KOLAHUN

Anton Pavlovich Chekhov, M.D. (1860 -1908)

"Medicine is my lawful wife, and literature is my mistress. When I get fed up with one, I spend the night with the other. Though it is irregular, it is less boring this way, and besides, neither of them loses anything through my infidelity." 

A quote by Dr. Anton Pavlovich Chekhov, born on this day in 1860, in the small town of Taganrog, Ukraine. He described his childhood as not having one. His father was abusive to him, his siblings and his mother and at the age of sixteen, his bankrupt father left him behind to manage the family's failing finances in Taganrog while he, himself, moved to Moscow.

With his father hoping to avoid debtors' prison and his mother emotionally broken, Chekhov put himself through school, by working odd jobs and sending money to his family in Moscow. In 1879, he was accepted to Moscow University's school of medicine.

He made little money as a physician, often treating people for free; a habit that continued well into his success as a author and dramatist. Two years after completing medical school, he began coughing blood, but he hid this from others as he pursued medicine and writing.

$75 Per Speeding Ticket

In full disclosure, I've spent hundreds of dollars in fines levied by the NOLA traffic cameras, mostly going a bit over 30mph where the speed limit is 25mph.  My emotional response:  it's fucking annoying.  

More analytically, however, there are two competing interests.  First, do these cameras REDUCE traffic accidents?  Who knows...but anecdotally, they have made me and my neighbor drive slower.  So logically, they probably work.

Second, however, is the question of justice?  Are they being implemented fairly?  To that, I'd say NO.  As per the article, the cameras are placed in somewhat devious ways:

A visit to the hardest-working traffic camera in town makes plain the reason for its success -- and why it has many motorists hopping mad. The camera is positioned about a block down from where Henry Clay, one of New Orleans' smoother streets, widens dramatically into a broad boulevard. The sidewalk on the avenue's uptown side is lined by a tall brick wall, reducing the odds that, say, a child might suddenly run into the street.

In short, drivers judge the street as one where they can safely travel at perhaps 35 mph. But the speed limit is 25 mph. At 31 mph, the camera trips, and a $75 ticket is issued. At 35 mph, the fine jumps to $110.

Plus, the delay in actually receiving the ticket in the mail leaves a latency period where the punitive ticket doesn't change driving behavior - because you haven't gotten the ticket yet!  If you got a ticket by an actual cop, you're much more likely to drive slower for the next few weeks.  But with a camera, you get the ticket in the mail in a couple of weeks, blissfully and ignorantly driving the same in the meanwhile.  

Finally, I'm going to search to see whether the City audits the collections and releases where the funds have been allocated.  Hopefully, this isn't a money-grab to cover under-funded accounts.  

 

10

There are only 10 types of people in the world: those who understand binary, and those who don't.

Clinical Diagnosis of HIV in neonates?

Jaspen et al attempt to find clinical clues which may herald HIV infection in exposed neonates in South Africa:

417 HIV-infected and 125 HIV-exposed, uninfected infants, median age 46 days (IQR 38-55), were included. The median CD4 percentage in HIV-infected infants was 34 (IQR 28-41)%. HIV-infected infants had lower weight-for-age, more lymphadenopathy, oral thrush, and hepatomegaly than exposed uninfected infants (Adjusted Odds Ratio 0.51, 8.8, 5.6 and 23.5 respectively; p<0.001 for all). Sensitivity of individual signs was low (<20%) but specificity high (98-100%). If any one of oral thrush, hepatomegaly, splenomegaly, lymphadenopathy, diaper dermatitis, weight <50th centile are present, sensitivity for HIV infection amongst HIV-exposed infants was 86%. These algorithms performed similarly when used to predict severe immune suppression.

