Map of life expectancy at birth from Global Education Project.

Tuesday, August 22, 2017

The estimable Atrios observes:

Since the election there's been this weird back and forth about whether Trump voters were motivated by The Economic Insecurity or by The Racism. . . .

I think it's important to note that the average Trump voter isn't actually an unemployed coal miner, because facts matter, and the portrayal Trump as Working Class Hero (sometimes they remember to write "White") is silly and wrong. Trump's base are not the marginal voters who switched to him from Obama, they are the same Republicans who vote Republican every 4 years. But as for the "but they're racists!" argument. Yes, yes they are. People who are racists generally vote for Republicans.
So on the way home yesterday I got behind a car with four bumper stickers.  The driver was a white guy in his 30s with tattoos on every visible square inch of skin.

The first bumper sticker read "Pave the Bay." That's supposed to be a parody (ha ha, very funny) of "Save the Bay," the movement to clean up and protect Narragansett Bay, which is the defining geographic feature of Rhode Island. His proposed engineering project seems implausible, and I don't see what is to be gained by it. I suspect that for some reason he just doesn't like people who want to save the bay.

The second bumper sticker read "Speak English, or go back to whatever sorry-assed country you left." Ha ha again. Funny thing, he had an Italian flag decal in the back window.

Third bumper sticker: "Some people are alive simply because it is illegal to kill them." So he wants to kill people. That seems nice.

Fourth bumper sticker, and I'll bet you can guess it. "Trump. Make America Great Again."

The Trump base is scheduled to show up in Phoenix tonight. What the over-under on the number of confederate battle flags?

Saturday, August 19, 2017

The view from abroad

I don't think most Americans are fully aware of how precipitously the stature and influence of the U.S. around the world has fallen since we installed a malignant clown in the presidency. It's important to get this information across, because it's an undeniable fact that is still true regardless of your personal view of the Resident. I commend to your attention former U.S. correspondent for The Guardian, Simon Tisdall, who actually kind of liked George Bush the First and even gives some props to Ronald Reagan. This is a long form piece which you should read, but here are some pull quotes:

Reactions [from abroad] range from amazement and amusement to shock and dismay. How has this frightening travesty come about? What does it mean for the America we love? And what does it portend for a world accustomed to sensible, reliable, rational American leadership? Every country has its political mavericks and clowns. But to put a shadow figure like Trump, a profoundly ignorant, self-obsessed narcissist lacking any discernible moral compass, in charge of the nation’s affairs looks like an act of collective madness. . . .

This reckless divisiveness, this shameless moral ambiguity, this historical know-nothingness, this thinly-disguised bigotry – these are not the qualities one expects of an American president. This is not leadership. This is not change. This is not greatness renewed. This unworthy man, and the far-right ghouls who cling to him, set a dreadful example for the rest of the world, from the very country that is deemed by many to be the ultimate symbol of justice, liberty and democratic governance.
He goes on to say that the U.S. is "better than this." But is it? That remains to be seen, because it isn't only far right ghouls who cling to him. It's Paul Ryan, and Mitch McConnell, and most Republican politicians. Not to mention most of the people who voted for him, who seem only more and more devoted as he turns his office into an atrocity.

People need to understand that voting is not a gesture. It isn't a communicative act. It determines who will occupy offices of power and responsibility. So don't vote for insane idiots just because you think it sends some kind of a "message." That is all.

Thursday, August 17, 2017


Public monuments matter. They make assertions about the values shared by the groups that erect and maintain them. When those entities are governments, in a purportedly democratic society, the monuments are claims about the public consensus.

Monuments are also considerably more complicated than one might think without giving them much reflection. For one thing, they are time dependent. They purport to be about a person, or multiple people, or events. But that which is memorialized existed, or happened, some time before they were erected. So as statements, they refer not to the time of their subjects, but to the time of their creation. Maya Lin's Vietnam memorial was controversial because of the assertion it seemed to make about how we should view the Vietnam conflict at the time the monument was erected.  But after a while, that is also in the past. When we view monuments today, they are saying something about the time of their creation, and that may be jarringly different from our time. As it turns out, Lin's memorial has not only held up very well, it has come to seem even more appropriate over time. Her vision was prescient, not limited to the historical moment. But  obviously that isn't always the case.

My office is in the middle of Providence River Park, and specifically that part of the park that is full of monuments. There are monuments to the dead of both World Wars, to the Irish famine, and to the Shoah. The latter was erected last year, as it happens. This year, a monument (privately sponsored but on public land) to the Easter Uprising was installed next to the Irish famine memorial. There is also a Civil War memorial which, obviously, commemorates Union soldiers.

