign has proceeded, Silver has analyzed the race and provided reams of commentaries, caveats, and digressions worthy of a Talmudic scholar. But he's been extremely clear about the bottom line over the past few weeks: Obama is the favorite.

That means he is likely to win but is not a lock. A very simple analogy will suffice: as of today, with three days to go in the race, Obama is up by two and Romney has the ball on his own 17 with one timeout and 1:20 on the clock. Most teams in that situation won't win, although of course some will. Now, if you were to bet on Team Romney, you'd want something better than even-up odds. If you offered a bet with anyone at that moment in the game that Team R would win, you would find no end of people willing to take you up on the bet. This is where we are in the Presidential Race, and this is what Silver has been writing for some time.

The bet scenario is in fact quite real, as Silver, in what appears to have been a fit of pique, took an even-up bet on Obama with Joe Scarborough, host of MSNBC's "Morning Joe". Two grand will be donated by the loser to the Red Cross. The bet arose from some trash talking on Morning Joe, where Scarborough called Silver "a joke" and more-than-implied that he was in the tank for Obama. See here for further explanation (including the incoherent warbling of NYT's most famous tweedle-dee, David Brooks), and here for a rundown of other attacks on Silver.

The comments indicate that Scarborough is either irredeemably stupid, or frightfully uninformed for a TV news anchor, or deeply cynical, or some combination of all three. A casual perusal of Silver's blog indicates that he's a guy fascinated with statistical analysis much more than he is of partisan politics. There is never a potshot laid at Romney, even when he so richly deserves it. Yet because he happens to be a guy delivering news that one with a Republican bent doesn't want to hear, suddenly Silver himself becomes the subject of personal attacks due to his perceived partisanship.

Ladies and gentlemen: the Republican Party of 2012.

What being against Nate Silver really means is that you are against a particular way of thinking about the world, and the boundaries go well beyond calling the Presidential horse race. It's a mindset that refuses to accept any information that does not fit with predefined conceptions about the world, whether that information relates to an increase in global temperatures, the existence of evolution, or the value of public health. In short, it is a medieval understanding of the world, and the contempt shown for Nate Silver--an otherwise harmless and bright dweeb--is an exemplar of that way of thinking, if it is worthy of the term "thinking" at all.

I am distrustful of Republican political philosophy for a variety of reasons, all of which may be wrong. But I will be voting for Barack Obama--a politician for whom I now have very little enthusiasm--not so much because of these differences in philosophy, but because of the Brownshirt-flavored anti-intellectualism of the modern Republican party.

ps. Also worth noting that Silver's new book, The Signal and the Noise, is an exceptionally good read.

Monday, October 1, 2012

Ezra Klein's Medical Metaphor of Congress

With which we agree entirely: "If Congress was your doctor, they'd give you too few antibiotics and, when that failed, give up on the idea of antibiotics altogether".

We'd frame it ever-so-slightly differently here: first they'd give you the wrong antibiotic (military spending), then underdose it (budget sequestration), then give up on the idea of antibiotics altogether (threaten to default), then claim you do not suffer from an infection (return to embrace of Bush 43 economic policies), and then deny that there are such things as germs in the first place and allege that your illness is due to insufficient faith (self-explanatory). Only Twitter will not allow for that length, which is among the reasons why we've never been able to embrace Twitter.

Saturday, September 29, 2012

The Psych Approach to David Brooks

My mother and I tend to agree about most political issues, but we have a long running dispute about the wisdom of one political pundit, New York Times columnist David Brooks. The role Brooks occupies is a relatively new entry in the NYT columnist lineup, not really replacing the true "House Conservative" position of William Safire, one which was adopted by Bill Kristol and is currently held by the ever-fascinating Ross Douthat. No, he's more of a living, breathing embodiment of what George Bush 43 referred to as the "compassionate conservative"; he's a man who believes in the policies of the Republican party--at least the economic and tax-regulatory ones--while showing an interest in social issues related to the quality of how people live and what can be done to make people's lives better. Also unlike the Saffire/Kristol/Douthat crew, Brooks's rhetoric is milder and more gentle. Not that someone like Douthat is in the same camp as, say, Mark Levin, but you get the point.

Momma calls this "centrism" and thinks he's nifty; I call it "inherently contradictory for the most part" and think he's shallow but coated with a thin patina of gravitas...which fools people like Momma, bless her soul. "Nitwit" seems too strong a word, especially as he has such a fine command of the English language, but his analytical mind doesn't seem to far off that description from where I stand.

Comes this week's entry: The Psych Approach, a column devoted to taking a look at the social science research known as the Adverse Child Experiences, or "ACE", study. ACE is a survey of about 17,000 people, and looks at particular formative experiences (such as alcoholism in a parent) and current life/health issues (self-reported alcoholism, stress, depression, smoking) in an attempt to look for correlations. For instance, this report demonstrates a significant correlation between alcohol use in a parent and current drinking problems. Further, they go so far as to say in this flyer that "[adverse child experiences] account for one-half to two-thirds of drug use."

I haven't seen the academic data, and while it looks a little slippery--for instance, it's never made clear what constitutes "alcohol problems" so different responders may have wildly varying definitions, making absolute comparisons tricky--it nevertheless seems like a solid piece of epidemiologic research, one that not only documents the importance of formative experiences on current social and health issues, but quantifies it as well. Thus a useful body of data for someone interested in thinking about public policy, like, say, a politician...or at least his or her staff that have the time to read such stuff and think about how government policy can have an impact on such issues.

And here's where Brooks takes his cue. He starts off by noting that maybe government has been looking at fixing the wrong thing:

In the past several decades, policy makers have focused on the material and bureaucratic things that correlate to school failure, like poor neighborhoods, bad nutrition, schools that are too big or too small. But, more recently, attention has shifted to the psychological reactions that impede learning — the ones that flow from insecure relationships, constant movement and economic anxiety. 

And the fix for this? Well, in short, get everyone on the same page to work creatively and for the common good in a "failure is not an option" mode:

When you look over the domestic policy landscape, you see all these different people in different policy silos with different budgets: in health care, education, crime, poverty, social mobility and labor force issues. But, in their disjointed ways, they are all dealing with the same problem — that across vast stretches of America, economic, social and family breakdowns are producing enormous amounts of stress and unregulated behavior, which dulls motivation, undermines self-control and distorts lives.

Maybe it’s time for people in all these different fields to get together in a room and make a concerted push against the psychological barriers to success.