Neonatal HIV can be notoriously hard to diagnose.  In the developed world, we screen patients of all ages for HIV with a rapid, anti-body test, but then confirm it with a more advanced PCR test.  In neonates, however, because they get maternal antibodies in utero and through breast milk, the anti-body tests could be a 'false-positive' - i.e. the test says positive, but it's actually false because it's detecting the mother's transmitted anti-bodies.  So the general strategy in the developed world is to skip the preliminary (less costly) antibody test and go directly to the (more expensive) PCR test.

This strategy fails in the undeveloped world where the (more expensive) PCR tests aren't available.  The two prevailing strategies are a) look for very much cheaper antibody tests and b) look for ways to clinically screen patients and then refer only the higher suspicion ones to get the more expensive tests (as Jaspen et al have done).

Strategy A is the preferred way and some money is being spent on that.  My preference would be that more money be spent on that.  In the meanwhile, those nurses/house officers/doctors have to 'get through the day' with whatever tools they have.  And if they find that more lymphadenopthy can increase the clinical probability that a neonate has HIV, they may feel more confident sending that mother and baby by bus over many kilometers to a more sophisticated testing and treating center.  

It's suboptimal.  But until we get better and cheaper tests, it's the prudent field level strategy.  

Dominos in North Korea

The headlines of the major international news sites and newspapers blared the death of Kim Jong Il today.  He died 2 days ago, but the news was left out of public consumption, presumably to maintain order and choreograph the unveiling of his son.  Good riddance.  

The man was a mass murderer who promoted the deaths of millions of his country's men, women and children.  In the 90s, he ruled during a terrible famine.  He set up labor and death camps.  Death could only have been too kind to him.

And now the question remains - what of the North Koreans? Or simply the 'Koreans' as they were known before the bifurcation of the peninsula at the start of the Korean War in 1950.  They live in fear, in isolation, in brainwashing and in hunger.  The vested international actors are South Korea, China, Japan, the US and Russia.  

China's going through economic hardships themselves, if one were to believe the warnings of Paul Krugman (and I generally do).  The South Koreans have prospered since the 1960s and do they really want the burden of unification that the West Germans went through?  The US is mired in multiple wars across the world and has little interest in this time of divided government and a realpolitik president in getting involved in another conflict or country rebuilding.  Russia seems to be cash-heavy, but is undergoing its own version of public outcry against a kleptocarcy.  

So who's got the incentive to do anything but maintain the status quo and let the hermit kingdom continue?  Meaning, onward continue the silenced suffering of the (North) Koreans.  

Vox Arborum

I had a sneaking suspicion that tree population was linked to voter turnout in the City.

I soon found out, since Golden Gate Park is not a voting precinct, trees living there cannot vote.

Something must be done!

 

Horto in Urbs

The Perversion of Oncology Economics

In an insidiuously chilling editorial in the NEJM, the intersection of micro- and macro-economics of oncolgy is explained.  Oncology through the 20th century consisted of using available poisons to hurt cancer cells (bad guys) quicker than other body cells (good guys).  Given the obvious potential to seriously harm patients, only few physicians did so.  This anachronistic process led to these few physicians 'selling' chemotherapy medicines out of their office.  

Towards the end of the 20th century, this vending became incredibly profitable as cancer medications became more expensive (and as people stopped dying of communicable diseases with better public health, vaccines and antibiotics).  But as the rate of medical costs soar, medical payers (CMS and private insurers) have begun focusing on decreasing oncology care costs.  And so we now end up with a non-sustainable system.

But what's the actual problem?  Greedy pharmaceuticals - not really, as they're not humanitarians, they're capitalists.  The governmentn - well, for anyone to the left of Rick Perry...perhaps.  But what exactly is the government supposed to do - pay more for medicines when it doesn't need to?  