Some 20 years ago, I worked as a consultant for the sponsors of the New England Holocaust Memorial in Boston. Again, it was privately financed but stands on public land. It has been vandalized twice this year.

Most of the memorials near my office do not, as far as I know, attract much controversy today. People in Providence don't have a problem honoring the war dead or the victims of the Shoa. The Irish memorials would be problematic for some English people. The question of English responsibility for the Irish famine is contested, as is the righteousness of the Easter rebellion. But English identity has not been enduring among North American settlers, whereas lots of people still think of themselves as Irish. So these go up on public land without any visible fuss.

All that throat clearing leads to this. The Confederate monuments which have suddenly become incandescently controversial do not, in fact, refer to the Civil War. They refer to the post-Reconstruction era, the rise of Jim Crow, and the Reign of Terror that re-established white supremacy in the South. They were erected during that era, generally 50 years or more after the Civil War, as a message about the present, not the past. That is not to say that the past was any less reprehensible. The cause of the Confederacy was treason in defense of slavery. The heroes of the Confederacy are not remembered for any other accomplishments of historic significance. Whether the monuments refer to 1865 or 1915, that is still true.

Nevertheless, it is important to keep in mind that they were not erected to commemorate history, but rather to enforce a current ideology -- an ideology which it is imperative, in the present era, that we utterly repudiate. Anyone who does not understand this is unfit for public office in 2017.

Monday, August 14, 2017

It is happening here

The BS debate about how Democrats can win back Trump voters through economic populism needs to end now. Donald Trump appeals to Republican voters because he articulates and enables racism. That's what they mean when they call him a "straight shooter" and says he "tells it like it is" even though he lies ever time he moves his lips. He refuses to condemn Nazis and Klansmen because a) they are his base and b) they are among his closest advisers. (Bannon, Gorka and Miller, to get specific. His Attorney General is also a racist.)

Here's an interview with historian Timothy Snyder. I'll give you a pull quote:

What's most striking, if you want to try to link what happened yesterday to our own history, is that we now have a president who doesn't regard Nazis as a symbol of evil. . . .  His reaction to this event is to say that everyone is at fault, and we should all hold together. That's not the reaction that one would expect from the president of the United States. But it is consistent with what I've been trying to get across for the past few months. It's consistent with Trump and Steven Bannon's attempt to do away with the part of the American story that celebrates entering and winning the Second World War. It's consistent with their attempt to do away with the part of the American identity that has to do with being anti-fascist, or anti-Nazi. It's consistent with their botching the Holocaust Remembrance Day in January. It's consistent with the utterly bizarre way that Sean Spicer talked about the Holocaust, when he said Hitler didn't kill his own people. It's consistent with Trump being the first major American politician in recent memory to skip visiting the Ghetto Memorial when he came to Warsaw in August.
And above all, it's consistent with his “America First” slogan. This is what America First means. America First means an America where a Nazi Germany was not the enemy. So that's the broad historical circle. We have an administration which has "America First." What "America First" meant when it was used during the WWII era was that we should not resist Nazi Germany. Mr. Trump's remarks on Saturday are totally consistent with that. This is who and what the administration has been from the very beginning.
And believe me, the white supremacists are getting the message loud and clear.

This must end. This racist, malignant, demented psychopath must be removed from office. If we can't get that done, our century of progress has ended.

Thursday, August 10, 2017

Crispy Critters

That would be millions of us Homo sapiens as much of the Middle East and Europe bake in unprecedented heat. Yes, Iraq is normally hot in the summer, but not it is close to uninhabitable:

As temperatures rose towards 51C on Thursday, Iraq’s government declared a mandatory holiday, allowing civic servants to shelter at home.
So far this month in the Iraqi capital, every day but one has reached 48C or higher, and the forecast is for the high temperatures to continue for the next week. July was little different, in Iraq and in Syria, where the capital, Damascus, has also been several degrees hotter than usual nearly every day since late June.
In Kuwait, where birds have reportedly dropped from the skies, and Riyadh, where building work has ceased this week, locals have called for mercy from a hotter-than-normal air mass that has remained nearly stationary over central Arabia for more than three weeks, stretching the capacity of electricity networks beyond limits.
For those of you who don't know, that's 124 degrees Fahrenheit. In Europe temperatures are hitting 104 Fahrenheit, as they have in the U.S. northwest. Healthy people will survive that, but it's pretty damn miserable. In Seattle, where the 90 degree heat is rare, the misery is compounded by suffocating smoke from wildfires in British Columbia. I could continue to go around the world, from methane seeping from the melting arctic permafrost to the possible collapse of the West Antarctic ice sheet, and on and on. A major precipitant of the Syrian civil war was the collapse of Syrian agriculture due to extended drought and the flood of unemployed refugees into the cities.

