Tuesday, January 28, 2014

Good Studies Go to the Back of the Bus

It's a rare day when my daily newspaper doesn't include at least one medical or health related article. My subjective impression is that they frequently report on potential “breakthroughs,” but many of them are never heard of again, suggesting that the early results were not reproducible.

A new study by Senthil Selvaraj and two colleagues suggests that newspapers do not publish the best available studies. In medical research, the main criterion of a good study is whether participants were randomly assigned to receive either the treatment or some control procedure such as a placebo. In medical jargon, this is called an RCT study, which stands for randomized controlled trial. The major alternative is an observational study, in which the participants are contrasted with a comparison group that may differ from them in uncontrolled ways (a cross-sectional study), or are compared to themselves at an earlier time (a longitudinal study). Some observational studies are merely descriptive and lack a comparison group.

© mercatornet.com
The authors selected the first 15 articles that dealt with medical research using human subjects published after a predetermined date in each of the five largest circulation newspapers in the US. Referring back to the original research reports, they classified each study on several dimensions, the most important being whether it was an RCT or an observational study. For comparison, they selected the first 15 studies appearing in each of the five medical journals with the highest impact ratings. These impact ratings reflect how often studies appearing in these journals are cited by other researchers.

The main finding was that 75% of the newspaper articles were about observational studies and only 17% were about RCT studies. However, 47% of the journal articles were observational studies and 35% were RCT studies. A more precise rating of study quality using criteria developed by the US Preventive Services Task Force confirmed that the journal studies were of higher quality than the studies covered by the newspapers.

They also found that the observational studies that appeared in the journals were superior to the observational studies covered by the newspapers. For example, they had larger sample sizes and were more likely to be longitudinal rather than cross-sectional.

In one sense, these results are not a surprise. We could hardly have expected newspaper reporters to be as good a judge of study quality as the editors of prestigious medical journals. The authors, like many before them, call for more scientific literacy training for newspaper reporters, but it's hard to be optimistic that this will happen.

What criteria do the reporters use in selecting studies to write about? I was struck by the fact that observational studies resemble anecdotes more than RCT studies do. In addition, the newspapers chose observational studies with smaller sample sizes. These results could be driven by the base rate fallacy—the fact that the average person finds anecdotes more convincing than statistical analyses of much larger samples. In fact, the lead paragraph of these stories is often a description of some John or Jane Doe who received the treatment and got better. The results could mean either that reporters fall victim to the base rate fallacy, or that they think their readers are more interested in anecdotal evidence.

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The Singer, Not the Song

In 2010, social psychologist Eric Knowles and two colleagues published a study showing that some of the opposition to health care reform results from prejudice toward African-Americans and dislike of Barack Obama. The research was a panel study in which participants were interviewed several times over the internet.

During the first contact, Knowles measured implicit prejudice against blacks using a variation of the Implicit Association Test. This test measures an automatic tendency to associate white Americans with the concept “good” and black Americans with the concept “bad.” This bias this is unintentional and occurs without our awareness. Knowles found that the people high in implicit prejudice toward African-Americans reported more negative attitudes toward Obama before the 2008 election and were less likely to vote for him. This is one of several studies to show that racial prejudice influenced votes in both the 2008 and 2012 elections.

These negative attitudes toward blacks spilled over onto Obama's policies. People high in implicit prejudice were more opposed to health care reform in 2009, before the Affordable Care Act (ACA) was passed. How do we know their opposition to health care reform was due to prejudice rather than political conservatism, which is highly correlated with prejudice in this country? Knowles did an experiment in which he described a health care plan. For half the participants, it was presented as Bill Clinton's 1993 plan and for the other half, it was presented as Obama's plan. (The actual description was of features that both plans had in common.) Implicit prejudice had no effect on attitudes toward the “Clinton” plan, but when it was attributed to Obama, the more prejudiced participants were more opposed to it. This study was replicated two years later with the same results.

Fast forward to 2014. Aaron Chatterji and colleagues just published a study asking why members of the House of Representatives did or did not vote for the ACA. The study only included Democrats, since only one of 177 Republicans voted for the bill. The researchers looked at whether three variables were related to the legislators' votes: (1) the percentage of their constituents without health insurance, (2) Obama's margin of victory or defeat in the 2008 election in their district, and (3) political contributions from health insurance companies. The statistical analysis also controlled for eight demographic variables, such as the age and racial composition of the district, and five Congressperson characteristics, such as their own 2008 margin of victory. The results were:
  • Percentage of constituents without health insurance was unrelated to the legislators' votes.
  • Obama's margin of victory made a significant difference. The 219 Democrats who voted for the ACA came from districts in which Obama's average margin of victory was +30%, while the 39 Democrats who voted against it came from districts in which Obama lost by slightly under 10%. Obama's margin of victory accounted for 47% of the variance in these Representatives' votes.
  • Political contributions from the health insurance industry also had no relationship to voting.
The authors note that if the Congresspeople had the best interests of their constituents in mind, there should have been greater support for the ACA from Representatives whose districts contained a higher percentage of uninsured people. At different places in the article, they refer to this as either ignoring their constituents' preferences or ignoring their constituents' needs. The latter is more accurate, since they have no measure of voter preference. Maybe some of the people who needed the ACA did not prefer it (or did not know they preferred it). It is primarily the needs of their poorer constituents that these legislators ignored. This is no surprise, since there is a growing body of research showing that politicians votes are consistent with the opinions of their constituents in the top third of the income distribution, but the opinions of the lower and middle thirds are disregarded.