No, I'd say the fault lies in the fundamental pay scheme of modern American medicine which emphasizes pay-for-service rather than pay-for-outcome.  Here's a model of how it would work, per the NEJM article:

One solution is adopting clinical pathways for which practices are paid disease-management fees that are not based on chemotherapy sales. For instance, one large oncology group has developed care pathways specifying preferred drug combinations and sequences — for example, allowing only a few first-line, mostly generic regimens for patients with non–small-cell lung cancer, as compared with the 16 possible drugs and many more combinations included in National Comprehensive Cancer Network pathways. This approach has been shown to result in equal or better survival, less use of chemotherapy near the end of life, and 35% lower costs than usual care.

"The Plural of Anecdote is not Data"

Nancy Pelosi channeled the above phrase from an unknown source in the political sphere.  But in the sphere of medicine, sometimes clinicians are confronted with the case that, in fact, no data exist and all that's left to help guide decisions are the plural of anecdote, whatever that may be called.

Here's a NEJM article in which pediatricians Stanford confront the problem.  Of note, among the various fields in medicine, few are as poorly researched as pediatrics:

Without clear evidence to guide us and needing to make a decision swiftly, we turned to a new approach, using the data captured in our institution's electronic medical record (EMR) and an innovative research data warehouse.

They simply did a quick case-control study withing their own institution's database, found some apparently north-star-ish advice and made a clinical treatment decision.  Luckily for the patient and them, the situation worked out for the best.  They then conclude grandiosely:

Our case is but one example of a situation in which the existing literature is insufficient to guide the clinical care of a patient. But it illustrates a novel process that is likely to become much more standard with the widespread adoption of EMRs and more sophisticated informatics tools. Although many other groups have highlighted the secondary use of EMR data for clinical research,2,3 we have now seen how the same approach can be used to guide real-time clinical decisions. The rapid electronic chart review and analysis were not only feasible, but also more helpful and accurate than physician recollection and pooled colleague opinion. Such real-time availability of data to guide decision making has already transformed other industries,4 and the growing prevalence of EMRs along with the development of sophisticated tools for real-time analysis of identified data sets will no doubt advance the use of this data-driven approach to health care delivery. We look forward to a future in which health information systems help physicians learn from every patient at every visit and close the feedback loop for clinical decision making in real time. (Emphasis added)

These authors have identified a fundamental problem in clinical analysis - the volume of perplexing clinical questions supersedes the available volume of decent studies answering them.  In this case, most clinicians revert to, what worked yesterday, or the day before.  And clinicians with longer memories can go back even further.  And those special clinicians with higher computing power can even figure out mental matrices in which they subdivide patients based on comparative characteristics.  

But, of course, what these Stanford pediatricians have done is outsourced the mental computing to a local computer which does the hard work.  And good for them and their patients.  Perhaps the epidemiologists can figure out how to synthesize these datum to produce meaningful statements, similar to meta-analyses.  

But clinicians shouldn't fool themselves or their patients into accepting that this is 'optimal' medicine.  It's not.  It's second best.  Nor is this a problem if clinicians de-throne themselves from the alter of deities and begin to explain to patients the uncertainty in diagnoses and treatments.  

Take Two Twitters and Call Me in the Morning

Chorbev et. al describe in the Journal of Telemedicine and Applications a plausible model for improved diabetes through group share.  They set up a platform where:

We have developed a healthcare social network that provides methods for distance learning; opportunities for creation of virtual self-help groups where patients can get information and establish interactions among each other in order to exchange important healthcare-related information; discussion forums; patient-to-healthcare specialist communication. The mission of our virtual community is to increase the independence of people with diabetes, self-management, empower them to take care of themselves, make their everyday activities easier, enrich their medical knowledge, and improve their health condition, make them more productive, and improve their communication with other patients with similar diagnoses.

On one hand, one of the flaws with this is that this network captures those who already are invested in improving their care - the self-selection bias.  If you're online and have the choice between TMZ (Humpdashian!) versus your HbA1C, even with marginal costs, the uninterested patient will choose Humpdashian.  But on the other hand, the Gladwell understanding of the social network model, would argue that given the low cost of interaction (send some emails, perhaps check your sugars more often or take your insulin more regularly), even with low motivation, the participation of these patients should be high.  So while each patient doesn't have to do so much, the fact that many are doing a bit improves substantially the median health outcome.