If your tribal identity depends on denying what is obviously true and right in front of your nose, I expect that nothing I can say will matter to you.

No, it's not the only thing that matters, but if we don't get very serious about this, very soon, nothing else will matter very much.

Monday, August 07, 2017

CRISPR critters

I suppose I should say something about the recently announced work of Shoukhrat Mitalipov of Oregon Health and Science University, who claims to have successfully edited the genome of human embryos, in this case to eliminate a disease causing mutation. This work is as yet unpublished and not peer reviewed, but let's assume it is sound.

The technique, which has been much in the news, is called CRISPR/Cas9. I'm not going to go into the technical details here but you can certainly look it up if you are interested, the Wikipedia article is actually reasonably accessible if you have some basic understanding of genetics. But getting under the hood doesn't really matter. This is a genetic system that evolved in prokaryotic cells to combat viral phages. It turns out that it provides a method for precise editing of DNA. Previously, the best they could do was shoot DNA into a nucleus and hope that it would be incorporated somewhere; or they could selectively eliminate genes. This provides a method for editing specific genes.

Before Mitalipov's work, however, attempts to edit genes in human embryos weren't very successful, mostly because the editing didn't work in every cell. The Mitalipov team got in early, however, and they claim to have had potentially clinically useful results. This sounds like good news for people who carry genetic disorders and who want to have children, and it may well be. But it's setting off all sorts of ethical alarm bells.

Obviously you have to make a bunch of embryos and you'll end up destroying most of them. That already happens with in vitro fertilization, however, and the anti-abortion ideologues seem to have pretty much gotten used to it. As I have said many times, they do not really believe that blastocysts are human beings or that zygotes have the moral status of persons. That's just an excuse.

Once we've gotten past that, the obvious question is whether the technique could be used, not only to fix hereditary diseases, but to make designer babies -- with enhanced intelligence, physical capacities, specific talents, whatever their wealthy parents want.

I have a two-part answer to this. The first part is that the border between fixing disease and enhancement is very fuzzy. The boundary between say, just being short and dwarfism, or not being the brightest bulb on the tree and cognitive disability, is essentially arbitrary. So if you don't think enhancement is ethical, you need to decide where to draw the line -- and that's always going to be open to dispute.

Part two is that phenotypes are not generally highly determined by genotypes. While a single mutation can definitively cause certain diseases such as Huntington's or Sickle Cell, for the most part our genetic heritage interacts with our environment to create us. For example, people might be at risk for developing Type 2 diabetes if they consume a particular diet; while many people with the same genetic profile will never get Type 2 diabetes. Do we blame it on their genes or the culinary culture?

Intelligence, musical ability, athletic ability -- all of these are also products of genetic heritage unfolding within a particular environment and personal history. You might have John Coltrane's genes, but if you don't practice, or you could never afford a saxophone in the first place, you won't be John Coltrane. Furthermore, these proclivities for some outcome to occur within some given environment are determined by a whole suite of interacting genes. Scientists have so far found only very small influences on outcomes such as heart disease or IQ from any given gene variant, and even these often turn out to be spurious on further investigation, or might not occur at all in a different environment.

If you tried to maximize the genetic profile for intelligence, it might well be at the cost of some other characteristic, such as longevity or sociability or something else people would be loathe to damage. Or it might only work if the child could be guaranteed some specific form of nurture, and otherwise be affirmatively harmful.

So this is a bridge we won't have to cross for a long time, if we ever get there. Nonetheless I can't say it's impossible that nobody will ever try it. People should probably try to be educated about this issue and we should be talking about it, but there's no need to panic.

Wednesday, August 02, 2017


I've written about the North American warrior game here before, and if you've been hanging around long enough you know that my views on it have changed along with the evidence. Our biggest worry used to be spinal chord injuries. Rule changes to prohibit using the helmet as a ram, and coaching at the youth level to emphasize keeping the head up during contact, greatly reduced that risk.

But it's time now to face the truth: no conceivable rule changes that would let you keep on calling it the same game can keep the players' brains from turning to cornmeal mush. The fundamental problem is the helmet. This may be counterintuitive. It seems that the helmet is there to protect the brain, but the opposite is true. The helmet protects the skull and the face, which enables the head to collide forcefully with other players and the ground. When that happens, the brain sloshes around and smashes against the inside of the skull. Rugby players do get concussions and are apparently at risk for Chronic Traumatic Encephalopathy, but not as high a risk as North American football players precisely because they don't wear helmets. That forces them to protect their heads.