Of course, Obama's margin of victory or defeat is also a salient indicator of constituent preferences, and these Congresspeople were very responsive to it. However, the presidential election was not a referendum on health care reform, which played only a minor role in the campaign, but is more reasonably regarded as a measure of Obama's popularity. It appears that the legislators voted for or against the ACA based on the evidence of Obama's popularity in their district.

The common thread among both studies is that both citizens' and legislators' attitudes toward health care reform seem to be less influenced by the substance of the policy than by attitudes toward the President himself. At the present time, politicians in 24 states (including Pennsylvania) are ignoring the needs of their poorer citizens by refusing to implement the ACA's provision to expand Medicaid. Is this decision also driven by attitudes toward the President?

By the way, the fact that political contributions from insurance companies had no effect on voting doesn't really contradict the hypothesis that politicians are influenced by campaign contributions. The health insurance industry never clearly favored or opposed the ACA, since it has both advantages and disadvantages for them. In fact, the authors never predicted whether health insurance money would make a Congressperson more or less likely to vote for the bill.

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Pete Seeger (1919-2014)

© sarosenamy
          "I still believe the only chance for the human race to survive is to give up such pleasures as war, racism and private profit."

In the clip below, Pete Seeger sings "Waist Deep in the Big Muddy" on the Smothers Brothers Comedy Hour in 1968.

Saturday, January 25, 2014

Suicide, Homicide and Guns

There are a number of reasons social psychologists are confident that the availability of firearms is a major cause of violent death. In an earlier post, I discussed some of the many studies of the priming effect of weapons on aggression. These studies suggest that the presence of weapons, or pictures of weapons, increases aggressive thoughts and behaviors. Since these are laboratory experiments in which participants are randomly assigned to conditions, they permit a relatively strong inference of causality. However, due to the obvious constraints on our willingness to provoke aggression in the lab, some people find these studies to be artificial, and feel more comfortable with field studies of the availability of firearms in the real world.

Many of these field studies are ecological, in the sense that they measure both the availability of weapons and the number of deaths at the aggregate or population level. For example, in an early study, Archer and Gartner (1987) found that the homicide rate in countries around the world is highly correlated with the availability of handguns. But correlation does not mean causation, and the countries involved in this comparison differed in many other ways besides their weapons policy. Most recent studies have attempted to statistically control for alternative explanations such as urbanization, poverty, alcohol use, depression, etc. However, since the number of alternative explanations is theoretically infinite, there are limits to this approach.

© nypost.com
Gun advocates also attack the validity of the measures used in these studies. For example, in most studies, the availability of firearms is determined from gun registration statistics. However, it could be argued that many homicides are the result of unregistered guns in the hands of criminals. Can this assumption account for the positive correlation between gun availaility and murder? Yes, but only if you assume that those areas that contain the most legally registered guns also contain the most illegal ones.

A more time-consuming but more conservative procedure is to start with a suicide or homicide and work backward, looking at each individual case. In these observational studies, for each suicide or homicide victim, regardless of the manner of death, it is determined whether firearms were available in the home. These people are compared to a matched control group of people who did not commit suicide or were not murdered, such as participants in a national health survey. This allows you to compute a likelihood ratio—the likelihood of a homicide or suicide when a gun is available compared to the likelihood when it is not.

In a study published this week, Andrew Anglemyer of the University of California at San Francisco and his colleagues did a thorough literature search and located 15 such observational studies. They then did a meta-analysis of these data. A meta-analysis is an analysis of analyses, a way of statistically combining the results of several studies to estimate the size of an effect. These were their findings:
  • You are 3.24 times more likely to commit suicide when a firearm is readily available than when it is not. These findings do not differ for men and women.
  • You are 1.94 times more likely to die of a homicide with a gun in the home than without. This effect differs for male and female homicide victims. Women are 2.94 times more likely to be killed when a firearm is available, while for men, the effect is almost nil—only 1.29 times more likely.
The meta-analysis shows that having a firearm available has a greater influence on suicides than on homicides. This makes sense, because most firearm suicides kill themselves with their own gun, while most firearm homicide victims are killed with someone else's gun.

The homicide data show that firearm availability only increases the risk for female victims. Other studies show that women are most likely to be murdered by someone they know. This suggests that firearm availability makes it easier for domestic violence to become lethal. On the other hand, there is no evidence that owning a firearm increases the risk of homicide for men, since they are usually not killed with a gun belonging to themselves or a family member.

In an accompanying editorial, David Hemenway, a leading authority on firearm victimization, points out that this pattern of results is due to Anglemyer's choice to analyze only individual-level, observational studies. He argues that the meta-analysis substantially underestimates the effects of firearm availability on male homicides because it only asks whether the victim had access to a gun, when the more important question is whether the perpetrator had access to a gun. Therefore, he suggests that future studies of homicides be either population-level ecological studies which measure the number of guns in the community, or individual-level observational studies of the availability of firearms to perpetrators rather than victims.

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Friday, January 24, 2014

The MPG Illusion

A friend called my attention to a teaching award given by the Social Psychology Network to Richard Larrick of Duke University for a class demonstration based on his and Jack Soll's 2008 Science paper, “The MPG Illusion.” The exercise “offers an example of how psychology can be used to address climate change.” Before reading any further, please take this one-item quiz.