More systematically, the Gladwell argument discounts the power of networks to find answers.  The beginning examples of chaos theory generally use the patterns of birds or fish as the analogy to describe the complex patterns developed without hierarchy:

Chaos theory looks at how very simple things can generate very complex outcomes that could not be predicted by just looking at the parts by themselves.
 
You may have noticed the wonderful swirling patterns of birds flying together in the sky or fish schooling in the oceans. At first glance we would think the birds would have to be rather intelligent to work out how to fly in formation like that. We would probably also assume there must be a 'bird in charge' giving  instructions to all the others. 

Research into swarms has shown, however, that all that is required is for each bird to maintain the distance between itself and its neighbours and fly in the average direction of its neighbours. From this alone the wonderful, swirling, complex patterns the birds or fish make are seen. Simple rules can generate complex behaviours that just seem to emerge out of nowhere. While each individual agent does not need much intelligence, the is swarm intelligence which resides with the collective.

And this is the argument put forth by the social network as improved health model.  It's actually the feature (rather than the bug) of this model that it's non-hierarchical.  In this way, simple modifications to the program or to the rules set forth to the patients can have large, cascading effects.  And done well, these can still be inexpensive in cost to the patients (effort) and to society ($$).  

GORT,

KLAATU

BARADA

NIKTO

The Ministry of Information

“more power to the misinformed”

 

Do Protocols Make Dumber Clinicians?

There's a lot of push-back from clinicians arguing that patients are individuals and can't be pegged into uniform clinical protocols.  This argument necessarily invokes the straw-man in the guise of the 'physicians don't have control anymore' lament.  I readily counter with the refrain that common things occur commonly and that most patients do fall within the parameters of protocols.  Most patients with DKA need insulin, fluids and potassium.  Most patients with community acquired pneumonia improve with empirically chosen antibiotics.  

But the more important part of the rebuttal is that for the exceptional patients who don't conform, the clinician still has the choice to change treatment.  As of yet, there's no one arguing that when justified, a clinician still doesn't have final decision making authority.  Not insurance companies.  Not the government.  And not the egg-head proponents of protocolized medicine.  

More defensively against protocols is the argument that they make trainees stupider.  It's perplexing why this should be so.  Currently, it's probably the case that trainees have too many models to study - each attending teaches a different method.  Consolidating these should simplify the majority of cases, allow trainees to understand the basics and, as there are always exceptions, enable them to treat these non-conforming clinical quandaries.  

This just published JAMA retrospective study on how well Critical Care fellows fared on their Board exams gives some initial evidence that, in fact, protocols don't make them dumber.  The study divided up the fellows based on how many protocols were in place in their institution and then compared how they performed in relevant sections of the boards.  What they found was that there was no difference in clinical knowledge between programs with a high number of protocols and those with a low number of protocols.  

Results Ninety of 129 programs (70%) responded to the survey. Seventy-seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty-eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. Forty-two programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bivariable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, –16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, −5.36; 95% CI, –20.7 to 10.0).

Conclusion Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.

 

 

Gleevec, India, Patents and the Fate of Affordable Medications

An important editorial by Dr. Druker - one of the key investigators of Gleevec [imatinib] - and how a legal case in India may affect the affordability of generic medications across the world.  The argument in India centers around how much modification a pharmaceutical needs to make in order to be granted a full new patent on the modification.  

The Indian law states should have the following characteristic (paraphrased from an MSF editorial):  "a new form of a known medicine can only be patented if it is not obvious and shows significantly improved therapeutic efficacy over existing medicines"  Novartis, Gleevec's manufacturer, contends that smaller changes are material and should be granted full patent privileges.  