It's a provocative thought. It also is exactly the kind of thought that someone who believes that government policy can make a difference in people's lives would express.

Now, once upon a time, it was a thought that could have been expressed out loud by a member of the Republican party. The disagreement, the Republican would insist, is not whether government can affect change but simply how the government should go about doing so. But that Republican party is long gone, and what appears to be an interesting observation from Hypothetical Presidential Candidate David Brooks would have been derided by his opponents for being "socialist"--which, in the language of modern Republicanspeak, means "anything with which I disagree".

It's a sentiment that would have been expressed by the kind of Republican who, twenty years ago, would have endorsed a public/private solution to the problem of tens of millions of Americans lacking health insurance. In fact, such a solution was proposed and became known as "Obamacare" and was met with fanatical opposition by the current Republican party. Yet the law is thoroughly Republican in its philosophy and was a disappointment to people who a generation ago would have been considered "centrist Democrats". Though now, through the magic of political alchemy, they somehow have been branded "far-left radicals" (and, of course, "socialists").

In short, it's a habit of looking at the world that is not welcome by the modern, Tea Party-dominated Republican party. For David Brooks to find himself fascinated by such research--sponsored as it was by the US Federal Government via the CDC--and to think that such research might somehow lead to the world being a better place is nice. For him to think that the tail-wagging-the-dog Republican party which he so often lauds gives a damn is naivete in the extreme. Which we're used to from him by now.

Monday, September 17, 2012

Why Romney Failed...Wait, You Say the Campaign's Not Over?!

In the immortal words of Brad DeLong, why oh why can't we have a better press corps?

Even casual political readers this week can feast themselves on any number of Romney campaign obituaries and detailed post-hoc analyses of how the campaign stumbled--in past tense, no less!

Except the game ain't over. Yes, it's late in the third and Obama's up by 8 with the ball. But as the Arizona Cardinals discovered yesterday to their near-horror, even seemingly sure things can evaporate with an unfortunate error. An interception pick-six from Team Romney (a memorable one-liner zinger during the debates a-la "there you go again"--even though Carter's point was correct) and a two-point conversion (hundreds of millions of dollars of TV ads complements of Karl Rove & Co.) and you are headed down to the wire. This game ain't over, folks--but you might get a different impression from reading news analysis this week.

If you were reading all the political stories this week from Politico to Wall Street Journal (well, the op-eds anyway) to TPM you would have been reading story after story obsessed with the horse race rather than the underlying substance of the campaign. As political junkies, we don't mind a little bit of horse race analysis with our news, but the POTUS campaign coverage is alas mostly devoted to who's-ahead-other-campaign-in-chaos topics. As Sahil Kapur trenchantly observes, "once the 'Romney in disarray' narrative gets stale, it'll probably shift to 'Romney's comeback." And neither "narrative" should have any bearing on why someone should or shouldn't vote for Governor Romney or President Obama.

The central problem is that these stories crowd out much more important news. A little noted item in early September involved Romney saying that global warming is real and caused in part by humans. This is a policy statement of tremendous importance and should have been major news since it indicated a Romney policy shift away from one of the more insane anti-scientific tenets of the Republican base. (Although given Romney's previous slippery, contradictory statements on the subject, it might have simply been another "Etch-a-Sketch" moment in his say-anything-to-please-everyone campaign.) We should note that we think President O's response to on this and other topics makes much more sense. However, either way, Romney's statement was important--really important--and hardly anyone noticed it.

The Billy Rubin Blog is contemplating what to write in the event of a Romney loss: suffice it to say that we agree with the central premise of this article by Charlie Pierce. But before the media calls the game, maybe they should spend as much time and effort as possible to get actual news out about what the campaigns are saying. Yes, we thought the Clint Eastwood stuff was amusing, and maybe says something about whether Romney is qualified to be President...but not that much. Analyzing his statements on the middle class, however, really is important.

Wednesday, September 12, 2012

Media Avoids Numbers: Now There's a Surprise

There's a quick little ditty about raising the speed limit in Texas to a whopping 85 mph in the Paper Of Record this week. It quotes some local politicos as they talk with a certain puckish pride of these new autobahn-worthy speed limits. It details that Texan spirit of just-wanna-get-there, and includes a yarn about Governor Rick Perry getting pulled over a few years ago outside Austin when he was Lieutenant Governor. It mentions the almost incomprehensible size of the state and the vast stretches of nothingness between the big cities.

Cute. But what it doesn't mention is any kind of data to indicate how dangerous such new speed limits are.

This isn't difficult in the internet age. With a couple of clicks and the right words entered into Google, one can come up with a range of popular news pieces as well as scholarly articles about the actual, known dangers of such high speed limits. There's a lot of data out there to pluck off the tree. NYT couldn't even give a nod to this? I mean, if you're going put up a postcard about a fantastic speed limit--even if it's mostly intended to be a puff piece--don't you think it might be important to consider an obvious implication of the change? And we haven't even talked about gas consumption.

Not every article has to be a grim humorless slog through public policy. But one sentence about the potential dangers (not speculation, but the objectively known data!) of moving the speed limit well above where it was one generation ago doesn't seem to me to be too much to ask.

Tuesday, September 4, 2012

When A Few Isolated Deaths Should Be Important News

As we have recently discussed here and here, we're not big fans of the "One Person Dead Somewhere From Something Weird, Be Scared Shitless" news stories that frequently populate the health sections of various news organizations. But we think the story of these two deaths associated with the use of Neti Pots bears some careful attention.

Why is that, you ask? Isn't that a complete contradiction from what you've been writing--in recent entries, no less? Plus haven't you already castigated the media for covering deaths associated with this very organism (Nagleria fowleri)?

I don't think it's a contradiction, but a quick explanation of Neti Pots is required. The Neti Pot is used mainly for people with sinus congestion: the goal is to flush the sinuses via the nose with a salt-water solution and clear the mucus away. Having had major sinus problems over the past year for the first time ever, I've become a fan (though reluctantly, for sure--it's no fun cramming 200 ccs of salt water in your nose!).

There is one simple catch to the use of a Neti Pot: you have to use sterile water. Boiling water in your tea kettle and letting it cool down will work perfectly fine. Why? Because your tap water isn't perfectly sterile. Depending on where you live in the US and the type of water treatment facilities your state government runs, there can be a small number of various types of microbes living in your tap water. Note that I say living and not lurking: these guys are perfectly harmless if they travel down the gullet into the highly acidic environment of the stomach where they go no further. Tap water is one of the great advances of civilization--and one at which the libertarian wing of the Republican party appears to be at odds.