The linked study in JAMA has gotten a lot of publicity. In case you've been too obsessed with a certain orange idiot's twitter feed to pay attention, the researchers got families to donate the brains of deceased football players. 110 out of 111 met the diagnostic criteria for CTE based on microscopic examinations of their brain tissue.

Now, this doesn't mean that nearly 100% of NFL players will ultimately get the disease. The families donated the brains because they were worried, and indeed, basically all of these players had observable pathology when they were alive:

Among the 111 CTE cases with standardized informant reports on clinical symptoms, a reported progressive clinical course was common in participants with both mild and severe CTE pathology, occurring in 23 (85%) mild cases and 84 (100%) severe cases (Table 3). Behavioral or mood symptoms were common in participants with both mild and severe CTE pathology, with symptoms occurring in 26 (96%) mild cases and 75 (89%) severe cases. Impulsivity, depressive symptoms, apathy, and anxiety occurred in 23 (89%), 18 (67%), 13 (50%), and 14 (52%) mild cases and 65 (80%), 46 (56%), 43 (52%), and 41 (50%) severe cases, respectively. Additionally, hopelessness, explosivity, being verbally violent, being physically violent, and suicidality (including ideation, attempts, or completions) occurred in 18 (69%), 18 (67%), 17 (63%), 14 (52%), and 15 (56%) mild cases, respectively. Substance use disorders were also common in participants with mild CTE, occurring in 18 (67%) mild cases. Symptoms of posttraumatic stress disorder were uncommon in both groups, occurring in 3 (11%) mild cases and 9 (11%) severe cases.

Cognitive symptoms were common in participants with both mild and severe CTE pathology, with symptoms occurring in 23 (85%) mild cases and 80 (95%) severe cases. Memory, executive function, and attention symptoms occurred in 19 (73%), 19 (73%), and 18 (69%) mild cases and 76 (92%), 67 (81%), and 67 (81%) severe cases, respectively. Additionally, language and visuospatial symptoms occurred in 54 (66%) and 44 (54%) severe cases, respectively. A premortem diagnosis of AD and a postmortem (but blinded to pathology) consensus diagnosis of dementia were common in severe cases, occurring in 21 (25%) and 71 (85%), respectively. There were no asymptomatic (ie, no mood/behavior or cognitive symptoms) CTE cases. Motor symptoms were common in severe cases, occurring in 63 (75%). Gait instability and slowness of movement occurred in 55 (66%) and 42 (50%) severe cases, respectively. Symptom frequencies remained similar when only pure CTE cases (ie, those with no neuropathological evidence of comorbid neurodegenerative disease) were considered (eTable in the Supplement).

Sure, a lot of people develop dementia, but not this young. The median age at death was 66, the youngest was 47,  and 3/4 were younger than 76. You would most definitely not expect to see such a prevalence of brain damage in the general population in that age cohort. So granted, we don't know the actual prevalence among football players, and it's likely less than it appears from this sample. But . . .

The danger is obviously real and it's turning out to be unacceptable to a lot of players. We're seeing a spate of early retirement from the game. Sure, kids who are already dreaming of NFL glory are unlikely to give up playing in high school and college, but we have to expect that fewer and fewer players will allow their boys to take up the game. That, I think, is how the game will ultimately die, when the pipeline of players dries up. Regretfully, I have to say I hope that it will.

Thursday, July 27, 2017

The Republican War on Reality, continued

Two essays in the new NEJM worth your attention. R.A. Charo discusses the anti-science of the anti-abortion movement. Some of this is a bit complicated, and I suggest you read it rather than relying on my summary. But the starting point for much of it is the fact that about half of all blastocysts fail to implant. If life begins at conception, that means that God murders 50% of all babies who are ever conceived. When this happens, the woman never even knows that she was, in the terms of the anti-abortion movement, "pregnant." She just has a normal menstrual period.

Ergo, if you believe that a blastocyst is a human being with all the rights of a person, that the death of an embryo is morally indistinguishable from the death of a baby, and that destroying embryos is murder, you are compelled to believe that the spontaneous death of 50% of all embryos is the greatest public health crisis conceivable (sic). You are compelled to believe that it should be the highest national imperative to pour money into research and interventions to stop this holocaust. But you don't believe that, because you don't really believe that embryos are the moral equivalent of babies. Your movement must be about something else.

Now we have Henry Aaron and colleagues. (No, not Hammering Hank, rather the health care economist.) Why have some health insurers pulled out of the ACA exchanges, why do a few rural counties have no participating insurers, and why have some requested substantial premium increases? Republicans claim it's because the ACA is "failing" due to inherent flaws in design, but this is not, you know, true.

