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A new study by Senthil Selvaraj and two colleagues suggests that newspapers do not publish the best available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.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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.
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.”
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 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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
When it comes to persuading the
Pittsburgh Post-Gazette to publish
my letters, I'm batting about .050. My one success, almost ten years
ago, was a note about music. Of course, newspapers get many letters,
and it's their right to choose which ones to publish. Ordinarily, I
wouldn't bore you by griping about their decisions. However, I've
managed to persuade myself that my latest experience may be of
interest to other letter writers, so I'm going to risk playing the
fool.
My
story begins on December 8, when the P-G
published Molly Rush's letter advocating single payer health care.
This was followed on December 16 by a reply from Jim Roth—a
pharmaceutical salesperson(!)—implying that single-payer is too
costly and denies health care to some citizens. If you're going to
continue, you should stop and read Mr. Roth's letter.
The next day, I
wrote the following:
Mr. Roth notes
that all countries with single-payer finance it with a value added
tax. However, the type of tax used to fund health care is
irrelevant. The important point is that single payer costs those
countries considerably less than our complex system of public and
private insurance. According to a 2013 report of the Organization for Economic Cooperation and Development (OECD), the US currently
spends on average $8,508 per person each year on health care,
compared to an OECD average of $3,322. Yet the US is 26th
out of 40 OECD countries in life expectancy. The amount Americans
spend on health care due to the combined burden of taxes, insurance
and out-of-pocket costs would be greatly reduced under single-payer.
Mr. Roth claims
that people in single-payer countries have longer wait times for
elective surgery and are sometimes denied such care. This depends on
the country and what you consider “elective surgery.” US
insurance companies also refuse to cover some elective procedures.
However, if these were serious problems, you would expect residents
of single-payer countries to be dissatisfied with their country's
health care system. A 2013 survey by the Commonwealth Fund compared
consumer satisfaction in the US to nine European countries and
Canada, all with single-payer. Americans were by far the most
dissatisfied,with 75% saying the system needs fundamental changes or
should be completely rebuilt.
Finally, Mr.
Roth suggests that we could lower health insurance costs by allowing
it to be sold across state lines. It is true that if some states
were to deregulate health insurance and if residents of any state
were allowed to buy that product, premiums might come down. But
those people would be buying insurance with little value should they
become seriously ill. The Affordable Care Act is intended to prevent
exploitation of consumers by establishing a baseline definition of
adequate health insurance.
Of course, the
primary purpose of single-payer is not just to save money, but to
save the lives of some of the millions of Americans who are currently
uninsured.
On
December 29, the P-G published
two replies to Mr. Roth. Both offered primarily anecdotal evidence
suggesting that at least one family—the author's—had lived in a
single-payer country and was satisfied with their health care system.
The main difference between them is that the first referred to the
British system and the second the Dutch. While both were
well-written and persuasive, I thought they were redundant, and might
have been better supplemented by my data referring to larger numbers
of people and countries.
It's possible my
letter was rejected because it is poorly written or exceeds their
250-word limit. However, Mr. Roth's letter, at 318 words, also
breaks this rule, as do many others they publish. They could easily
have edited my letter. Clearly, exceeding the word limit was a mistake. In
retrospect, I should have dropped the third paragraph.
My hypothesis,
based on this and other previous experiences, is that my letter was
rejected because it contained too much data. Imagine an experiment
in which parallel letters to the editor are sent to a random sample
of newspapers. Both letters would make exactly the same points, but
one would support each point with research, while the other would
support them with anecdotes or merely claim that these were the
author's personal opinions. My guess is that fewer of the
data-driven letters would be published.
I have
two possible, though somewhat inconsistent, explanations for my
hypothesis. The first assumes that the editors wanted to present the
single payer argument sympathetically. It's based on a common cognitive error known as the base-rate fallacy.
People find anecdotal evidence more persuasive that statistical base
rates, even though the base rates summarize data from larger, more
representative samples. The people who made the decision may have found the two letters they published to be more persuasive
than mine.
My
second explanation makes the reasonable assumption that the
gatekeepers at the P-G are
opposed to single-payer. If so, they may assume that my inclusion of
data makes the letter too
persuasive. That is, they may be willing to acknowledge that there
are some Pittsburghers who favor single-payer, but it may be
unrealistic to expect them to publish statistics suggesting that the
arguments of single-payer advocates are factually correct.
I hope I'm wrong.
I really want to encourage the use of research evidence to change the
health care system, and society in general, for the better. If this
strategy is counterproductive, that's genuinely disturbing.
