Recently I participated in two blogs asking whether cancer screening saves lives.  I wrote one of them, and offered comments on the second, which was posted in response to mine.  I enjoyed both, for reasons I mention below.  Citing references to the cancer literature, I pointed out that we have good evidence that Pap smears for cervical cancer saves lives, and colonoscopy for colorectal cancer saves lives, but no good evidence that mammography saves lives.  There is similarly no good evidence PSA screening for prostate cancer saves lives. Mammography and PSA screening may be worthwhile, but not because screened individuals can be shown to live longer.

The links to these posts are at http://tpmcafe.talkingpointsmemo.com/talk/blogs/f/r/fredmoolten/2010/07/cancer-screening-redux---does.php and at

http://tpmcafe.talkingpointsmemo.com/talk/blogs/n/o/no_one_really/2010/08/so-does-cancer-screening-save.php

Because the data are compelling, there was no serious counterevidence presented that refuted the point.  Some contributors cited data on breast cancer and prostate cancer mortality that are accurate, but which did not address the issue.  Others disputed my logic.  The more inflammatory response to my contributions, however, was a personal and sometimes venomous attack on my character and my motives.  In essence, I was an evil man determined to let patients suffer so that insurance companies could profit.

A sampling of these responses gives a sense of their flavor: "You are a liar", "Asinine", "Ignore Fred Moolten's bunk", "It makes me sick that a sellout like you actually teaches. I just wonder if your price was more or less than the academics that took BP's offer", "You have no shame", "Find another line of work - you stink at this", "You are a bad, bad man", and "You are vile".

Others of a kinder, gentler nature offered suggestions on how I might improve my character.  I thank them, but in truth, I'm incorrigible, and my character flaws will accompany me to the grave.  Those who know me well have long since given up trying to reform me.

Readers may wonder, therefore, whether my claim to have enjoyed the discussions was sincere or sarcastic.  It was sincere.  I try to document positions I take with evidence and a rational tone, but I've long ago learned that it reinforces my credibility with members of the general public uninvolved in the discussions when those who argue against me come across as irrational, insulting, snide, or sarcastic.  At times, a mischievous side of my nature has motivated me to bait discussants into insults for that purpose, although I haven't done it in this instance.  In any case, the two posts will find their way onto Google, and my points will be judged both from the evidence and the tone of the arguments used against them, and will therefore help inform individuals seeking to understand better the benefits and harms of screening.  Anyone interested in the issues should probably read the posts rather than rehash the arguments here.

Any value to my perspective from the nature of attacks on it may be outweighed, however, by the detriment TPM suffers from a level of discussion debased by personal attacks.  These have often been the norm rather than the exception in exchanges I've read over the past year. In that sense, we sink to the same level as the large multitude of web commentary that frequently offers more vitriol than information in response to legitimate issues.  We can choose to occupy that level or rise above it, and the latter might be worth considering.

In my profession as a scientist, debate and argument are elements essential to a proper understanding of issues, but the rules are simple - don't be personal.  Address the issue but don't attack the individual.  Comments violating these rules are routinely deleted, and the result is civil discourse that is both efficient and enlightening.  Much of the media and the web, however, embrace the concept that readers can say anything they want.  Why the difference?

The standard justification for the lax standard is "freedom of expression".  This excuse, however, would be more compelling if those freely expressing insults and obscenities were similarly required to accept responsibility for their comments by revealing their true names.  Without the veil of anonymity, much of the inappropriate commentary would disappear.

I believe the principal reason the media and some web sites invite anonymously expressed exchanges of insults is that it is lucrative.  Readers are attracted to sites that stroke their egos by affording them the pleasure of seeing their remarks on the printed page or screen, and the enhanced readership translates into enhanced revenue.

This is unlikely to change any time soon, but need it remain a dominant mode of expression on TPM?  I don't believe it would be practical to enforce here the rules science operates by, but perhaps we could take a small step toward greater civility.  My recommendations are twofold.  First, I would suggest that TPM management restate a policy of civility, with frequent reminders.  Second, I believe any of us who would like to see us move at least slightly toward the position of scientific organizations, NPR, and other responsible venues might make the same suggestion ourselves in response to comments framed in attack mode, and ask those who express themselves that way to tell us their names, so that we can judge the real person behind the comment by the way he or she acts.  We do that in real life, why not here?

 

An article by David H. Newman in the July 21 issue of the Journal of the National Cancer Institute (JNCI) calls attention to a question rarely addressed in discussions of cancer screening - does it save lives?  A quick answer is "very possibly not", but it depends on how one defines cancer screening.