I agree with Dr. Druker on this:

However, the price at which imatinib has been offered for sale by Novartis around the world has caused me considerable discomfort. Pharmaceutical companies that have invested in the development of medicines should achieve a return on their investments. But this does not mean the abuse of these exclusive rights by excessive prices and seeking patents over minor changes to extend monopoly prices. This goes against the spirit of the patent system and is not justified given the vital investments made by the public sector over decades that make the discovery of these medicines possible.

Public institutions around the world have continuously played a critical role in the research that leads to vital new medicines reaching the market. Without access medical research becomes a luxury good. Most of my colleagues would be very uncomfortable if we felt that this would be the result of our decades ofeffort.

 

Water-world - India and Bangladesh

According to this Al-Jazeera article, a recent signing between India and Bangladesh resolved many land-border issues:

India and Bangladesh have signed a raft of agreements during a visit to Dhaka by Manmohan Singh, India's prime minister, including one to resolve long-running border disputes.The South Asian neighbours concluded a land boundary agreement on Tuesday to demarcate their 4,000km shared border and sort out 162 "enclaves" - small pockets of one country's territory surrounded by the other."Both of our countries have now demarcated the entire land boundary and have resolved the status of enclaves," Singh said at a ceremony with his Bangladeshi counterpart, Sheikh Hasina, in Dhaka.

But what may be the key graf in this story isn't the above headline but rather the unresolved disputes left over water access between the two countries.  The 1996 Ganges water sharing treaty - already in peril due to political and economic tensions - is possibly being tested by the changes in climate change leading to a conflict between asymmetric partners:

A review of current literature on the Ganges reveals that the issue of majo r concern is the quantity of water available to the mega-city of Kolkata and to southwestern Bangladesh, both of which rely on the Ganges water for short- and long-term needs. However, there is evidence that theunderlying causes of water quantity problems are of po

litical and economic nature, both in the conditions that had lead to the construction and implementation of the Farakka Barrage itself, as well as those precluding a fair and workable long-term water sharing agreement. Politically and militarily, India is by far the stronger of the two nations, and wishes to not only maintain its dominance but also enhance it; these factors are reinforced by India's advantageous terms of trade, economic growth, and position as the upper riparian state. Any future effort to resolve the ongoing dispute between India and Bangladesh must address these underlying variables to be successful in the long run.

 

HIV Pre-exposure Prophylaxis and the Underground Economy

Recent large trials have shown some positive evidence that pre-exposure prophylaxis for HIV works.  The first was the iPrEx trial showing it worked in men who have sex with women.  Then we have the HTPN 052 trial showing it works in preventing transmission from one HIV+ partner to his/her HIV- partner in heterosexual couples.  

As these positive results have seeped into the mainstream press, inevitably, there's been a run on anti-retrovirals, as reported here by marketwatch:

The State of Florida Agency for Health Care Administration (AHCA) recently sent out an alert to Florida health care providers and pharmacies notifying them of stricter requirements for incoming pharmacy claims for HIV/AIDS medications. AHCA informed AHF that the change is in response to an increase in demand for Truvada for use as a prevention pill by HIV-negative individuals and the fraudulent prescriptions that are appearing as a result.

 And while the state of Florida is absolutely right to maintain legitimacy and control over prescription medicines, there's a larger story here.  What we see here is an excess of demand for HIV medications over the supply.  Good.  This reflects the fear that HIV- negative individuals have of being infected with the virus and the hope they are clinging to that pre-exposure prophylaxis works.  We want these individuals to take care for themselves and in doing so reduce the overall transmission of the disease.  We've been working on this for 30 years!

The stated fear of opponents of wide-spread pre-exposure prophylaxis is that it will lead to more promiscuous behavior - which should perhaps be called the bare-back theory.  And that used improperly, the virus will soon find resistance to the medications, making them less efficacious in other patients.  But there are still lots more positive benefits to pre-exposure prophylaxis medications than negative ones.  In vulnerable sex workers.  In stable discordant couples - both heterosexual and homosexual.  There are lots of people who would benefit.  