Some insurers did initially set premiums too low because they didn't know enough about the characteristics of what would become the newly insured. When they subsequently raised premiums this was an adjustment, to be sure, but it did not result in sharp enrollment declines, and markets were set to stabilize in 2017. But as soon as the new president took office, he immediately set out to undermine the ACA.

On his first day in office, Trump signed an executive order directing his administration to be as permissive as possible in providing exemptions from ACA provisions, including the individual mandate. Then the House of Representatives passed the American Health Care Act, which would repeal the individual mandate retroactive to plan year 2016. The Congressional Budget Office estimates that the resulting exodus of healthier enrollees from the individual market would drive a 20% increase in individual market premiums for 2018.3The President has also sown doubt about whether the federal government will continue to reimburse insurers for cost-sharing subsidies that they are legally required to provide to most marketplace enrollees. . . .

The Kaiser Family Foundation estimates that ending the payments would require insurers to raise premiums for “silver” plans by 19% on average across states using the enrollment platform.4 These steps have been all the more damaging because they appear to be part of a deliberate strategy to undermine the ACA. President Trump has noted that withholding cost-sharing reduction payments could seriously damage the individual market and that market turmoil increases his leverage in seeking repeal of the ACA. To that end, the administration reportedly opposed adding language to recent appropriations legislation giving it clear legal authority to continue the cost-sharing reduction payments.

Faced with these risks, some insurers are abandoning the individual market. Anthem, one of the country’s largest insurers, cited policy uncertainty, especially regarding cost-sharing reduction payments, as a major factor in its decision to leave Ohio’s market.

Now, about that individual mandate and "freedom." This is very simple. If insurers are required to cover people with pre-existing conditions, then people who are healthy can just not buy insurance until they get sick. This makes insurance more expensive,  so people who are just a little bit sick won't buy it, so it gets even more expensive and so it goes until nobody can buy insurance. The whole point of insurance is that you buy it in case you will need it. You are not allowed to wait until your house is on fire to buy homeowner's insurance which will cover you for said fire, and you are not allowed to wait until you wreck your car to buy auto insurance which will cover you for said car wreck.


And, regarding my last post, Here's Michael Jeffries in The Boston Globe:

Most Americans have no quibble with Obamacare itself, but for Republicans, repealing it is and always has always been a way to repudiate former president Barack Obama. Since taking office, President Trump has done several things that he previously chastised Obama for, but these contradictions have had little impact on his party or their supporters. This is largely because GOP voters’ disdain for Obama and support for Trump cannot be separated from findings about racism. Studies conducted after the election confirm that racial resentment directed toward people of color predicted both overall support for Trump and voters’ propensity to switch from Obama to Trump.
GOP voters know they don’t like Obama, but they do not know Obama’s legislative record, whether it pertains to the economic recovery or health care legislation. A December 2016 poll showed that 67 percent of Trump voters believed that unemployment had risen during Obama’s tenure, even though it dramatically declined. A February 2017 poll found that one third of all Americans did not even know that Obamacare and the Affordable Care Act were the same thing. Over half of the Republicans in that poll did not know whether Medicaid would be impacted by repealing Obamacare. Medicaid will be gutted by the new bill.

So the naked truth is that racial resentment directed toward Obama set off a chain of events that will likely cause 20 million people to lose their health insurance and ignite a public health crisis of unimaginable consequence. Some time ago, I wrote about one of the myths of white supremacy: the idea that its ill effects are limited to targeted groups. I explained, “What white supremacy does, eventually, is normalize and spread the abuse, trauma, and destruction initially prescribed for targeted groups.” The damage prescribed by hateful ideologies is most severe within targeted groups, but it is never contained. 

Monday, July 24, 2017

Sorry for my absence . . .

The crisis we face is simultaneously so terrifying and so bizarre that I haven't been able to respond properly. Writing about the quotidian issues that interest me seems inadequate, while others who have a much larger audience are saying what I might say about our larger problems. But I've decided I'll keep on blogging, for my own sake if not for yours.