It is almost certain that early detection of premalignant growths such as polyps found by colonoscopy or abnormal cells in the uterine cervix detected by Pap smear can save lives through the local removal or eradication of the growths.  When it comes to the value of detecting actual cancers, however, the evidence is less convincing.  Indeed, the JNCI article, in reviewing evidence regarding two major malignancies, breast cancer and prostate cancer, concluded that no convincing evidence exists to suggest that screening for either saves lives.

This may surprise many readers, particularly regarding breast cancer, for which mammography is often considered lifesaving for a small subset of women, with the principal disagreements related not to this conclusion but to the age at which mammography should begin.  In fact, though, any such surprise will reflect a distinction that is rarely made by the public, and often disregarded within the medical community as well, including pronouncements from government agencies and other official sources - the difference between "disease-specific mortality" and "all cause mortality".  For breast cancer, disease-specific mortality is defined by the death rate from breast cancer, whereas all-cause mortality, as the name implies, represents the rate of death from all causes.  It is a way of asking, "on average, how long can you expect to live?"

Many but not all mammography screening studies have demonstrated a reduction in breast-cancer specific mortality.  This appears to be fairly well documented for women between the age of 50 and 75, but an unequivocal reduction in younger women has been controversial and is likely to be very small.  Despite the evidence for a reduction in breast cancer deaths, however, multiple studies involving nearly half a million women in aggregate have failed to show a reduction in all-cause mortality, implying that whether or not a woman is screened by mammography may not affect how long she is likely to live. What explains this discrepancy?

Two possibilities suggest themselves. First, a small difference in all-cause mortality may be obscured by the inevitable statistical variation that one finds in population studies.  In other words, the consequences of mammography may be swamped out by all the other variables that lead to deaths, whereas they are more easily detectable when only breast cancer deaths are examined.  Implicit in this possibility involving a low signal to noise ratio is that any true difference in all-cause mortality is likely to be very small.  It might also operate in either direction - i.e., mammography might actually cost lives, albeit to a very small extent.

The second possibility is that mammography essentially makes no difference at all, because reductions in breast cancer-specific mortality are offset by increases in other causes of death resulting from mammographic screening.  Parenthetically, it's important to point out that reductions in disease-specific mortality unaccompanied by reductions in all-cause mortality (or even increases in all-cause mortality) have been demonstrated for a variety of other illnesses, and are not limited to breast cancer.

A variety of threats to life might ensue from mammography, including those that are stress-related and perhaps some late effects of the radiation doses used.  The greatest threat, however, is that of death related to surgery, anesthesia, and their complications.  Surgical mortality is very small, but it is not zero, and it might well nullify gains from early detection.  In addition, surgical mortality occurs at the time of surgery and its aftermath, while deaths resulting from a cancer that progressed because mammography was not performed might not occur for an additional 5-10 years.

Most salient, however, is that many of those deaths may have occurred never.  We now know that perhaps one third of true mammographically detected cancers would, if undetected, fail to become clinically apparent.  In fact, about 25 percent seem to disappear spontaneously, so that they would not even appear on a subsequent mammogram. These are not misdiagnosed cases, but cancers that while fulfilling the pathologic criteria for breast cancer, simply don't act malignantly.  Our problem is that we don't know how to distinguish these harmless cancers from the life-threatening ones.

We can perhaps summarize the above considerations in terms of a set of categories listing the consequences of mammographic screening:

1. Good outcomes.  A cancer is detected and successfully eradicated, never to return.  If undetected, it would have progressed to kill the patient.

2. Bad outcomes.  A cancer is detected that would never have progressed.  An operation is performed to remove the cancer (probably lumpectomy followed by local radiation), but the patient dies from surgical complications.

3. Semi-bad outcomes: A cancer is detected that if not removed, would have been lethal 5 or 10 years later, but the patient dies from surgical complications.

4. Null outcomes:

            a. Mammography reveals no cancer, and none develops

            b. Mammography detects a cancer that is surgically removed, but recurs.

            c. Mammography reveals a cancer that would have caused no harm if undetected.  It is successfully and permanently removed by surgery, with no complications.  Note that although the final effect on mortality is zero, anecdotes describing this scenario have been used in testimonials to claim, "Mammography saved my life".  That claim could also be made regarding item 1 above, but no-one knows how to decide which category it belongs in.