If you're like most people, you gave the wrong answer because we mistakenly assume that a vehicle's fuel consumption is a negative linear function of miles per gallon. That is, we assume that you save the same amount of energy when you go from a car that gets 10 MPG to one that gets 20 MPG as you do when you upgrade from 40 MPG to 50 MPG. To see why that's wrong, please watch this video.


One way of summarizing Larrick and Soll's point is that switching to a more fuel efficient car has diminishing returns on the amount of energy (and money) saved. Therefore, when government increases the CAFE (Corporate Average Fuel Efficiency) standards required of auto companies, that also has diminishing returns. This is illustrated in the table below, and in the graph, both of which chart gallons per 10,000 miles as a function of miles per gallon.

Miles per Gallon
Gallons per 10,000 Miles
10
1000
11
900
12.5
800
14
700
16.5
600
20
500
25
400
33
300
50
200
It follows that gallons per miles is a more meaningful measure of fuel efficiency than miles per gallon. When Cass Sunstein served as administrator of the Office of Regulatory Affairs during President Obama's first term, he was able to get gallons per 100 miles added to the fuel economy sticker on new cars beginning in 2013. Unfortunately, as you can see, it's in smaller print than miles per gallon.


Larrick does not say what effect he expects his demonstration to have on its audience. In discussing this with my friend, we realized that there are two ways students might respond to these data.
  1. Switching from a fuel inefficient vehicle to one that's slightly less inefficient vehicle—say, from 10 to 15 MPG—saves more energy than most of us thought. People should be strongly encouraged to upgrade their gas guzzlers, even if they don't upgrade them very much.
  1. But switching from a fuel efficient car to one that's even more fuel efficient has less effect on your pocketbook and the planet than most of us thought.
The danger is that students will draw the second conclusion rather than the first. In fact, conservative commentators have referred to the Larrick-Soll paper when criticizing government attempts to encourage greater fuel efficiency.

Buying a highly fuel efficient vehicle may not make financial sense for the individual. If you're choosing between a Toyota that gets 40 MPG and a Honda that gets 50 MPG, you save 50 gallons every 10,000 miles with the Honda. If the useful life of the car is 100,000 miles, and if gasoline costs $4/gallon, you save $2000. The Honda is not likely to pay for itself on the basis of gas mileage alone. If you buy it, you're doing it for the planet rather than yourself.

But any improvement in fuel mileage is important for society. If you multiply the 500 gallons saved by the Honda by the number of vehicles in the US fleet, that has a substantial effect on the amount of CO2 in the atmosphere. In the long run, this benefits us all, whether we buy a fuel efficient car or not. Some of you may recognize this as an example of the commons dilemma, in which one choice is better for the individual in the short run, but the other choice is better for everyone in the long run. One way of getting people to do the right thing in a commons dilemma is through a government intervention such as the CAFE standards.

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Saturday, January 18, 2014

Decline and Fall: This Week's Evidence

Catch-22 Revisited

Since the NSA is spying on foreign heads of state, it doesn't take much imagination to think they might also be spying on members of Congress. Earlier this month, Sen. Bernie Sanders (I-VT) wrote to Gen. Keith Alexander, head of the NSA, asking, “Has the NSA spied, or is it currently spying, on members of Congress or other American elected officials?” He defined spying as “gathering metadata on calls made from official or personal phones, content from websites visited or emails sent, or collecting any other data from a third party not made available to the general public in the regular course of business.”
© CBS News

Gen. Alexander's reply did not deny spying on Congress. It was straight out of Catch-22. He couldn't answer the Senator's question, he said, because to do so would violate his privacy.

[T]his telephone metadata program incorporates extraordinary controls to protect Americans' privacy interests. Among those protections is the condition that the NSA can query the metadata only based on phone numbers reasonably suspected to be associated with specific foreign terrorist groups. For that reason, NSA cannot lawfully search to determine if any records NSA has received under the program have included metadata of the phone calls of any member of Congress, other American elected officials, or any other American without that predicate.

If you read Gen. Alexander's letter, you see that he only answered that part of the Senator's question dealing with metadata and ignored the rest of the forms of spying he asked about. The General and his colleagues undoubtedly had a good laugh about the clever way they were able to dodge Sen. Sanders' query.

Memo to Sen. Sanders: I hope you've never visited any embarrassing websites. If you have, the NSA can threaten to leak this information to your constituents unless you vote the “right” way.

Another Reason Not to Vacation in Florida

I'm sure you've heard that Curtis Reeves, a retired cop, fatally shot Chad Oulson, the man sitting in front of him at a movie theatre, who refused to stop texting his baby sitter as they waited to watch Lone Survivor. Mr. Reeves' attorney has indicated he will plead self-defense under Florida's Stand Your Ground law, since he was hit in the face by an “unknown object” and therefore feared for his safety. Mr. Oulson allegedly threw popcorn at him. Ousler's wife was wounded as she tried in vain to protect him.

© thinkprogress.org
Florida's legal community apparently regards Mr. Reeves' acquittal as a serious possibility. “Here's the problem,” said Stetson University law professor Charles Rose, “We're trying to look into the mind of the defendant and posit what he thought was happening. That's often why these cases go (to) trial—because you just can't tell.” You also just can't tell how creative defendants can be if you allow them to report their own “thoughts.”

According to a witness, Mr. Oulson's last words were, “I can't believe I got shot.” Apparently he didn't realize the NRA, the American Legislative Exchange Council, and the Florida state legislature were sowing the seeds of his demise.

Memo to Mr. Reeves: Popcorn may indeed be life-threating, but only if you ingest it.