Anyway, while drinking tap water is harmless (unless, of course, if you're living in a place where fracking is commonplace), your nose ain't built to defend itself from these microbial badasses in the same way the stomach is, so flushing one's sinuses with a healthy amount of tap water constitutes a game of Russian roulette. As the NYT piece documents, two people have died from the tap water Neti Pot flush. True that in a country of 300 million it ain't much, but this news piece comes with a simple public service announcement. Boil the water, folks. And diphenhydramine or loratidine and their ilk work too.

Monday, September 3, 2012

Labor Day Links

A commentary in the NYT by economist Uwe Reinhardt looks at whether or not there is a physician dearth or glut. Not being highly conversant in the byzantine vocabulary of the dismal science, I cannot evaluate the merits of the article--nor am I totally sure that Reinhardt comes squarely down on one side of the argument (though he seems to imply we have too few physicians as a consequence of bad policies dating back to the mid-90s). The relevance here is that if you are contemplating attending medical school, you shouldn't let a story like this sway you one way or another. Yes, all sorts of things in medicine are changing, and yes, we have no way of knowing how those changes will affect things like salary and lifestyle and what subspecialties will be available; but we'll still need doctors a generation from now, so just apply.

NYT also notes a new strain of swine flu has claimed its first human victim, in addition to the fact that the CDC has stated that the strain can be spread human-to-human instead of the (less scary) pig-to-human manner. As we recently noted with the breathless coverage of the spread of West Nile Virus, fear can quickly warp a realistic sense of the danger this virus poses. Cheeseburgers, beer, and cigarettes continue to be considerably more lethal for the moment. (Though that said, we maintain a healthy respect for influenza here at the Billy Rubin Blog. When available, get your vaccinations!)

Sarah Kliff, a health policy reporter at WaPo, writes about health legislation in California defining the phrase "essential health benefits" to make explicit to insurers what services must be covered for the new customers being delivered to them compliments of the Affordable Care Act, aka Obamacare. (We could just as easily call this "Romneycare", though the Republican Presidential nominee would deny this to the point of an epileptic fit, so desperate is he to prove his bonafides to various Brownshirt constituencies. Whatever. At any rate, while the law is Federal, the States become the arbiters of local coverage to be provided by insurance companies.)

What's beyond mere wonkishness in this post is that the legislation includes acupuncture in the "must cover" list, while leaving out infertility treatment as well as hair restoration. Also off the list (so far) is chiropractic, as well as "massage therapy". This is an early signal of the kinds of battles that may well be looming as we begin to make hard choices about how we will spend money on health care in the years to come. Well-organized special interest groups may come to define what kind of care gets reimbursed, regardless of whether or not there is scientific evidence to support claims for health benefit. For instance, "acupuncture" is covered--but for what indication? Is it just acupuncture in general? Psychologists doing talk therapy are currently hamstrung by much tighter regulations than that, having to provide a specific psychiatric diagnosis for each session, even if several of those sessions could be easily described as "normal people working through normal problems".

I don't hold a strong opinion about this right now--there is a sufficient amount of incredibly expensive procedures in "mainstream medicine" that have little data to support their practice (back surgeries, anyone?). I am, however, concerned about medical reimbursements driven more by advocacy groups than by a rational analysis of studies designed to discover whether a given treatment really does have a benefit. I have no beef with people who want to go to their weekly rolfing session; I do not feel particularly inclined to subsidize it through my annual insurance premium.

Thursday, August 30, 2012

Let's All Calm Down About West Nile, Folks

Between trying to avoid the coverage of the Republican National Convention (no offense, guys--I will do the same for the Dems shortly) and winding down my vacation time, I haven't been soaking in much news this week. That said, it's almost impossible not to turn on a radio or flip through internet news sites without hearing some story about how West Nile Virus is sweeping the country. Normally I offer links for curious readers, but there are so many stories right now there's no point to it, as all one needs to do is to google the virus for the latest.

But before we all lose our collective heads over this outbreak, let's traffic in some numbers. As of  August 28 there have been 66 deaths attributed to West Nile out of 1,590 known cases of the disease. Now a 4 percent mortality is nothing to sniff at, but the overall number of cases is incredibly small. By comparison, as of mid-August the number of children who died from influenza--a disease whose mention hardly registers a batted eyelash at Labor Day cookouts--numbered 34, with a considerably higher number in adults (measuring adult influenza deaths is trickier, but suffice it to say that it's a much much larger number than that).

I could go on in this vein for awhile using different diseases for comparison. The point is that 66 deaths or 1500 illnesses in a country of 300 million people is not cause for panic. Getting into your automobile is considerably more dangerous than getting bitten by a skeeter while going for an evening run in Texas, the state with the most cases and deaths by far in the US. Don't put those sneakers away just yet (though the Rubin Blog does recommend putting on an inspect spray before lacing up). So let's all take a deep breath, folks.

Tuesday, July 3, 2012

Health News Belongs In the Health Section, Right?

Unless the New York Times thinks that a drug giant paying a $3 billion fine doesn't fit the definition of "health news". I tend toward disagreement. The article about GlaxoSmithKline and its whopper of a fine can be found in the Business section, but it appears nowhere under the health banner. This is particularly unfortunate because I suspect there's a lot of people who scan the "Health" headlines without ever entertaining a thought of browsing the Business stories. And in theory they'd be most interested.

Though tucked away in the wrong spot, the article is a good primer on issues related to inappropriate promotion of drugs by their manufacturers. In this case, GSK was fined for a variety of shenanigans, mostly related to its psychiatric formulary (the details of such misbehaviors, predictable as they are, are briefly sketched out in the article).

Perhaps the article's most important point is that, while seemingly a huge fine, it may be regarded as no more than a parking ticket to company executives. For starters, no individual will face any charges. "What we're learning is that money doesn't deter corporate malfeasance," former NY attorney general Eliot Spitzer is quoted as saying. Stifle the laughter: Spitzer, before his own fall from grace, sued GSK on behalf of New York back in 2004 for similar issues, so he's an appropriate sound bite for the article.

Thursday, June 28, 2012

Quick Take on the Supremes and the ACA

In the coming days there will be no end of commentary about the Supreme Court upholding the Affordable Care Act--foolishly called "Obamacare" by both proponents and detractors--in terms of both legal and political analysis. The early reactions are mostly predictable, and the media is running with the "elation among Dems, fury among Repubs" story and milking it for all it is worth.