So, the Senate Majority Leader is insisting that his members vote tomorrow on a bill that will radically re-make 15% of the U.S. economy, without telling them anything about what's in it. Does that seem strange? Here's former Republican Senator David Durenberger, who thinks, yes that is rather odd:

This week, the Senate once again is set to vote on a health care bill that will radically change how people get coverage and who can afford their care. But unlike normal times, Senators, you are being asked to approve a Motion to Proceed to a vote:
  • Without knowing what the non-partisan Congressional Budget Office will say about the impact of major amendments and the final bill on coverage and premiums.
  • With full knowledge that the Senate parliamentarian, who rules on what can and can't be allowed in a budget bill, has said that the Senate must remove provisions intended to prevent an insurance market death spiral of sicker patients driving up costs.
  • Without knowing the details of the secret state Medicaid waivers the Trump administration insists will make the bill work.
  • Without knowing how your own state budget will be impacted.
  • Without knowing how you will defend the provisions you will only learn about later, including the payoffs and other things that will be sneaked into the bill at the last minute.
  • Without even knowing which bill you are being asked to vote on, what the defining amendments will be and how much time you will have when being pressed for a final vote you’ll be stuck with. Forever.
So why is McConnell doing this? For the past seven years, the Republican party has been obsessively demanding the repeal of the Affordable Care Act. They told their voters they were supposed to hate it, without explaining why they were supposed to hate it. (No, there aren't any death panels and the government didn't take over health care.) As it turns out, the only reason to hate it was that it was signed by a president with an African father. There actually isn't any way to repeal it without hurting tens of millions of people, but the Republican leadership is determined to do it anyway because if they don't, they'll face challenges in the next primary. So they have to keep what they are doing a secret for as long as they can.  Call your Senators' offices. Demand that they vote NO.

Monday, July 17, 2017

Not again . . . .

There seems to be a flavor of the month the past couple of years of universities covering up for grotesque behavior by prestigious professors -- in this case the dean of the USC Keck School of Medicine. It's kind of hard to believe he had time for it, given what is presumably a demanding job, but he was spending his off hours doing meth and smack with prostitutes and drug dealers. His kept woman OD'd in a hotel room, and the police happily covered it up. The university obviously found out about what was going on and let him quietly resign with an excuse that he was taking another job, but allowed him to continue to rep the school of medicine for fundraising purposes. Oh yeah -- he had been accused of sexual harassment in an earlier job at Tufts -- disposition of the case covered up --  and assaulting a colleague at a later job, outcome also kept secret.

Now, as far as I'm concerned if he was effective at his job I don't personally care what he was doing in his free time -- that's between him and his wife, mostly. However, they obviously would have responded very differently in the case of any ordinary faculty member. The knee jerk response for these big shots is that they are allowed to get away with just about anything. The ruling class within the university sticks together, even in cases where it really matters to the mission including academic fraud and sexual harassment. It just doesn't seem to change.

But really, check out the article. It's just a blockbuster investigation, great journalistic work.

Wednesday, July 12, 2017

Ignorance is bliss?

A majority of Republicans now tell Pew Research pollsters that colleges and universities have a negative impact on the U.S. That's a big change from just two years ago, and it's most pronounced among people who identify themselves as conservative.

Now why would they think that? What is the negative impact we purportedly have? I suppose the place to start in trying to figure that out is what we actually do.

First, obviously, we educate young people. What does "educate" mean? It actually has several components, which I will get to.

Second, we do research. We work to increase human understanding of the universe, including humans and human society. We do this based on standards for observation and inference, upon which there is a substantial area of broad agreement but considerable disputation around the edges. These vary somewhat among disciplines, some of which allow for a substantial values component in their discourse, others of which at least pretend to have little or none.

Our standards for observation and inference have a lot to do with the nature of the education we provide. Students do memorize facts. They also learn methods of inference and critical thinking. They learn how to distinguish categories -- what is, what ought to be, what is beautiful -- and to talk about each of these in the manner proper to its nature. They learn skills for learning. They learn logic, critical reading, methods of discourse and argumentation. Colleges and universities produce people with the knowledge and skills to expand scientific knowledge, manage enterprises, develop technology, solve problems. Without colleges and universities, we would be living like people in the 15th Century. We wouldn't have modern medicine, or telecommunications. Colleges and universities also train actors, musicians, film makers, chefs, architects, public policy makers, and engineers.

So what is bad about them? Let's go back to those categories -- the true, the good, the beautiful.

Being a conservative Republican nowadays requires believing some things that are objectively not true. Most notably, it requires believing that human activity is not causing the climate to change. It is people working in universities who are determining that yes, that is really happening. (Also, there's that little question of evolution and the history of the universe.) People in universities, including in schools of public health such as where I work, also figure out that people can be harmed or helped by features of their physical and social environment, which provides the rationale for policies such as pollution control, early childhood education, expanded health care access, and yes, gun safety policies. Note that conservatives have literally forbidden federal funding of research in the latter field -- truth that is contrary to ideology is not to be discovered.

I could go on with this but the bottom line is, reality has a well-known liberal bias. We study reality, and that's bad.