Cruel But Not Unusual

Speaking of the death penalty, the state of Ohio executed Dennis McGuire using a new, untested combination of lethal drugs. It took him 25 minutes to die. According to witnesses, which included his family, he writhed in agony and made “loud snorting sounds” while he was dying.

Mr. McGuire's lawyers sued to prevent the execution, arguing that the drugs could lead to “air hunger,” which would cause him to suffer “agony and terror” as he struggled to breathe. A medical doctor testifying for the state said he had no idea how long the drugs would take to kill him. But the judge accepted the Ohio Assistant Attorney General's argument that, in spite of the Constitution's guarantee against cruel and unusual punishment, “you're not entitled to a pain-free execution.”

© cathleenfalsani.com
The apparent reason for this failed experiment is that the usual drug cocktail used for lethal injections is in short supply and the pharmaceutical corporations have raised the prices. This has sent the states scrambling for a cheaper method. The combination of an anti-anxiety drug and a morphine derivative used by Ohio is actually just a larger dose of the drug mixture typically used as an anesthetic during a colonoscopy.

The McGuire family has announced they intend to sue the state of Ohio for causing him “unnecessary pain.” According to Douglas Berman, an Ohio State law professor, this will be difficult to prove since Mr. McGuire is unavailable to testify. (Unlike Mr. Reeves.)

Bruce Burns, a Republican State senator from Wyoming, has introduced a bill to bring back the firing squad in that state.

"Insane, Mad, Delusional"

A draft of a report from the Intergovernmental Panel on Climate Change suggests that it might be necessary to “extract vast amounts of greenhouse gases from the air” in order to prevent the global warming for which we are currently headed. The IPCC suggests some familiar methods of carbon dioxide removal such as planting more forests and carbon capture and storage (CCS)—capturing and burying emissions from power plants. CCS is untested and would be very expensive. However, the IPCC goes on to mention more radical geoengineering proposals such as injecting aerosols into the stratosphere to block solar heat. A recent climate model simulation showed that such schemes might have disastrous side-effects which could render large parts of the planet uninhabitable.


The man Americans elected as their president in 2000 reacted to the draft by calling these plans “insane,” “utterly mad,” and “delusional in the extreme.” He went on to say that:

The fact that some scientists who should know better are actually engaged in serious discussion of those alternatives is a mark of how desperate some of them are feeling due to the paralysis in the global political system.

Either that or they have a grant from Exxon-Mobil.

As both Mr. Gore and Naomi Klein have suggested, the appeal of these geoengineering schemes is that they allow us to believe that we can continue our current forms of energy consumption without having to change our behavior. Their appeal to energy companies is that they leave existing corporate power relationships in place.

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Catch-22

The Catalyst

This Will Not Surprise You

Wednesday, January 15, 2014

Living Downstream

As I write, 300,000 citizens of nine counties in West Virginia are gradually being allowed to use their tap water, although there may be legitimate questions about whether it is safe. The water is contaminated by 4-methylcyclohexane methanol (MCHM), a toxic chemical used to process coal, which was stored by Freedom Industries in antiquated containers poised on a hilltop overlooking the Elk River, just a mile upstream from the intake of Charleston's water treatment plant. This toxic chemical spill is symptomatic of a broader problem in how we deal with environmental and social problems.

© nofrackingway.us
A metaphor that is useful for describing intervention strategies is the distinction between upstream and downstream approaches, or the difference between prevention and remediation. Upstream strategies seek to prevent the problem; downstream approaches occur after the problem has occurred and try to minimize the harm that is done. Of course, some strategies are a combination of the two; there is a continuum between pure upstream and downstream approaches.

Consider the problem of waste. The downstream approach is discarding the waste—that is, we wait until it accumulates to the point of inconvenience and then either displace it (throw it “away,” as in a landfill), or attempt to dilute it by allowing it to escape into the public air, land and water. Of course, there is no such place as “away,” and dilution fails when the concentration of waste becomes too high (or when the waste is discharged a mile upstream from the water supply intake valve).

Upstream (prevention)                                                                                Downstream (remediation)
➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔
Source reduction                                 Reuse                                           Recycling                                            Discarding

Recycling and reuse are more upstream approaches, with reuse being farther upstream than recycling. The difference can be illustrated with glass bottles. The old bottles can be ground up and used to manufacture new bottles (recycling), or the old bottles can be sanitized and reused.

The upstream solution to waste is source reduction: Produce less waste in the first place. Sometimes, this involves curtailing manufacture of the product. In other cases, the product can be produced more efficiently, so as to reduce unnecessary waste. Increased efficiency is usually an easier sell, since curtailment typically involves more sacrifice. For example, it's probably easier to convince people to insulate their homes than to set back their thermostats.

The most significant example of the need for source reduction is in energy production. Consider all the harm that is done to human health and safety by our reliance on fossil fuels—coal, oil and natural gas. We could meet all our energy needs much more cheaply with renewables. While solar and wind power generate some pollution, it is miniscule by comparison to fossil fuels. Yet we don't do it, even though it is now obvious that human survival depends on it.

From the perspective human well-being—the greatest good for the greatest number—upstream solutions are almost always more desirable than downstream solutions. They are typically cheaper and involve less inconvenience, or in the case of health problems, suffering. It would have been cheaper and better to slightly inconvenience Freedom Industries by requiring them to keep their containers in good repair, rather than forcing 300,000 people to do without water for several days. The cleanup cost will probably ultimately be borne by the taxpayers, since our laws are written so that Freedom Industries can easily write off its costs or declare bankruptcy.