At the Billy Rubin Blog, however, I'm not feeling so predisposed to shout mighty huzzahs in the face of the landmark ruling. Since I ain't a lawyer or a policy analyst, I can't comment on the ruling's legal aspects or how it will affect the coming elections. But this doesn't seem to be the Great Victory For Progressives that the mainstream media has already made it out to be. Sorry to rain on the parade, folks, but I'm inclined to think of this more like the Battle of Thermopylae: at best it's a rearguard action, and the odds of victory remain quite long since the opponents are determined and numerous. But I hate war metaphors, so ignore that particular piece of poetic excess.

I'm not so cheerful because a huge number of Americans--not millions but tens of millions--have no understanding of the ACA beyond the fact that it's a law and that most people refer to it as "Obamacare". Beyond this, they couldn't explain the law's contents in even the most cursory of fashions. Most, but by no means all, of those tens of millions of Americans are opposed to the law,  despite their broad support for the basic points of the law, as this recent poll demonstrates. Simply put, this means that far too many Americans are frightfully uninformed of even the most basic political issues, since this isn't some arcane matter requiring careful reading for months at a stretch (in the way that, say, the Eurozone financial crisis is). Though given that more than 60% of one thousand adults polled didn't think that Obama is a Christian, their inability to understand the ACA is no real surprise. It is difficult (impossible?) to have a functional democracy with this kind of ignorance.

I'm not so cheerful because this bill itself, the very bill that is being hailed by many Democrats as something akin to manna from heaven, is a generally crappy bill that was a far rightward compromise that left true progressives in a state somewhere between disappointed and appalled. Indeed, the "individual mandate" that Fox & Friends yowls about as being pure socialism was essentially invented in the offices of the conservative Heritage Foundation years before. Progressives wanted a single-payer plan: basically, Medicare for everyone. They were willing to settle for what became known as the "public option", where people could opt-in to government health insurance or get their own.

But that's not what they got--despite huge levels of support in the House and commanding levels of support in the Senate. In previous decades, when a majority of both the House and the Senate support legislation, and send it to a sitting President friendly to that legislation, a law gets passed. Only in this case that didn't happen: we got the individual mandate of the ACA because of a few allegedly "centrist" Dems and the fact that the Republican Party over the last generation has decided that--at least when it is not the party in power--Senate majorities must be sixty rather than fifty for a law to pass, and because the Democratic leadership is apparently so cowed by the Republicans that the bill shifted far to the right. Not that it ended up generating one single Republican vote in either chamber, but somehow the bill became a boon to the health insurance industry.

I'm not so cheerful because this President, for whom many of us had great hopes, has turned out to be not the socialist he's constantly accused of being by the imbecilic ranters of Fox and its ilk, but rather as one who starts out with centrist policies that get pushed ever rightward through various phases of acquiescence so that he may appear to be "above" mere partisan politics. We could easily substitute the President's name in this little one-off that describes outgoing Republican Senator from Maine, Olympia Snowe: "if [a Republican] proposed to spend one trillion dollars to erect a 100- foot-tall solid-gold Winston Churchill statue on Mars, [Obama] would no doubt decide, after careful deliberation, that the wise course was to trim the height down to 90 feet and perhaps use a cheaper bronze alloy in the base." Such is the "post partisan" approach of our President. He cut his stimulus package in half in order to entice three Republican Senate votes--votes which were utterly unnecessary for passage.

This man is not bold, he is not a shrewd negotiator, and we are stuck with him, or rather worse, for the next four years.

I'm not so cheerful because despite the fact that Constitutional Law scholars overwhelmingly agree that the ACA was constitutional and that the rationale for the challenge was weak, somehow the legality of the law was seriously in doubt, and most of those very ConLaw scholars figured the law would be overturned. When 90 percent of lawyers are in accordance that a law is both valid and likely to be declared unconstitutional, you are living in a country where significant chunks of the judicial branch are little more than formally robed hacks in service of a partisan machine, no more or less different than the judges who were part of Tammany Hall.

I'm especially not cheerful because the swing vote in this case was written by a man who is nearly certain to be under enormous pressure from various attach├ęs of the Republican Party in the months to come for having deviated from the pre-defined script. And besides that, although I am no legal scholar, there was something quite peculiar in his holding: some think that Roberts is using this opportunity to forestall criticism of a string of highly partisan 5-4 future decisions such as the gutting of the Voting Rights Act among others; others still believe that Roberts's tepid support of (and perhaps switch to?) the majority will allow for a later successful challenge anyway.

Even though the law has just barely squeaked by, it is still very much in jeopardy. The House will almost certainly remain Republican, and the White House and Senate are up for grabs. My only political forecast of this column: if the Republican Party can win the Senate but lose the White House, expect the law to be repealed, followed by a veto, followed by an impeachment. Would that the Democratic party possessed such fierce determination and rigid discipline within its ranks.

That's the view from here tonight. As we are fond of saying at the Billy Rubin Blog: cheer up, the worst is yet to come.

Wednesday, June 27, 2012

Germany Figures Out How To Unite Jews and Muslims

Pretty simple, actually: try to ban circumcision.

They seem to be taking rather the opposite approach in Zimbabwe, where male legislators set an example for their citizenry recently by having become circumcised as part of a concerted effort to control the HIV epidemic, since circumcision dramatically reduces HIV transmission. "Members of both main parties--normally bitter rivals--had the surgery," the article notes. This is leadership!

As the data on circumcision and HIV transmission are pretty widely known in public health circles, and given that there is other data suggesting other health benefits of circumcision, we at the Billy Rubin Blog suspect that the German court ruling is little more than anti-semitism masquerading as concern for children. But at least in this case the term "anti-semitism" joins those two normally factious cousins under one banner. Well done, members of the Fatherland!

Sunday, June 10, 2012

The Ongoing Yutz Chronicles of Ross Douthat

Every once in awhile I decide to tempt fate and find out whether I can stomach a Ross Douthat column in the New York Times. Invariably I find I cannot, though I hold out hope that someday he'll stop writing like a first-semester undergraduate straining to maintain that there really are simple and tidy answers to the world's ills--or indeed, that the world is in fact quite a simple place to begin with.