At this point, I believe the implications of current evidence justify the following conclusions:

Any adult woman who desires mammographic screening should have access to it.

If she is age 50 or older, the screening should be covered by insurance.  If she is younger, policies that cover her should also be available, although perhaps at a higher cost (remember that there is no-evidence that mammography is life-saving even in older women, and the reductions in breast cancer-specific mortality are even smaller in the below-50 age group).

No woman should feel guilty over her decision to be screened or to forego screening.

These conclusions are subject to change on the basis of further evidence.

Statements from authoritative sources should be scrutinized to determine whether they refer to disease-specific mortality (almost always the case) or all-cause mortality.  Reductions in disease-specific mortality should not be misrepresented as reductions in all-cause mortality.

Medical science must pursue research to distinguish life-threatening cancers from harmless ones.

Mammography should be considered a medical rather than a political issue.

 (Similar conclusions appear to apply to prostate cancer screening).

Anyone without a JNCI subscription can purchase 1-day access to the full article for $32, at  Cancer Screening

We are in proximity to two consequential events - one upcoming and hopeful (Earth Day a bit more than a week from now), and one ongoing and terrible - the West Virginia coal mine disaster that reminds us that our comfort has been purchased at the cost of the health and lives of men who spend their working hours where the sun never reaches.

The two are related, because as the world warms, a future of uncurtailed reliance on coal has become a threat to all of us, and the need to transition to renewable forms of energy grows ever more urgent, along with the need to cushion the human impact of the transition on those whose livelihood is affected..

I've put a music video up on YouTube that's relevant to these things.  It was composed before the mine disaster, but that tragedy adds an exclamation point to the thoughts and feelings it expresses.

The URL is Promise To The Future

HHS Secretary Kathleen Sebelius has announced the inception of a new program provided by the healthcare reform law to establish high risk pools for individuals with pre-existing conditions. The first participants will be eligible to enroll on July 1, coverage must include an actuarial value of at least 65 percent (i.e., the percent of average healthcare costs to be paid by insurance), there will be no pre-existing conditions exclusion, total out of pocket expenses will be capped, and standard rates will apply, based on average rates insurers charge in the individual market irrespective of health status.  This rrather dramatic start to healthcare reform involves federal subsidies to states from a fund of $5 billion, and may ultimately limit the number of enrollees if the funding runs out before the program expires in 2014 and is not supplemented.  In states not choosing to participate, the program will be administered by the federal government.

More details are available at New high risk insurance pools and HHS announcement

It is sad.

At times of crisis, this nation cries out for heroes. In the past, they have appeared when the need was most urgent - Tom Paine, Patrick Henry, John Adams in the distant past, to name a few, and FDR and MLK, among others of more recent generations.

And yet, not all who seemed ripe to lead rose fully to the occasion, but disappointed. Consider that most turbulent of eras, the 1850s and 1860s, when the nation was riven by discord over the peculiar institution of slavery. Strong, heroic voices sounded - Thoreau, John Brown, Julia Ward Howe, and others - but none sufficed to exercise a commanding leadership so desperately needed on a national level. One hope did arise - a young politician named Abraham Lincoln, who spoke eloquently of the evils of slavery and inspired in millions the belief that a national savior might rescue the land from its errant course.

They elected him President - less than half the popular vote but enough - and he disappointed. The disillusionment began early. His job was not to end slavery, he declared, but to keep the Union from fragmenting. Job though it may have been, he did not begin to do it well, stumbling in both the domestic and military sphere in his first two years, and violating the Constitution by suspending Habeas Corpus. His ineptitude was a derisive theme echoed in many quarters among opponents, and with some grudging acceptance by erstwhile supporters.

Fortune then turned his way, and the military campaign gained strength. The Confederate rebellion began to collapse and finally yielded, in part due to the ruthless strategy of General Sherman, whose scorched earth disregard for the welfare of civilians in his march through the South generated enduring resentment but left the region so devastated that rebuffing the Union advance became hopeless .

And so, President Lincoln, whose political fortunes once seemed bleak, was reelected. Even his detractors had never questioned his ability to give a good speech, and he proved his eloquence once again in his Second Inaugural Address, asking the nation to bind up its wounds and come together. Not long afterwards, he was assassinated, and the job to rebuild the nation was left to others. Some said, though, that if he had lived, he might have ultimately proved to be a good president. Some harsh critics muted their rhetoric.