The upstream-downstream model can be applied to any social or environmental problem. For example, it would be cheaper and more humane if we could prevent depression, but at the present time, depression is treated by giving people drugs that act primarily to mask its symptoms.

Why don't we rely on upstream solutions more often? In many cases, upstream solutions are less transparent. They are farther in space and time from the problem. People smoked tobacco for centuries before it was conclusively demonstrated that smoking causes lung cancer. Yet, compared to other cancers, this is a relatively obvious relationship. Finding upstream solutions to mental health problems may be even more challenging than preventing physical illness. Because upstream solutions are less obvious, it's more difficult to convince the public that they should be implemented. It's also harder to find financial support for the research needed to investigate upstream solutions.

But knowledge of how to prevent harm and evidence of its effectiveness was not the problem in West Virginia. The name of the polluting corporation turned out to be ironically appropriate, since so many corporations identify “freedom” with the absence of government regulation and oversight. Going without water for a week doesn't engage metaphors about freedom, although it should. It's hard to think of many things that reduce your freedom more than having to queue up for water for drinking and bathing, having to close local businesses, coming down with a pollution-related illness, etc.

While upstream solutions provide the greatest public good, not all people benefit equally from their adoption, and some are harmed by them. One person's freedom may conflict with another's. Since those that benefit from prevention are usually average citizens and those that are harmed are “corporate persons” and their wealthy owners, the issue is unequal political power. MCHM is one of tens of thousands of industral chemicals never tested for its risk to human health. But the real problem is that regulatory agencies are routinely captured by the industries they are supposed to be regulating. The Freedom Industries storage plant had not been inspected since 1991. In West Virginia, politicians' reliance on coal money has produced an environment in which they not only fail to act to reduce obvious health and safety hazards, but openly defy the Environmental Protection Agency. Pennsylvania residents might want to think about the potential for air and water quality disasters here, given our leadership's subservience to the natural gas industry.

Inequality of power is combined with a political system that is little more than legalized bribery, provided that the political contribution is sufficiently upstream from the decision to avoid being obvious. And in this country, due to the feedback loop running from inequality to political power to even greater inequality, the problem is increasing exponentially.

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Monday, January 13, 2014

Best Films of 2013

I should have written this post two weeks ago. I waited to see The Wolf of Wall Street, but it doesn't make the list. How many times have you seen the Hollywood film that, for the first 90% of its running time, encourages the audience to sympathize with clever bad guys who outwit the squares and have a great time in the process. The filmmakers then tack on an arbitrary ending in which they get caught, so they can claim that the message is “crime does not pay,” when we all know the real message is the exact opposite. The Wolf of Wall Street is that film on steroids. I'm sure Marty and Leo had a blast making it. There's no evidence they ever gave a thought to Wall Street's victims.

Here's my dirty dozen, starting with my choice of the best film. The others are in alphabetical order.


Twelve Years a Slave. Who would have thought that for two years in a row, the best film of the year would be about slavery? A number of folks claim that this is the most realistic film about slavery ever made. I'm not sure how we'd know that, but it certainly seems plausible. One of the keys to its success is the fact that Solomon Northup was an educated, free man before being kidnapped into slavery, which allows the audience to better identify with his suffering. But its real strength is the absence of made-for-TV censorship—think Roots—of the slavemasters' brutality. I have to laugh when I read the conservative critique of the film's emphasis on human suffering as "torture porn"—for example, the claim that director Steve McQueen held the scene of Northup on tiptoes with a noose around his neck for just too long, as if this were somehow an unfair argument against slavery. On the other hand, one of the few false notes in this great film is the all-too-convenient “good cop/bad cop” contrast between slaveowners Benedict Cumberbatch and Michael Fassbender. Does anyone really believe in good slavemasters?

Blue Jasmine. Woody Allen's modern interpretation of A Streetcar Named Desire gives Cate Blanchett the part of a lifetime, a self-centered rich woman who can't cope with her unexpected downward mobility, and she delivers. The fact that her ex-husband was a Bernard Madoff-like swindler is only an incidental detail, but it's enough to make this film a stronger critique of Wall Street criminality than Scorsese's Wolf.

Closed Circuit. There are a lot of problems with this film, including the ridiculous romance between the two leads and the need to explain some complicated British laws, but it deserves credit for tackling important issues such as the way law enforcement entraps potential “terrorists,” and uses false claims of national security to cover up its mistakes.

The Fifth Estate. I've previously explained why I think this is an interesting film, even though it unfairly takes the US government's side by overemphasizing the alleged harms done by Wiki-Leaks' release of the Bradley Manning files. Benedict Cumberbatch does a terrific job of impersonating Julian Assange.

Fruitvale Station. This is the best low budget film of the year. It recounts the last 24 hours of the life of a young black man who was killed by an overanxious cop at a San Francisco transit station. His mother's behavior clearly illustrates the futility of a purely religious response to injustice.

42. As a Dodger fan who grew up in the New York area in the '50s, I enjoyed reliving the Jackie Robinson story, even though I know some of the details have been changed to turn it into a more traditional Hollywood biopic.

The Hunt. This Danish film—my only foreign language film this year—tells the story of a man falsely accused of molesting a little girl. It gets the important points right, including the leading questioning of the girl by authorities, and the tendency of this man's former friends to still believe her over him even after her charges are shown to be factually incorrect.