Today's column caught my eye because Douthat takes on the topic of eugenics. He notes, with partial accuracy, that eugenics were central to American progressive political philosophy 100 years ago, and key proponents included Planned Parenthood founder Margaret Sanger, a fact well known among antiabortion activists (as can be found here for example). The accuracy is merely partial in that he ignores how readily eugenic philosophy was absorbed by political thinkers on the other side of the spectrum as well, and hardly needs pointing out unless one has never encountered the word "Nazi". And while that particular political brand never caught on in the US, there were plenty of establishment types who had no love of progressive ideals and yet justified their politics through the work of Herbert Spencer and Francis Galton.

There's some potentially interesting stuff here given that prenatal testing and (so far) legal abortion may lead to a variety of ethical conundrums well beyond what we already face. But Douthat really seems to be interested in tarring perceived political opponents rather than exploring ideas, so he uses the Sanger connection to call the process of aborting a fetus with Down Syndrome "liberal eugenics". Curiously, he notes that approximately 90% of all parents who receive a "positive" test indicating they are carrying a Down baby will elect to terminate the pregnancy. Is this some kind of liberal affliction?

I am of the view that if Douthat could only figure out a way to point out that murder should really be called "liberal murder", he would have it on the pages of the Times forthwith. We'll have to stay tuned, I guess.

Wednesday, May 23, 2012

Annoying & Misleading Health News Titles

From the New York Times today comes this question: "Is Marathon Running Bad for the Heart?" Since one would normally assume the answer to be "no", the only logical conclusion one can reach is that the story casts doubt on the conventional wisdom, and perhaps the cardiac benefits of long-distance running aren't so great after all.

Yet the story basically does conclude that marathoning is quite safe for prepared athletes, and that heart attacks are extremely rare events. When such an event occurs, and a runner dies on the course, it makes big local headlines, thus warping the relative danger of the event. "The science suggests that, over all, distance running and racing are extremely unlikely to kill you — except when, in rare instances, they do," the article notes, although here at Billy Rubin central we don't understand why they added on the last caveat, since it appears to be redundant. Anyway.

Guess I would have preferred a title more along the lines of, "Study Confirms Running Still Safe for the Heart" or "Deaths from Marathons Extremely Rare but Dominate News Coverage After Races". The content of the story I wouldn't change, but I'm wondering how many people didn't read the story, glanced at the headline, and thought, "See? I knew running wasn't a good idea", as they sit on their couch watching the second hour of SportsCenter.

Wednesday, April 25, 2012

Blood, Death, Children, and Movies

I've just shown my 10 year-old children their first R-rated movie. Before you call the cops on me, I'd note that simultaneously, I've forbade my children to see a different movie--though it got a PG-13 rating.

Essentially, the first movie, despite its rather ominous rating, was a movie that I thought a child of ten years might be able to handle, though I knew it would stretch their limits. The second, PG-rated movie, despite several warm reviews I've heard not only from professional critics but friends as well, remains to my mind out-of-the-question as out-of-bounds despite lots of moviegoers singing its praises as its haul passes the $500 million mark in just over a month.

The envelopes, please? The latter movie is, of course, The Hunger Games, based on the trilogy by Suzanne Collins, a dystopian fiction that has been massively popular in its own right. From what I can tell, The Hunger Games seems a savvy commentary on mass communication, the reach of governmental power, the mechanisms by which people in positions of power are capable of maintaining their power, et cetera. I say that it seems that way because I haven't seen the movie and don't intend to. And I certainly don't believe that my children should be seeing it, now or anytime between now and, oh, say, their sixteenth birthday. Why's that?

Kids killing other kids. I heard Kenneth Turan's review on NPR while commuting to work, and when he explained the general plot outline, I had heard enough.

I don't mean to say that I think that The Hunger Games is necessarily a bad movie and that it shouldn't be seen by anyone. Far from it, it sounds like a provocative film (maybe: hard to tell) and by all means let adults and young adults flock to it. But I don't think children need to see a movie about children killing other children. I don't really care how well the movie is made, nor how deep its philosophical preoccupations. I'm simply astonished that a movie involving a plot line in which kids kill other kids could possibly receive a PG rating. Indeed, I'm appalled. Do we collectively think this is an acceptable story to tell our children?!

Meanwhile, I couldn't help but chuckle as we sat in our family room watching the R-rated The Red Violin, likewise a movie focused (in part, at least) on children, death, and blood, though to my mind in a manner entirely acceptable for a child of ten. The R rating is due to a brief moment of tush and breast--in a manner that can only, in this desensitized age, be described as "mildly erotic at best"--and a scene in which a male actor basically makes love to the eponymous violin. (Owing to the time-honored double standard of male and female nudity, however, no actual cock makes it way onto the screen.) For the nude scenes in question, my daughter hid her eyes unbidden behind a pillow; my son didn't make a peep, so hard to know precisely what was going on in the moment with him. I could speculate. At any rate, The Red Violin is a movie as much about love as about death, and it is most definitely not about killing.

Side by side, seeing these two ratings matched against each other, it is hard for me to feel anything but despair that our national ratings board would discourage pre-teen children from watching a movie in which the naked human form is displayed (briefly!) in an otherwise heartwarming tale about love conquering time and death, while simultaneously being apparently nonchalant about the visual portrayal of the most grotesque actions imaginable in cinema. The Hunger Games may be deep; it may be reflective; it still sounds like Snuff to me.

Might those astounding box office draws have played a role in the rating so as to allow for the largest possible audience? Hmm.

Sunday, April 15, 2012

Physician-Assisted Suicide in the US: Don't Compare it To Europe

Earlier this week the New York Times held a "Room For Debate" roundtable on Physician-Assisted Suicide that left me mostly frustrated. Each of the eight participants took no more than about four paragraphs to share their viewpoint, which is far too brief to introduce laypeople to some of the minefields associated with the practice. The topic is just too complicated for that kind of brevity by my reckoning. None of the authors gave more than a glancing nod to issues surrounding palliative care, a huge omission since it's at least possible, if not likely, that many people who support PAS do so out of a largely erroneous belief that people with terminal diseases, especially cancer, often die horribly painful deaths that modern medicine simply could not prevent. I'm assuming that these writers, several of whom are renowned experts in this field, eschewed writing about palliative care not by choice but by length limitations imposed by the editors, but that's just a guess. Hey Times--give 'em eight grafs! I promise your readers will read it!