The CDC has started the discussion on the proper use of pre-exposure prophylaxis (see below).  Admittedly however, there are political and scientific motives for not forcibly pushing these yet.  But as we fill in the knowledge gaps, the right way to use this modality will be the same as birth control and condoms and other preventive measures - emphasis on the risk of improper use while encouragement on proper application.

 

Toothpaste out of the Tube - Hospitalists

Over the past ten years, the care of general internal medicine patients has specialized to 'hospitalists'.  These are doctors who are general doctors who 'specialize' in taking care of patients while in the hospital.  This has happened because:

1. clinic work has gotten so busy, practitioners don't have time to go see his/her patients in the hospital
2. hospital care of patients has gotten more complicated with dozens of new drugs and testing modalities
3. clinicians want the 'shift-work' benefits associated with hospitalist care

With that in mind, here's a study showing that there's not much financial benefit to the use of hospitalists:

Results:

In propensity score analysis, hospital length of stay was 0.64 day less among patients receiving hospitalist care. Hospital charges were $282 lower, whereas Medicare costs in the 30 days after discharge were $332 higher (P < 0.001 for both). Patients cared for by hospitalists were less likely to be discharged to home (odds ratio, 0.82 [95% CI, 0.78 to 0.86]) and were more likely to have emergency department visits (odds ratio, 1.18 [CI, 1.12 to 1.24]) and readmissions (odds ratio, 1.08 [CI, 1.02 to 1.14]) after discharge. They also had fewer visits with their primary care physician and more nursing facility visits after discharge.

Limitation:

Observational studies are subject to selection bias.

Conclusion:

Decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge.

Primary Funding Source:

National Institute on Aging and National Cancer Institute.

 

This is sobering news for the use of hospitalists.  But, as with the toothpaste analogy, it's unlikely we're going to go back to a system where internists become generalists and decide to re-learn the care of complex hospital patients in addition to taking care of their clinic patients.  So this implies that we have to figure out why that secondary cost - the 30day ER re-visit - is high.  

Are patients let out of the hospital too early by hospitalists who don't know enough about the patients?  Do hospitalists understand post-hospital care sufficiently?  Is there appropriate return to the primary care physician?  Are there enough appointment slots in clinics for hospital follow-up patients? 

 

A House Divided

In 2010, California's Citizens Redistricting Commission began the long process of redrawing the state's Congressional, State Senate and Assembly legislative districts, closely watch by many politicians, political canidates, policy wonks, pundents, community based organizations, lobbyist, political action committees, lawyers, fundraisers, all those "connected" types - but largely unnoticed by residents of the low-income African American community being divided in half by a proposed voting district division line that, if approved on August 15, will divide San Francisco's second largest African American neighborhoods into two separate State Assembly districts, effectively diluting their political voice on each side of the line by making them minority voters in their own neighborhood.

According the the Commission's website, "How the district boundaries are configured can make the difference between empowering and maximizing the voters’ voices or minimizing and muting those voices."

You ain't kiddin!

Efforts are underway to encourage community resident and leaders to contact the Commission and convince them to move the boundary westward and maintain the integrity of the African American community in the Fillmore/Western Addition neighborhood that the proposed line would divide in half.

While districts shall not be drawn by the Commission to favor or discriminate against an incumbent, candidate, or political party, districts should be geographically compact, must be contiguous so that all parts of the district are connected to each other, must comply with the Voting Rights Act to ensure that minorities have an equal opportunity to elect representatives of their choice and, especially in this case, must respect the boundaries of neighborhoods and communities of interest and minimize their division, to the extent possible.

We'll see what happens come August 15.

Direct "Cash" Transfers For the Very Poor

At the very bottom of the income ladder of humanity, are the very poor.  They live at the ends of the rural earth.  Or in the slums of the cities.  We can speak of investment or microfinance and microsavings and all that.  But first, they need a chance to live.  They need direct cash transfers.