America today is not the America of the 1860s and its crises are not the crises of those times, but are equally urgent, and equally cry for leadership. Will a true leader emerge, or will he only seem to emerge, but then disappoint? I don't know. I believe myself capable of perceiving the potential for leadership. I voted in the recent election in a way to nurse that perception, hoping the potential will be realized, but it is too early to say what judgment history will pronounce. Perhaps the potential was an illusion.

I do know one thing. For potential to blossom into reality in the face of fierce adversaries, it must be nourished by those who want that to happen, because there will be many who wish the opposite. In the complex and exasperating world of politics, of compromise, of deal-making, of promises delayed or never quite kept, it remains important to stay fixed on him who has the capacity to deliver - to stay constant even when he has not yet accomplished results that may require years of effort punctuated by pitfalls and setbacks along the way. In the depths of frustration, the need for constancy can be forgotten. In the displeasure of the moment, supporters can become damning critics when impatience overwhelms long term aspirations.

Of someone whose supporters can be mistaken for adversaries, it is sometimes said, "With friends like these, who needs enemies?" True leadership can always count on an abundance of enemies. Can it count on friends in equal number, and with equal ardor?

The fate of the Obama Administration's agenda on healthcare and other critical items has been challenged by loss of a Senate seat, but equally by increasing public disenchantment and frustration.  Some of this reflects the inevitable responses to a recession that was never destined to yield to a quick recovery, some to inevitable Republican obstructionism, but some also to frustration on the part of the progressive left who have lamented what they perceive as lack of leadership on important issues.

President Obama's speech, while unlikely to achieve dramatic reversals in public perceptions, already seems to have succeeded at the margins in generating a more positive attitude on the part of some frustrated supporters as well as other members of the public.  This is critical for healthcare reform, because a timid Congress is unlikely to proceed with comprehensive reform as long as public opposition significantly outweighs public support.

For the moment, the positive reaction to the State of the Union speech may have opened a brief window of opportunity to act while favorable attitudes toward the speech still prevail.  In pushing Congress, Obama should seize that moment.  In pushing him, as well as Congress, we might wish to do the same.  A recent post-speech poll lends credence to this suggestion -Post-SOTU poll

 

 

 

 

The Massachusetts Senate election has created an impression among some of the more fearful Democrats in Congress that the current healthcare reform proposals have become too toxic to handle.  Nationwide polling data in the past several weeks have fueled this perception, but a very recent Kaiser Foundation poll suggests that the problem lies less in numbers than in intensity.  Those favoring the reform proposals are often much less enthusiastic than those who oppose them.

http://www.kff.org/kaiserpolls/upload/8042-F.pdf

The results show that the nation favors healthcare reform in principle, and is about evenly divided on the current proposals, but with strong opposition outweighing strong support.. Most of the individual provisions are supported, whereas opposition relates primarily to the mandate and to the estimated cost of reform, with the latter opposition based on the frequent misperception that the reform package would increase the deficit. 

In aggregate, the results suggest that the proposed reforms might garner net public support by emphasizing their potential to reduce the deficit.  Equally important, enthusiasm among supporters would likely increase.  Although the mandate is critical to other elements of reform, it could be tweaked, perhaps, in ways that reduce its negative effects on public opinion.

I wonder whether President Obama, in his State of the Union speech, might not be able to facilitate the effort to increase both public understanding and public support for the reform effort. It may well turn out that resistance to the reform proposals is fluid, and could be reversed among many voters - particularly in the Independent category, but also among some reluctant Democrats - as a result of feasible efforts to persist in achieving passage of this legislation.

When was the last time we the American people, in majority voice, embraced a policy that asked from us sacrifices for the good of others, but without benefit to ourselves, our families, or even our future selves at an older age?

I can't remember either.

I'm convinced most of us are not selfish people as individuals. We're generous, compassionate, capable even of meaningful short term sacrifices, as we are doing now by the millions in contributing to the relief of earthquake victims in Haiti. But these are impulses of the moment, and not the measure of how we pursue our destiny as a society.

Are we a selfish country?

It seems to me that the extraordinary social advances we've achieved over a few centuries have for the most part involved efforts led by a small minority of activists willing to risk inconvenience, hardship, or even danger for the good of others, but that the success of these efforts required the majority to harbor the same desire to help others without the need to endure the same hardships. Even the abolition of slavery was never a sacrifice for those regions of a divided nation that most struggled to achieve it.

Since then, we've seen Social Security implemented in its original design as a "layaway" program for us to set aside earnings for our later years, and Medicare as a similar protection for our parents, grandparents, and ourselves in old age. We've embraced civil rights in our outrage against racial discrimination, but have resisted affirmative action when it intruded on our own privileges. I issue no judgments on this last very complex issue, but cite it as an example of the boundary between caring that costs us little and that which requires a down payment.