We at the Billy Rubin Blog are strongly opposed to PAS--a topic that we have briefly touched on in our discussion of the profound media misrepresentation of Jack Kevorkian, as cold-blooded a murderer as has ever walked the earth and who got away with over 100 butcheries by cloaking himself in self-righteousness and preying on the public's abject fear of (mostly) cancer. There are more judicious docs who support the practice, such as Timothy Quill, who proposed a "constitutional right to suicide" that the US Supreme Court didn't come close to buying (it was rejected 9-0). While I respect guys like Quill and don't think they need to be stripped of their licenses (unlike Kevorkian), I do believe it is unethical to participate in suicides, even if some Northwestern States give it their legal imprimatur.

Too-abbreviated a discussion or not, one excellent point kept cropping up by the PAS opponents. PAS supporters are fond of invoking the situation in the Netherlands, where the practice has existed for decades and doesn't appear to be highly controversial today, nor does it appear to have become a back door for euthanasia as many in the US fear it will. But this is most definitely not an apples-to-apples comparison, since US health care mostly functions as a free-market phenomenon, where secondary incentives can play a role in motivating patients, families, and insurance companies to nudge people along the path. As this article notes, at least one such scenario like this has already played out in PAS-legal Oregon.

We'd prefer the Dutch abandoned the practice altogether, but either way we heed this observation from Dr. Petra de Jong, the head of Right to Die Netherlands: "Euthanasia and assisted suicide can only be legalized in a country with optimum health care, including palliative care. But most of all, with citizens having access to good health care, regardless of their income." Yep.

Sunday, April 1, 2012

The Story of Haiti's Cholera: No Silver Lining

Today's New York Times has a long report about the history of the introduction of cholera to Haiti following the earthquake. Introduction is the operative word there: despite all of the calamities that have befallen this most downtrodden of nations, cholera had spared the little half-island, despite outbreaks in nearby Latin America in the 1990s.

Cholera was absent before the earthquake, at any rate, and it ended quite likely with the arrival of Nepalese soldiers working for the United Nations. The short version is that it now appears that these soldiers unwittingly harbored the bacteria in their guts ("asymptomatic carriage" is common for diarrheal diseases like cholera and typhoid fever), and the bacteria was introduced to the water supply by inadequately-dug latrines leading to overflow into tributaries of the Artibonite, Haiti's principal river and the Haitian equivalent of what we think of as the municipal water supply--meaning the river in which hundreds of thousands of people bathe & wash.

After the bacteria took up residence in the guts of the locals, the outbreak was on, and since then 7,000 people have died, and we may be in for more as the rainy season begins anew. As we have noted before, this is a tragedy on a massive scale, and is getting scant play in the American news media, NYT and National Public Radio notwithstanding. The TV bigs must think that the quake makes for so much more exciting viewing. Maybe thousands of new graves in the coming months will change their minds.

The article does a good deal of post-hoc finger-pointing at the breakdowns in communication, coordination, and general inability to react quickly to the rapidly emerging threat of cholera in early 2011. I am a bit skeptical of its "if we had only done this" tone: there were so many moving parts, so many decisions that required coordination, so many barriers to organizational cross-talk that no single change would likely have prevented the outbreak. Which is not to say that there aren't important lessons to be learned, especially as we head into the rainy season, but it always seems so easy to identify problems through the retrospectoscope.

As the article details, now the level of trust between the Haitians and at least the UN is dismal. One local authority quoted in the article matter-of-factly discussed killing one of the soldiers--simply to make a political point. To describe this as "ominous" would understate the case significantly. And I'm dubious that such hostilities will be confined only to the UN personnel. If the bodies continue to pile up, the rage will spread like the cholera that came before it, with potentially equally lethal consequences.

Saturday, March 31, 2012

More False Equivalencies of Shallow Journalists (Or: David Brooks Tries To Think, But Fails Again)

We love reading David Brooks for the occasional laugh. Unlike most other conservative political pundits, who are simply hypocrites and liars and not troubled by the truth, Brooks makes a twice-weekly earnest effort at squaring the circle of his conservative philosophy with what's actually happening in the world. He's the Grantland Rice of the political page, possessing a deft touch for the sentimental phrase, living in a mental state of divorce from harsher realities.

This week's case in point involves his observations about what can only be described as the far rightward drift of the Republican party since the election of Barack Obama to POTUS. Brooks's Thursday NYT column details the fading political fortunes of a Gulf War veteran/San Diego Republican, one Nathan Fletcher. As part of his candidacy for Mayor of San Diego, Fletcher has adopted a few positions that most liberals or lefties would find amusing but irrelevant (he supports bike paths, apparently, which Brooks considers to be of weighty importance). But for that and some moderate stances on immigration and "the environment" he has run afoul of the Tea Partyists, and the hard liners have backed City Councilman Carl DeMaio. As a consequence, Fletcher, who sounds like the classic "good guy with whom you might disagree on political stuff", is leaving the Republican tent.

Now any perceptive, or any sane, observer would note that this represents yet another demonstration of the quantum change in the radicalization of the Republican party from respectable-but-flawed to utterly-nutso. It doesn't take a genius to have seen that process--in which the most dangerous, racist, xenophobic, paranoid elements have chased away any voice of reason--has robbed the party of honorable moderates like Fletcher, Lincoln Chafee, and Michael Bloomberg among others in favor of a rabble of Know Nothings. It doesn't require a political mind like Henry Kissinger's to understand that the ideological progeny of Barry Goldwater and Joseph McCarthy are now firmly in control of the party's destiny, and that at most Barack Obama merely catalyzed an inexorable process that's been rolling since Ronald Reagan's ascendancy.

And what conclusion does the perspicacious David Brooks arrive at? That since it's happening on the right, the same thing must by definition be happening on the left.

No, really. In all his mental arithmetical glory, this is Brooks's last paragraph: "Fletcher...represents a nationally important test case. Can the Iraq and Afghanistan veterans, who were trained to be ruthlessly pragmatic, find a home in either party?...As the two parties become more insular, is it possible to mount an independent alternative?"

That's my emphasis, for he spends an entire column dissecting the far right lurch and then finishes wondering about where a moderate's to go when both parties become so rigidly orthodox. Brooks is apparently unaware, or has conveniently ignored, the political career of Tammy Duckworth, Gulf War veteran and still happily at home within the Democratic tent. Ms. Duckworth, who lost both legs during her tour, ran for Congress in the Illinois 6th district in 2006 and lost a close contest to the Republican candidate after a series of predictably scuzzy political maneuvers. As for other vets who drift Democrat but have been ousted by orthodox lefties, I'm waiting to hear a list of examples from Brooks. And I suspect I'll be waiting for quite a long time.