Inside Llewyn Davis. Every music fan knows that for every Bob Dylan, there were dozens of others who were equally talented, but just couldn't get a break. The crushing blow is delivered by promoter F. Murray Abraham after watching him perform: “I don't see money here.” Thanks also to the Coen brothers for not making Llewyn Davis a Mr. Nice Guy.

Mandela—Long Walk to Freedom. The main criticism of this film is that it's superficial, but who could do justice to Mandela's life in 2.5 hours? The filmmakers emphasize his personal life and avoid political controversies. But I was caught up in one of the world's few progressive victories of the past 25 years, even though the film doesn't tell us how it really happened.

Nebraska. How often have you visited relatives only to be greeted with the question, “So, how long did it take you to drive here?” This film takes an unusual (for Hollywood) look at the dreary existence of many middle Americans, where the only thing to do after work is get drunk and the only hope for a better life is winning the lottery. The key scene is Woody's (Bruce Dern) inability to introspect when his son asks him why he married his mother, whether he's been happy, etc.

Out of the Furnace. This is the only pure thriller on the list, albeit with an implied critique of the global economy. If you think about its structure, it's actually a spaghetti Western set right here in Western Pennsylvania. It's a spaghetti rather than an American Western due to the hyperemphasis on revenge, and the over-the-top characterization of the villain (Woody Harrelson).

Rush. I went into this film expecting exciting Formula One racing scenes, and I wasn't disappointed. But I came away from it with much greater respect for Austrian driver Niki Lauda, especially in comparison to his loutish British competitor, James Hunt.

My apologies for this year's many worthwhile films I didn't see, either because they didn't play in Pittsburgh, or because they were in an out of town before we had a chance to see them. In the latter category are All is Lost, Bastards and Hannah Arendt.

This was the year for films “based on a true story”—in many cases, almost instant history. Six of my twelve films are historical, seven if you believe Inside Llewyn Davis is based on the life of folk singer Dave Van Ronk. Add in Captain Phillips, Dallas Buyers' Club, Philomena, and The Wolf of Wall Street, and you have a heavy dose of recent history. Speaking of true stories, I choose Robert Reich's Inequality For All as the year's best documentary. Although I suspect Jeremy Scahill's Dirty Wars may be more deserving, I haven't seen it.

What was missing? First of all, I was able to see very few foreign language films this year. We didn't see a new French film all year, and we saw our first Italian film, La Grande Bellezza on New Year's Day. (It turned out to be a warmed-over version of La Dolce Vita, and Paolo Sorrentino is no Fellini.)  Pittsburgh Filmmakers, our previously most reliable source of foreign films, seems to be phasing them out in favor of low-to-medium budget American films or documentaries. Some of these are worthwhile films, but most of them wind up on television in a few months, while most foreign language films never do.

There was also a notable absence of well-made genre films this year. I didn't see any top-notch Westerns, horror films, films noir, mysteries, or even sci-fi films. (I'm willing to suspend disbelief when watching science fiction, but after a promising first half-hour, Gravity was totally incredible!) It seems as though intelligent genre films are being crowded out, mostly by big budget, computer-enhanced action comic books.

As usual, there are a number of strong performances by leading men, including Idris Alba (Mandela), Benedict Cumberbatch (The Fifth Estate), Bruce Dern (Nebraska), Chiwetel Ejiofor (Twelve Years a Slave), and Matthew McConaughy (Dallas Buyers' Club). If you could add separate performances together, you might give a shout out to Daniel Bruhl for his successive portrayals of Niki Lauda (Rush) and Daniel Domscheit-Berg (The Fifth Estate). Hollywood sometimes uses the Oscar to reward an older actor for a lifetime's body of work. I hope they'll do that for Bruce Dern this year. Maybe that will make up for his failure to be nominated for The Incredible Two-Headed Transplant.

Also as usual, there were few good women's roles. Cate Blanchett has almost no competition, with the possible exception of Judi Dench (Philomena). I hope Sally Hawkins, who played Blanchett's sister, gets a Supporting Actress nomination. And if movies are still supposed to be fun, it would be nice to see Woody Harrelson get a Supporting Actor nomination for Out of the Furnace, even though Jared Leto (Dallas Buyers' Club) will probably walk away with most of the awards.

I can see no good reason to ever give the Best Director award to anyone other than the director of the best film, in this case, Steve McQueen.

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Based on a True Story, Part 1 (Captain Phillips)

Based on a True Story, Part 2 (The Fifth Estate)

Saturday, January 11, 2014

Surveillance Made E-Z

The most interesting thing about this year's toll increase on the Pennsylvania Turnpike is the discrepancy in the amount of the increase for those using E-ZPass and cash customers. The increase is 12% for cash and 2% for E-ZPass. This is the fourth straight year of toll increases; all four times, cash customers took the bigger hit. A trip across Pennsylvania now costs $31.38 by E-ZPass and $43.90 in cash.

Clearly the motive is to induce all drivers to use E-ZPass. It costs the state five to ten times more to process a cash transaction, either by paying a toll worker, or by photographing the license plate and sending the car owner a bill. But in the Orwellian world of the Turnpike Authority, the E-ZPass fee is called a “discount,” and Turnpike propaganda emphasizes the claim that E-ZPass reduces travel time. The Pittsburgh Post-Gazette, which never met a layoff of public employees it didn't like, jumped on the bandwagon, saying this change “makes sense for drivers and for Pennsylvania.”