It is in this context that we might consider some underlying principles that have driven the healthcare reform debate. After the fog clears from the obscuring verbiage that has characterized the argumentation, an undeniable reality emerges at the heart of the debate. The reforms propose to help millions of Americans whose low income status deprives them of adequate healthcare - by expanding Medicaid and by subsidizing millions of low income earners above the Medicaid level. This will cost about one trillion dollars. Someone has to pay it. No-one wants to volunteer.

Neither Republicans opponents nor Democratic proponents have been candid on this issue. Americans do not wish to be judged selfish, and a political party that imputed selfish motives to them would alienate the public. Republican opponents could appeal to those motives only indirectly, by suggesting that demands on middle income Americans were unfair and exploitative, or in the case of Medicare cuts, even harmful. The Democratic proponents were equally disingenuous. They appealed to the generosity of Americans toward those who need help, but implied that the need could be met by taxing the rich and squeezing the greedy insurance companies and drug industry, unwilling to acknowledge that the squeezing, however, deserved, would not yield the necessary revenues, and that sacrifices would be required of many outside of these reviled classes. At least this is a reality in the short run - in the longer term, proposed reforms should reduce cost increases throughout the American economy, but that brand of visionary perspective rarely resonates with the public even in good times, and even less within a recession.

Given these underlying fundamentals, what surprises me is not the resistance to reform, but rather the fairly broad approval for it as a concept, if not in the unsavory details. In that sense, the reform proponents may have done a superior job in deceiving the public into seeing reform as a cost always to be borne by someone else. The deception may be catching up with them, but I sense that good will toward the reform effort persists, and I admire the public for what I perceive to be its inchoate but inherent sense of community with the less fortunate among us.

What would happen if someone were bold enough to appeal to that unselfishness? An appeal for us to care about others often succeeds, and appeals to sacrifice for one's own good succeed often as well, but what would happen if the welfare of others and the principle of sacrifice were combined? Would that awaken "the better angels of our nature" or would it backfire in the light of attacks by opponents?

I'm cynical. I have sufficient faith in our inherent goodness of heart to believe appeals of this sort might work in the absence of attempts to undermine them. But the forces that benefit from that type of sabotage are good at it, and so the reluctance of political leaders to embrace appeals to unselfish sacrifice, directed to the public at large rather than to committed followers, is understandable.

I'm struck by the ability of some other nations to surpass us in a sense of shared sacrifice for the welfare of the community. The social welfare democracies of Europe are salient examples, but I don't attribute their achievement to the superiority of their residents as individuals. Rather, these societies tend to be smaller and more homogeneous than we are. Our heterogeneity creates the inevitable conflicts inherent in an "us vs. them" mentality, where the "us" - the majority - may fear exploitation by the "them" at a level that overcomes our sense of community. In more homogeneous societies, everyone is an "us", and in that sense, when we sacrifice, we are sacrificing for ourselves. "Never send to know for whom the bell tolls..."

Perhaps as our society trends toward at least a hint of greater homogenization, through communication and even intermarriage, we'll evolve in the "us" direction. But it will take a while.

　

　

There isn't any. Sixty Senate votes is better than 59, even if it's not truly "filibuster-proof". Defeat weakens a party and an Administration, and frightens the more timid members into retreating from ambitious but necessary undertakings. And most particularly at the moment, healthcare reform is under serious threat.

But if the silver medal is out of reach, the bronze may still be attainable, and may prove more silvery than one might first imagine.

Perhaps, at this hour on Tuesday afternoon, there is still hope Coakley can pull it off, but let's assume the polls are right and she surrenders a long-held Democratic Senate seat to Republican Scott Brown. Congressional Democrats are already considering how to proceed with Plan B.

One possibility is for the House to vote to pass the Senate version of healthcare reform, bypassing the need for another Senate vote, and sending the bill directly to the President for signature. The two versions are nearly identical in most respects, but some important differences remain, and unless settled, will make it difficult for House Democrats to agree to this approach. Rather, they will need assurance that once passed, the measure can then be amended in ways that satisfy their concerns, and which can be addressed through the reconciliation process, thereby requiring only 51 Senate votes. Among these is the abortion language, but that will probably not prove an intractable obstacle.