Or, as shown below, this type of program in Sierra Leone (where former UK slaves repatriated in the 19th century).  It gives women and children FREE access to health care.  And initial reports are that outcomes are improved:

"The results have been "nothing short of spectacular", said Robert Yates, a senior health economist in from the UK's Department for International Development, which is paying for almost 40 per cent of the £21 million programme, with most of the rest coming from donors such as the World Bank. Since waiving the fees, Sierra Leone has seen a 214 per cent increase in the number of children under five receiving care at health facilities, a 61 per cent decrease in mortality rates in difficult pregnancy cases at health clinics, and an 85 per cent drop in the malaria fatality rate for children treated in hospitals."

Once their survival isn't threatened, then comes the time for investment and education and so forth.  

 

Real World Consequences of The Debt Ceiling Fight

Companies, funds, etc. use money markets as short term investments to park cash.  Money markets, in turn lend this money out and so forth.  If a company needs to withdraw cash and the money market doesn't have cash-on-hand because it's lent out the money elsewhere, the money market borrows from the Treasury.  

However, with the debt ceiling threatening money market liquidity, companies are withdrawing funds. 

There is one faction unwilling to raise the debt ceiling - the Tea Party-ers.  Everyone else does, but is trying to leverage the threat of default to extract parochial goals.  John Boehner wants it raised.  Mitch McConnel wants it raised.  Obama, Pelosi and Reid do.  In a sane world, we'd just marginalize the Tea Party raise the debt ceiling.  

All Politics is Local - The Refugee Problem

In 2003, the US attacked and deposed the leader of Iraq.  This led to a massive sectarian civil war between 2006-08.  As the US was trying to maintain peace and find WMDs, many Iraqis aided the 'invading army' at great personal peril.  In 2011, as the civil war burns much quieter, many of these Iraqis want out.  It's very dangerous for them.  They'd also like to partake in the opportunities in America.  The US government response:

Terrorism fears in the United States are all but halting visas for Iraqis, even those who risked their lives aiding the American war effort, making them especially vulnerable ahead of the planned American military withdrawal.  The Obama administration has required new background checks for visa applicants, reacting to a case in Kentucky in which two Iraqi immigrants were arrested on suspicion of ties to an insurgent group, according to American officials in Baghdad.

Advocates say that the administration is ignoring a directive from Congress to draft a contingency plan to expedite visas should those Iraqis who worked for the United States government, especially interpreters for the military, come under increased threat after American forces are drawn down at the end of the year.

America is in a bad state economically.  We've left the memory of Iraq at the end of the 2008 elections.  So, who's the constituency for these Iraqis?  Why do we want more of 'these people' - especially if they could be terrorists - even though they've shown allegiance through heroic actions?  

In the same way, this newsgroup exemplifies the trans-national problem that the Somali's who seek refuge from both war and drought in Kenya:

very true...and may i add that i find the manufactured crocodile tears of western aid workers and NGO's in daadab who are busy advocating for the setting up of permanent structures for the refugees in kenya completely ridiculous and hypocritical...i have not once heard any of them, or any of their parent countries sitting at the UN request to have any of the refugees re-directed to their own home countries...i would like to see these people sending planes and ships to kenya to scoop up some of the refugees for resettlement in the west...it is always other people that they expect to bear the burden...

Fair point.  While we discuss the problem in Somalia in isolation - i.e. life is unsustainable there (which it is!) - it is an imposition on the Kenyans to cater for refugees.  Much in the same way that we here in the US need to protect the Iraqis who aided us and are in danger, we need to aid those Somali's who're close to death.  

We also need to find a way to respect and support Kenya's independent identity.  

Map of the Day - Horn of Africa Drought

Chart of the Day - Not Getting Our Money's Worth

Note that this is in the Bush II years, pre-Obamacare.  So did we really have the BEST healthcare in the world that a radical-socialist-muslim will soon destroy?