Although you can save on tolls by using E-ZPass, it'll cost you. There is a $3 per year fee, and you are required to keep a minimum balance in your account. The balance starts at $35. Every time it drops below $10, you must replenish it by another $35. You can either send them cash or a check, or have it automatically deducted from your bank account or credit card. Then there is the transponder—the device on your car which identifies it as it passes through the toll booth. You must rent it for $10 if you insist on replenishing your account by cash or check, but there is no fee if you have your account replenished automatically. (Pretty clever, eh?) These are not huge amounts of money, but when you multiply them by the number of users, it's a pretty good-sized float.

How much must drivers pay for the privilege of saving the state a lot of money? This is similar to the introduction of ATMs, when the banks laid off tellers and then announced they would charge a fee for the “convenience” of using an ATM. The banks backed off, at least when you use your own bank's ATMs, but the Turnpike Authority has no competitors. Where does the money go? E-ZPass has been outsourced. The Turnpike Authority pays $91 million a year to TransCore, a subsidiary of Roper International, to run E-ZPass. If the system generates a surplus—which it obviously should—I hope the money goes to the state rather than the contractor.

One concern about E-ZPass that the Post-Gazette didn't mention is its potential for invasion of privacy. E-ZPass creates a permanent record of the travels of hundreds of thousands of citizens. These records, which are in private hands, can be used against motorists in a number of ways. The concern is not just theoretical. In 2007, NBC revealed that divorce lawyers are using E-ZPass records to prove infidelity. The article reports that Pennsylvania and New Jersey are two of the four (out of 12) E-ZPass states that claim they only release records in criminal cases. However, the article recounts a case in which a Pennsylvania lawyer used E-ZPass records to help her client prove that her husband, who claimed to be at a business meeting in Pennsylvania, was actually in New Jersey with his mistress that night. Did the reporter not notice this inconsistency?

Later this year, Pittsburgh will start using surveillance cameras to ticket drivers for running red lights. Since the state police obviously know the distances between toll booths, how long will it be before they start issuing speeding tickets based on transponder readings?

In this modern world of massive NSA surveillance, E-ZPass may seem a minor threat. In September, it was reported that the Pittsburgh Parking Authority was using surveillance cameras mounted on police cruisers to photograph the license plates of 200,000 motorists each month, creating a massive data base of Pittsburghers' locations. The stated purpose was to locate and boot scofflaws who hadn't paid parking tickets, but the data were retained for up to 30 days and were available to anyone who requested it (including the reporter who broke the story). Their reported success rate was .01%–that is, one of every 10,000 cars they photographed was booted. A month later, the Parking Authority revised its policy. They now claim they delete the data every day.

The ACLU surveyed almost 600 police departments and state agencies about their license plate tracking policies. About half responded. The federal government, not surprisingly, refused to cooperate and the ACLU is suing them under the Freedom of Information Act. Of the departments that responded, about three-quarters use license plate tracking and 85% planned to increase their use. Few departments place any substantial restrictions on how they may be used, and many allowed non law-enforcement uses such as collecting parking fines and repossession of vehicles. When used for law-enforcement purposes, hit rates are typically below .5%. Retention policies vary widely; data are retained anywhere from one day to indefinitely.


Most departments purchase license plate reading technology with grants from the federal government. Data can easily be pooled in centralized data bases, and some regional data bases are already known to exist. License plate readers are also extensively used by private companies, repo men being the most frequent users.

The technology is so cheap and widely available that it virtually invites abuse, including data mining to identify potential criminals among people not previously suspected of crimes and discriminatory targeting, such as identifying people who visit mosques. Widespread knowledge of surveillance could have a chilling effect on people's willingness to exercise their rights of free speech, assembly, religion, etc. Most jurisdictions have no policies protecting citizens from abuse of these technologies.

And this doesn't even begin to address the tracking capabilities of cell phones, GPS devices and various other electronic gadgets people carry in their cars. Finally, this morning's New York Times has an article about legal problems associated with event data recorders inside new cars that might be used, for example, by insurance companies to deny claims because the policy holder appeared to be driving carelessly.

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Tuesday, January 7, 2014

Fracking Up Baby

This study has not been peer-reviewed. It was presented at a meeting of the American Economic Association on January 4. It has also not been posted anywhere, to my knowledge. I am relying on an article written by reporter Mark Whitehouse for Bloomberg News. (I will update this post if I get further relevant information.) The credibility of the study seems to be quite high. The researchers are Janet Currie of Princeton, Katherine Meckel of Columbia, and John Deutsch and Michael Greenstone of MIT, who have previously published studies of the health effects of pollution. The study was funded by the Environmental Protection Agency and the MacArthur Foundation.

The authors used Pennsylvania birth records to compare the health of newborn infants living within 2.5 kilometers (slightly over 1.5 miles) of natural gas fracking sites to a control group of infants living elsewhere in Pennsylvania. Public records allowed them to pinpoint the exact latitudes and longitudes of the gas wells and the mothers' homes. Those babies whose mothers lived near a fracking site had a 9% probability of low birth weight (less than 5.5 pounds), compared to 5.6% in the control group.

Photo by AP/Keith Srakocic

Low birth weight is an important predictor of infant health and survival, and is associated later in life with inhibited growth, lower educational attainment, and chronic diseases. There is growing evidence that one of its causes is exposure to environmental toxins. The fracking group also had a 5% chance of a low Apgar score, double the control group. The Apgar score is given by the doctor, who evaluates the child's heart rate, breathing, muscle tone, reflexes and skin coloring at the time of birth. A low score indicates problems in one or more of these areas.