Yet the most amusing aspect of seeing this particular argument, that the Dems are headed toward as equally nutty a place as the Republicans, is that it took place as the Affordable Care Act's constitutionality was debated before the Supreme Court. The Billy Rubin Blog staff is too emotionally spent to contribute to any discussion regarding its legitimacy, political or legal; you can guess what we think.

But like the law or no, no matter how loudly Fox News attempts to tell you otherwise, this law was by no means the gem that hard lefties enforced on the moderates of the Democratic party. Rather, it was very much the other way around: a crappy rightward compromise that a small minority of centrists enforced on the vast majority of Democratic congressfolk who preferred either a single-payer system or the so-called "public option". Despite overwhelming support within the party for either of those approaches, the "individual mandate" being argued before the Court this week was one originally developed by the right-wing Heritage Foundation as a free-market solution to universal health care coverage.

The main reason why this took place is because of a weak and largely ineffectual President. Regardless, I think the Democratic party passing a health care law thought up in the war room of the Heritage Foundation hardly qualifies as evidence of the Dems becoming more insular, David Brooks's nonsense to the contrary notwithstanding.

Tuesday, March 27, 2012

The Origins of "ObamaCare"

From the blog today:

"Yesterday the Supreme Court took up the case of whether all or part of the Affordable Care Act passed by Congress 2 years ago is constitutional. Twenty six states, all with Republican Attorneys General or governors, have filed suit claiming it is unconstitutional. The great irony of these suits is that the whole idea was not invented by President Obama (ObamaCare) or even Mitt Romney (RomneyCare). It's origin goes back to President Richard Nixon, who saw that many people did not have adequate health care and wanted a solution, albeit a Republican solution. He asked the extremely conservative Heritage Foundation to think of a solution and they did: make everyone buy insurance from a private company, that is, an individual mandate. For decades, this was the Republican response to Democratic attempts to expand Medicare to cover everyone. Only after Obama pushed through NixonCare did the Republicans begin objecting to what was, in reality, their own plan."

Well said.

Sunday, March 25, 2012

The Value of "DUH" in Political Discourse

At Billy Rubin central, we like snark just as much as the next guy or gal, but our amusement is dependent in part upon the wit used in the creation of said snark. And "duh" doesn't seem to rely on a great deal of wit--especially when written in all caps. To wit:

a. Though we don't share his political views, we're a fan of retired doc. Retired has been haranguing against the health care act for some time, and of late he has been pointing out what he believes is the erroneous use of data from the Dartmouth Atlas in forming public health policy. (Quick version: the atlas uses Medicare data to look at the distribution of medical resources across the country, and takes the editorial point of view that more care is not necessarily better care.) One of his blog posts tries to make the point that sometimes spending more on health care brings better outcomes, and then finishes off the title of the post with those piercing three letters d, u, and h.

Of course, it's the qualifiers that are critical: noting that more care is not necessarily better implies that it depends upon the comparisons. Health care in the US is undoubtedly better than Botswana (or, say, Cuba, a topic we've covered previously here) and the US spends much more as well. But within the US, regions that have a higher concentration of docs, facilities, and technology do not appear to benefit disproportionally on the whole. Even a cursory reading of the Dartmouth Atlas makes this clear.

As for whether sometimes spending more on health care brings better outcomes, one might as well say that sometimes it rains. I rather doubt that the researchers who put together the Dartmouth Atlas would quake in their boots at the evidence gathered in this post. As of now, the sole commenter on this post points out, "[it] shows that people don't read the caveats". We agree.

If one really needs to search for facts about health care which might be met with the chorus of "duh", one might simply look at our per capita expenditure on health care--which is twice that of any other nation of similar size in the world. We are most certainly not twice as healthy as other industrialized countries. We simply can't afford more care whether we want it or not. What's the difference between our health care system and those of comparable nations? The answer is nationalized health insurance (which, lest anyone misunderstand, is not the same as nationalized health care, for which the only comparison is Great Britain).

b. The clever folk at Gun Owners of America are circulating a cartoon on Facebook describing the "as yet unlearned lesson of 9-11-01". The lesson, helpfully illustrated by Ben Franklin, states that "disarming innocent people does not protect innocent people", with Ben usefully chiming in that "We Founders call this 'the theory of DUH'." Surely Trayvon Martin, innocent and unarmed as he was, would have appreciated this sentiment, were he not shot through the chest by a very much armed George Zimmerman. Though perhaps GOA believes that wearing a hoodie and being a black teenager disqualifies one from being 'innocent'. Stand your ground, Gun Owners of America!

(One also wonders why this is a lesson from 9/11. Does GOA believe that allowing passengers to carry firearms aboard flights is a good idea? It would seem that the hijackers would have been delighted by such a policy, but perhaps I'm too stupid to appreciate the subtleties of their point.)

The "duh" that forms the rider on these expressions serves only to indicate that no real dialogue is taking place. If one must say "duh" to make a point, it means that the truth of the point is so obvious that anyone not in agreement with said point is self-evidently an idiot. So why bother? The chuckle can be had among the elect, as they already know what's what and don't need to deal with the trivial details of constructing a plausible argument.

Saturday, March 24, 2012

WSJ Publishes Paranoid Rant on Organ Donation

I don't follow the financial news media closely enough to have an expert opinion, but I know enough about Rupert Murdoch to have assumed that it was at least possible that the quality of the Wall Street Journal would have been affected by his takeover of WSJ back in 2007 (I appear not to be the only one thinking this). And while it is hard to point to one single piddly article as evidence of a trend at WSJ or anywhere else, I can't help but think that this wild-eyed harangue against organ donation by Dick Teresi would have brought a smile to Murdoch's face. I'm also dubious that such a piece would have passed muster at Bloomberg or the Times--New York or LA, though it might have made the cut in the London version.

WSJ trend or no, it's deeply irresponsible fear-mongering. Teresi's argument against organ donation, insofar as there's any logic worthy of the term "argument", seems to revolve around three separate premises. The first is that, as an organ donor, you have no right to informed consent if you're brain dead. This is (marginally) true, although Teresi implies that physicians then swoop in on you, mad-scientist like, and perform unspeakable, ghoulish acts on your body. We'll get to that in a few paragraphs.