But the good and the beautiful matter as well. It was not always the case, but universities nowadays strive to be inclusive and celebratory of diversity. We encourage open debate and dissent. Now, lately there have been some highly publicized controversies -- in fact they are very few and far between -- about invitations to particular speakers who some members of a university community find offensive. These happen to be people called "conservative," which in these instances means racist and/or misogynist. Whether allowing these people to speak or not is proper is a debate I will defer. The point here is that racism and other forms of bigotry and exclusion are not generally condoned in colleges and universities, but they are condoned among conservative Republicans. So we have a disagreement over the good.

Finally there is that question of the beautiful. I expect that many people who consider themselves conservatives also have a feeling that people with college educations look down on their culture. This isn't actually true, for the most part. Some well-to-do people are snobbish, of course. And there are no doubt differences in artistic, culinary or sartorial preference among people of differing levels of education. But I can assure you that working class and low income people are just as valued and respected as wealthier people, if not more so, here in the school of public health and elsewhere in the university. We really are working to make life better for everyone, especially those in most need. And please don't confuse us with politicians.

Friday, July 07, 2017

Coercive psychiatry?

Two writers in BMJ maintain that there is a global trend toward more coercion in psychiatry. Their evidence seems largely impressionistic - I'm not sure they prove the case - but it does reopen a discussion that we haven't heard much of lately.

In the bad old days mental hospitals were indeed what Erving Goffman called "total institutions." Many people were confined involuntarily, and often for life. Their lives were controlled by rules and regimentation, and many cruelties were practiced on them including shackling, solitary confinement, and destructive brain surgery. As you probably know a mental hospital was Ken Kesey's metaphor for the oppressive conformity of 1950s America in One Flew Over the Cuckoo's Nest. Yes, it was fiction, but it resonated.

As I have discussed here quite often, the de-institutionalization movement closed most mental hospitals. This was partly a response to the more liberal values of the post-1960s era, partly a response to the availability of treatments that suppress some of the worst symptoms of psychosis, which made de-institutionalization more feasible. What did not happen, however, was the promised second half of the program, that is the creation of adequately supportive community-based housing and services. So lots of people wound up homeless, and in prison. The BMJ editorial evokes incarceration to support its thesis, but that doesn't really work: police, prosecutors and prison guards aren't psychiatrists. What this really points to is a lack of psychiatry, not that psychiatry itself is more coercive.

However, they also argue that involuntary commitment and forced treatment are becoming more common, along with solitary confinement and restraint. The justification, in their telling, is "risk management." Mentally ill people are seen as dangerous. It seems to me that in part, what we are seeing is simply the regression toward the old regime when the promised new one failed to materialize. But there are also those who have argued that more inpatient psychiatric resources are needed, on the grounds that not everybody can make it on the outside after all, at least not all the time.

Unfortunately people who are held against their will, and who have underlying behavioral problems, are difficult for staff to deal with. And it is very hard to discourage staff from taking the relatively easy path of drugging and restraint. It happens in nursing homes as well. So I'm not sure that what we are seeing is a corruption of the culture of psychiatry so much as it is a reflection of insufficient resources being put toward a more humane response to mental illness.

But there's a lot of that sort of thing going around.

Wednesday, July 05, 2017

The Rule of Rescue

I briefly mentioned the case of Charlie Gard in my last post. Now both the Pope and some clown have weighed in. (The link is to a comment on this, which I will allow to speak for itself.) Who knows exactly what the clown meant by his tweet, but the Vatican statement included the specific assertion that the Pope prays that the parents' "wish to accompany and treat their child until the end isn’t neglected," and the statement from the Pontifical Academy of Life that

We should never act with the deliberate intention to end a human life, including the removal of nutrition and hydration. We do, sometimes, however, have to recognise the limitations of what can be done, while always acting humanely in the service of the sick person until the time of natural death occurs.
To be clear, Charlie Gard has irreversible brain damage. He cannot hear, see, swallow, cry, or breathe. It is unlikely that he has any conscious awareness, but please try to imagine what it is like if he does. He is being kept alive by a machine that breathes for him, and by another machine that pumps nutrition and hydration into his body. If the machines are turned off, natural death will occur.  Indeed, it is probably fair to say that it has already occurred, and what we are seeing is only a simulacrum of life.

Oh, by the way, it costs a great deal of money to keep the machines going. The Vatican hospital has offered to continue the exercise, presumably indefinitely. Transporting him, with his machines, would be extremely expensive. Did you know -- and does the Pope know -- that some 3 million children under five die every year from "conditions that could be prevented or treated with access to simple, affordable interventions"?

Are the Pope and Donald Trump offering to do anything at all for any single one of them?

The title of this post refers to an ethical instinct that people have to provide succor to a single, identifiable individual who is in dire circumstances. They will say that no price is too high, that human life is infinitely precious. But obviously, nobody actually believes that.