This is not the first study to find that fracking is associated with infant health problems. Faith Hill, a Cornell undergraduate, found that Pennsylvania children born near fracking sites had lower birth weights and lower Apgar scores compared to a control group of infants born near permitted sites prior to any drilling. However, this study could have been confounded by migration away from the site after drilling began and a reduction in property values in the vicinity. The net result is that people living near drilling sites may have lower socioeconomic status or other characteristics that could explain their children's poorer health.

The Currie study attempts to deal with this problem two ways. It corrects statistically for geographical differences in maternal health. More importantly, it looks at a subsample of mothers who gave birth both before and after drilling began. These mothers serve as their own control group, which eliminates most alternative explanations. Of course, the mothers were older after the onset of fracking, but lower birth weight is typically associated with younger maternal age.

How does fracking result in poor infant health? The authors claim that water pollution is probably not the cause, since there were no differences between mothers who used public water systems and those who obtained their water from private wells, which are more likely to be contaminated by fracking. This leaves air pollution as the most likely possibility. Pollution may be due to leakage of gases from around the well or from open frackwater waste pools, which are allowed in Pennsylvania. 

Whitehouse ends his article with the following odd bit of false balance:

The study doesn't necessarily tell us whether or not fracking is worth doing. There may be offsetting health benefits related to the added jobs fracking creates, to lower energy prices or to the reduced use of coal or other fuels as more natural gas becomes available.

Seriously? Are children to be sacrificed for lower energy prices? The comment ignores the possibility that Pennsylvania could impose stricter regulations to reduce air and water pollution near fracking sites, if its state government were not a wholly-owned subsidiary of the natural gas industry. 

Fracking is exempt from the Clean Air Act, the Clean Water Act and other federal anti-pollution regulations. So far, government has largely ignored the precautionary principle when it comes to fracking. The burden of proof has been placed on opponents of fracking to demonstrate health problems after the damage is done. If the drilling companies want to claim health benefits of fracking, I hope they will show us their data.

As of this morning, none of Pennsylvania's major newspapers have reported the study.

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Saturday, January 4, 2014

The Oregon Health Experiment: The Gift That Keeps On Taking Away

Be prepared for a barrage of conservative criticism of the Affordable Care Act (ACA) that may be assumed to have negative implications for single-payer health care as well.

As I've noted before, the Oregon Health Experiment is a randomized control group design, far superior to most health care research. In 2008, Oregon hoped to expand Medicaid, but didn't have enough money, so they held a lottery. They invited everyone who was eligible to apply. Of the 90,000 applicants, 30,000 were randomly selected to receive Medicaid, while the losers became eligible for the control group. In previous data analyses, it was found that the Medicaid group spent 35% more on health care than the control group. They visited primary care physicians (PCPs) and were admitted to hospitals more often, and spent more on prescription drugs. They were also healthier and freer of financial worries, although most of the health differences are not statistically significant due to insufficient sample sizes in the study.

A new analysis by the Oregon research group reports that the Medicaid participants were also more likely to visit the emergency room (ER). Specifically, during their first 18 months on Medicaid, they made an average of 1.43 ER visits compared to 1.02 in the control group—a 40% difference.

This should not have been a surprise. If you reduce the cost of a service, people are more likely to use it. However, some ACA proponents claimed that Medicaid expansion would save money by reducing ER use. Although the ER accounts for only 4% of health care spending, an ER visit is more expensive than visiting a doctor. The pro-ACA argument was that if patients established a relationship with a PCP, they would have a place to go for medical care and these doctor visits would prevent potential emergencies. For example, Health and Human Services Secretary Kathleen Sebelius said in 2009:

Our health care system has forced to many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high quality, affordable care they need and helps prevent illnesses from turning into emergencies.

It is important to note that these results are not due to the fact that Medicaid provides health insurance for poor people. Private health insurance patients are also more likely to use the ER than the uninsured.

Increased ER use might not be seen as a problem if the visits were real emergencies. However, the study found ER use to be higher even for non-urgent care that should ideally have been treated by a PCP. These results could be used by the opposition to suggest that single-payer might cause an massive influx of people outside the ER waving torches and pitchforks and demanding free care.

There are several considerations that may place these results in clearer perspective.
  • The time frame of the study, 18 months, may not have been sufficient to change uninsured people's lifelong habits of going to the ER every time they were sick. A three-year study of Romneycare in Massachusetts found an estimated 5-8% reduction in ER use.
  • Medicaid expansion could have been accompanied by education regarding when to go to the ER and when to visit your PCP. Of course, some may argue that education is not enough and should be supplemented by punishment, such as a co-payment, for “inappropriate” ER use.
  • Taking a broader view, the problem may be with the health care system rather than the patients. PCPs tend to be available Monday through Friday from 9 to 5—times that are inconvenient for most employed people. You can't always get same-day appointments with a PCP. A 2012 survey by the Commonwealth Fund found that in the US, only 35% of PCPs see patients after hours. In nine European countries and Canada, the average was 80%.
This study is one of a growing number that show that providing health insurance to the uninsured alone does not save money. The ACA contains some cost controls, such as the Independent Payment Advisory Board, which may eventually reduce costs. Single payer eliminates the cost of private insurance, which will save much more. Other changes may be needed. One of them may be asking PCPs to become more consumer-friendly by seeing more patients on evenings and weekends.

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