The second premise is that, if declared brain dead, you may not in fact be dead. As such, Teresi wins an award for being allowed to express his inner six year-old in the eminent pages of WSJ. That's pretty much the substance of this "argument". The "not really dead" shtick is a fear that reached its zenith in Germany in the late 19th century, where the fear of premature burial was so profound that "waiting mortuaries" were built, though no recorded accidentally-classified living people ever rose in the manner of Lazarus. Republican lawmakers, most infamously Senate Majority leader Bill Frist, were eager to whip up such anxieties in the case of Terri Schiavo, and Teresi's scribblings are of a piece with that.

The third premise, which can only be described as "rich" as they come on the pages of the Wall Street Journal, is that organ transplantation is big business. "Average recipients are charged $750,000 per transplant," Teresi notes. He then reasons that maybe donors and their families can get a piece of that action: "It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal."

It's really quite amazing that WSJ allowed this bit of nonsense into its pages, for doctors and hospitals do not, under any circumstances, haggle with families over the lives of potential organ donors or "negotiate deals" with families. If there's a case of brain death where we might be able to harvest organs, and the patient in question does not have an organ donation status on their driver's license, members of an organ donation team, not the docs taking care of the patient, ask next of kin--once--if they would consider organ donation. If the answer is no, then it's no, and that's that.

Money is never discussed and certainly none ever changes hands. Teresi implies something sinister in the money involved in organ donation, which raises the question as to whether he is a fully functioning adult. What--does he think that medicine doesn't involve money? As to whether money affects organ donation the same way it does, say, the buying and selling of automobiles, it isn't the same at all. There aren't docs out there getting "finder's bonuses" for snatching the greatest number of bodies, though he barely stops short of implying this, and there aren't people out there trying to game the system, lurking the halls of hospitals, just waiting for the big payday when someone's EEG goes flat.

The actual process of harvesting organs from a body is, in its details, best left to be discussed among professionals or those with either the morbid curiosity or intestinal fortitude to sustain them. The same could be said of routine colectomies. In both cases the goal is to save the lives of the patients--and in organ transplantation, the medical teams often succeed mightily. In 2011, over 22,000 organs were harvested from ~6,000 patients declared brain dead: most of the organs donated were kidneys, livers, hearts and lungs. There are a lot of people alive today walking around because of those organs. I can't emphasize this enough: thousands of people wouldn't be alive were it not for organ donors and the process of organ donation. It's among the reasons why I'm in the biz (in medicine, that is: I have only passing involvement in transplants, mostly in infectious disease consultations on transplant patients). Two helpful fact sheets on organ donation can be found here and here.

Organ donation is one of the few true miracles of modern medicine. It is based on the clear calculation that one's body, when no longer of use to one's soul, might be able to benefit the souls of others by sustaining their bodies. If members of the Billy Rubin Blog staff went out to lunch (meaning: if I got into my car) and had an unfortunate mishap with an 18-wheeler, I would want to cry out, "TAKE EVERY DAMNED THING YOU WANT, FROM MY CORNEAS TO MY COLON!" Alas, I wouldn't be heard in such circumstances...which is why there's a little red heart at the bottom right corner of my driver's license. I highly recommend everyone else put that heart down there too, though Dick Teresi is welcome to have a special license that says in small type "I am a heartless, selfish bastard", which indeed he is.

Wednesday, March 21, 2012

Should a Chemo Drug That Doesn't Prolong Life Be Approved?

Being a touch late to the social media game, the Billy Rubin Blog just got its own Twitter page up and running this week (follow us!) and started happily chirping away about medical issues. Having never lived more than five minutes of my life according to Polonius's dictum that brevity is the soul of wit, I wasn't sure how Twitter and I were going to match up.

Yet lo, first day in, I see a very interesting tweet from USA Today Health dealing with the FDA approval of the GlaxoSmithKline drug pazopanib (trade name of Votrient™) for use as a "salvage" chemotherapy agent for people with a type of cancer known as a soft-tissue sarcoma. Votrient had already been approved for use in renal cell carcinoma, but in seeking approval for the sarcoma indication, GSK was seeking to expand Votrient's market: while any doc could legally prescribe Votrient for a sarcoma patient as an "off-label" medication, insurance companies would not be likely to pay its steep cost (as this cost analysis demonstrates for one health plan, Votrient can run up to $7,000 a month).

What made the article interesting and worthy of tweeting is that GSK was unable to demonstrate that Votrient actually prolonged the lives of the affected patients. GSK measured the drug's effectiveness in two ways: one by looking at survival, but two, by looking at something called "progression free survival"--or how long the tumors stay suppressed. The FDA summary notes: "median progression free survival was 4.6 months in the pazopanib arm and 1.6 months in the placebo arm...however, this improvement did not translate to an improvement in the overall survival...the median overall survival was 12.6 months in the pazopanib arm and 10.7 months in the placebo arm." [my emphasis]

So off I tweeted "FDA approves new GSK chemo med, but drug doesn't prolong life. Umm...then what good does it do?", which I thought a succinct summary that required not much further explanation. Later in the evening I felt my own twitter of delight when someone from parts unknown replied to my tweet, though delight morphed into mild disappointment when @JLM_drivel's reply was "r u joking? it says what it does, prolongs illness-free life. obv not grt drug bt may or may not be worth it". Such are the limitations of Twitter: hard to have a meaningful discussion in 140 characters or less. But no, I wasn't joking.

Look--GSK has what seems to be a very intriguing and promising drug on its hands. That it appears to have decreased tumor size indicate it has potential to be a useful adjunct chemo agent, or even with some molecular tweaking to be a beneficial drug in its own right. But a salvage chemotherapeutic drug that doesn't prolong life can't be described as "may or may not be worth it". It's not worth it! It isn't worth it at any price, but it most certainly isn't worth it at $7000 a month for 11 months.

If every patient annually diagnosed with soft-tissue sarcoma (about 10,000) took Votrient for that length of time, GSK would gross $770 million. Not a bad day's work for a drug that doesn't prolong life.

Not only is this not worth it, it has the potential to erode patient confidence in the system that's working to treat and maybe one day cure them. As this Bloomberg news piece notes in quoting doc Gary Schwartz, the head of the sarcoma service at Memorial Sloan-Kettering in New York, "if the patient comes to the oncologist with cancer, they want to be cured...but with sarcoma, they aren't cured, they want to live longer." They want to live longer. Votrient cannot deliver that, and if these very vulnerable patients take this drug without getting that in return, they and their loved ones will feel cheated by taking it.

That was what I meant when I asked "what good does it do?"--and until GSK can show that Votrient can prolong the life of these sarcoma patients, the answer will be "not much, progression-free survival be damned."