Hydrokinetics on the Mississippi?

On a day of rain and floods in NOLA, it's a good time to ask about the power of the big river to produce more than sewage - electricity:

FFP is focusing on obtaining federal permits for 25 hydrokinetic projects along the lower Mississippi River between Kentucky and Louisiana. Sites were chosen based on flow volume, flow velocity and the proximity to transmission facilities and potential customers. At each site, hundreds of turbines on pylons at the bottom of the river would spin like propellers and transmit energy to the riverbank.

Each turbine would produce about 40 kw of power, comparable to gasoline and diesel-powered home generators. By comparison, small wind turbines used to power homes and small businesses typically have capacities of 100 kilowatts or less.

The technology seems primitive - producing very little energy right now.  But as nuclear powered electricity loses it's luster and as we adopt greater machines based on electricity (Chevy Volt!), we'll perhaps need new forms of electricity generating energy.  The obvious unanswered questions - what are the macro effects of geo-engineering? 

THUNDERBIRDS

ARE

GO!

The Ministry of Information

“more power to the misinformed”

A Surprise Recommendation from the AMA

The American Medical Association represents the welfare of doctors.  Doctors benefit when they care for sick patients.  So the more sick patients, the more a doctor can earn.  It follows that parodoxically, in the peverse financial incentive of the US health care system, it's not in the fiduciary interest of the AMA to promote 'curing' any patient, even as the ethics of medical care promote this outcome.

So it comes as a surprise that the AMA has endorsed the following (h/t WSJ health blog):

In addition to resolutions backing the individual mandate to purchase health insurance and to adopt a bill of rights for medical residents, delegates to the AMA’s annual meeting have approved a resolution recognizing “competitive speed eating as an unhealthy eating practice with potential adverse consequences.”

Wouldn't it be more responsible for the AMA (as a lobbying organization for doctors) to sponsor the Nathan's Fourth of July Hot Dog Eating Contest?  It can have ER docs sitting by to pump stomachs.  And GI doctors doing EGDs to pull out some stuck hot dogs?  Or general surgeons taking those with stomach ruptures to the OR?  

Happy 4th of July, AMA.  

June McCarroll, M.D. (1867 - 1954)

And now, gentle readers, the Physician and Surgeon's Almanac for this day, Thursday, June 30, 2011.

Today is the birthday of June McCarroll, M.D. Born and raised in the East, she received her medical degree in Chicago before moving to California in 1904 to work on Native American reservations as a physician with the Bureau of Indian Affairs. She was likely the only physician practicing the vast Coachella Valley desert of southern California.

In 1917, while driving down a familiar road near Indio, California Dr. McCarroll had a driving accident. In order to avoid a head on collision with a truck going in the opposite direction, her Model T Ford was driven off the road and into a ditch. This gave Dr. McCarroll a new idea.

After receiving no response to her letters to the local chamber of commerce and county supervisors, McCarroll took her idea and matters into her own hands. She painted a white line down the center of the street to delineate the width of two separate lanes of traffic as a way to prevent future collision accidents.

Graph of the Day

From the Gates Foundation.  

It's a basic economic truth that a poorer person spends a larger percentage of her income on basic necessities, like food

• If you make $1000/month it's reasonable to spend 20% of your income, or $200, on food.  
• But if you make $1,000,000/month (see: NBA basketball players and Wall St. managers), it'd be pretty ridiculous to spend $200,000 per month on food.  How many $1000 dinners in a row can you really eat?  

 

O FORTUNA

VELUT LUNA

STATU VARIABILIS

 

The Ministry of Information

“more power to the misinformed”

 

Friday Evening Geography Quiz - #8 (very hard)

There are 20 current female Presidents/Prime Ministers in the world.  Can you name each woman and her country?  Data from filibustercartoons.com.  As usual, answers below map.

*oce

feroce

symploce

veloce

Duboce Park, San Francisco

 

It's Italian, so fo' git about it!