Friday, June 30, 2017

Common Sense

The various affluent countries around the world have somewhat different ways of organizing and financing their universal health care systems, but they all cover everybody, and they spend about half as much or less than we do. Right now the British system happens to be under strain because the conservative government is underfunding it. Vote Labor back in and they'll put in enough money to fix it.

But I want to talk about rationing. It just seems bizarre to me that people argue against universal health care schemes on the grounds that they require "rationing" or denying some services to some people on the grounds of cost. Yes, that is necessary, because resources are finite and taxpayers only want to reach into their pockets to a certain depth. Ergo, you don't spend a million dollars on the small chance that it will extend the life of a horribly sick person by a week. You have to draw the line somewhere.

But obviously, that already happens right here in the U.S.A., but in a worse way. Lots of people, even with the ACA but mostly because of states that didn't accept the Medicaid expansion, don't have insurance and can't get health care and yes, they die. That's the current reality. And, before the ACA, insurance policies typically had annual and lifetime limits. Insurers also won't pay for many treatments they consider too expensive, and they found ways to kick expensive people off of their policies. The whole pre-existing conditions thing means that if you need insurance, they won't sell it to you. That's rationing, but of a particularly arbitrary and cruel kind.

Whether a very expensive treatment that doesn't do a whole lot of good should be offered to people ought to be a decision that is democratically accountable. That's what they have in Britain. These decisions are made by a body called the National Institute for Clinical and Health Excellence (called NICE) through a transparent, open process. If people object to a given outcome -- and occasionally they do, although the process is generally accepted and supported -- they can complain to their MP. Parliament oversees the National Health Service and NICE, and they can guide policy. Which you can't do with your insurance company.

Update: There was interest in how we can get to universal health care in the U.S., given the institutional obstacles to implementing a single payer system here. Scott Lemieux discusses the possibilities. He isn't totally explicit, but he seems to endorse a Swiss type system, which is sort of ACA on steroids. 

Update #2, Baby Killers: I believe somebody suggested that the case of Charlie Gard proves that single payer systems are evil. Actually it's largely irrelevant to this discussion. This is an English baby with a mitochondrial disorder who is more or less already dead but is being kept on life support. The hospital wanted to turn off his ventilator but the parents went to court to stop it. Meanwhile they were crowdfunding a couple of million dollars to fly him to the U.S. for an "experimental" (actually quack) treatment. The British court said no, the treatment is useless, and it is in the best interest of the baby to turn off the machinery. The European high court has now agreed. So this is comparable to Terry Schiavo and it has nothing to do with the National Health Service or what kind of insurance the family has. There is, however, tangential relevance: spread that $2 million around properly, and you could save a hundred children's lives -- say African kids dying of diarrheal disease, by getting clean water supply to their villages. Think about it.

Wednesday, June 28, 2017

Ideological Blinders

Here's Eduardo Porter in the NYT giving an overview of why universal coverage is worth it from the societal perspective. It shouldn't take wonkery to establish that, but apparently it does.

If you will look up at my banner, you will see that I have already known for some time that health care in the U.S. of A. is too expensive. You don't actually need to tell me that. Funny thing though -- it's a lot less expensive in all those communist totalitarian dungeons in Europe and the Great White North that provide universal coverage to everybody. In fact, the U.S. government spends as much on health care as the British government, but the British government covers everybody and they live longer! Same with Canada! Same with Norway! And the people don't feel oppressed. In fact Norway is the happiest country on earth. Yet it has -- wait for it -- socialized medicine. That's right, you pay your taxes, and the government pays for your health care. Done.

The hospitals don't post their prices, as far as I know, because there is a single payer and the single payer negotiates a single price. Which is lower than the price here. As a consumer of health care, you can't comparison shop they way you might for, say, thermal underwear because:

a) You don't know what you actually need, you need an expert, a doctor, to tell you.

b) You have no way of comparing quality.

c) You might have an urgent need that doesn't give you the luxury of comparing prices at 3 different hospitals. In fact, if you live in a rural area, there might only be 1 hospital. And you might be unconscious!

I must also point out that whether or not you can afford the health care you need is not only a function of whether you had the entrepreneurial spirit, talent and drive to become as rich as Ayn Rand; it is also a function of the pure luck of whether you are hit by a cosmic ray that causes a gene mutation that gives you cancer, or hit by a bus, or born with a genetic predisposition for diabetes, or any of an infinite number of possible misfortunes. The Free Market does not allocate these misfortunes by an invisible hand, rather shit happens.

So we need to at least start by acknowledging some simple, indisputable truths. That does not seem to be within the philosophy of some people.