Of the major issues that must be resolved, one involves the source of revenue to subsidize low income earners. The Senate version depends heavily on taxing high end "cadillac" health insurance plans, while the House version entails income tax surcharges on wealthy Americans. Regardless of their respective merits, it is likely that the public will react more favorably to the House version.

The second is the public option.

How ironic! When 60 votes were needed, that option was sacrificed to avert a filibuster. At the time, that move seemed an unfortunate necessity to ensure Senate passage, and in that sense, reform was hostage to one or a few recalcitrant Senators, most notably Joseph Lieberman. The circumstances have now reversed. Reform is now hostage to the wishes of the House, which will not pass the Senate bill without reasonably secure guarantees that appropriate amendments will follow and are likely to pass.

What is striking amidst these deliberations is a conspicuous feature of recent polling. The public has soured on healthcare reform, with a majority disapproving the current package (although most polled individuals admit being unfamiliar with it). On the other hand, the public has consistently favored a public option at about a 60-70 percent level. Restoring the public option to the reform package may not turn majority disapproval into approval, but may well drive opinion in that direction.

It stands to be a "twofer" - rehabilitate both the public option and public support.

All of the above is too complex, and time perhaps too short, to be confident it will succeed, but it may. Unlike reform of insurance practices, the tax provisions are clearly within the purview of the Senate reconciliation mechanism, and it is highly likely that the public option will qualify as well. Senator Lieberman's vote is not needed, nor the votes of Baucus, Conrad, Nelson, Landrieu, or Lincoln. With Vice-President Biden as a potential tie-breaking vote, only 50 Democratic Senators need to support the reconciliation measure. Since failure to enact reform will be unpopular, and the potential tax and public option changes are likely to be seen favorably by the public, this type of arrangement may well succeed.

The reconciliation mechanism was deemed too risky to pursue when a 60-vote Senate majority seemed achievable. It is still risky, but it now may be the lifeboat that rescues reform. And a bronze medal with a silver liningl.

 In response to a post elsewhere on this site, I made a comment that I have been urged to repeat here as a post of its own.  In doing that, I hope those who have already read it will forgive the repetition.  What follows is what I wrote:  

At a time when Democratic objectives in Congress, particularly on the more liberal side, are facing serious obstacles, it's natural to feel and express frustration, but I still believe some perspective is needed in order to choose the best course forward. With that in mind, I'd like to offer my own perspective.

Many Democrats are conservative and resist some of the more liberal provisions in proposed legislation. This is not a betrayal. Most conservative Democratic senators come from conservative states - North Dakota, Montana, Louisiana, etc., and most conservative "Blue Dog" representatives come from conservative districts. In voting the way they do, they are not betraying the liberal agenda but representing their constituents, and I expect in many cases their own sincere beliefs. There is a name for this - it's called democracy - and until the people themselves in those states and districts change their views, we must accept the compromises needed to pass legislation. Asking liberal Democrats to run in conservative regions is an invitation to Republicans to take over Congress. To repeat the well known principle - politics is the art of the possible - and I see no point in railing against that reality, or blaming the President for accepting it.

On specific issues, I'm also concerned about what I perceive to be excessive claims of betrayal or weakness, implying that even with the current makeup of Congress, the Obama Administration should simply have accomplished far more to advance progressive goals. The most salient example is healthcare reform, and here, I must express my own substantial frustration - not at the reform package but at the misconceptions about it I often see posted in blogs including at times on TPM. The claim is made that it might be better to pass no reform rather than the disastrous package purporting to be reform that is currently at stake in Congress. The basis for my frustration is simple - I have a background in the medical field to start with, and I have spent hundreds of hours during this past year informing myself about the healthcare system and reading the legislative proposals and analyses of them by experts. As a result, I've concluded, with considerable confidence, that despite significant shortcomings, the reform package is a monumental advance in American healthcare, with the potential to save many tens of thousands of lives over the next decade, preserve even more in the way of health, and avert almost all medical bankruptcies.

Not being infallible, I'm willing to be shown wrong, but to be blunt, I don't want to be called wrong by people who have spent much less time on this issue, know much less about it, and are mainly echoing claims made by others whom they read on the Web, and whose views are often strongly biased by ideology. In fact, if one reads the analyses of very liberal bloggers on healthcare reform, a spectrum of viewpoints emerges, but if one limits the analyses to those liberals who also have a long history of healthcare expertise (Mahar, Klein, Hacker, Gruber, etc.), the almost universal theme expressed is that passing the proposed reforms is imperative despite their shortcomings, and that is will lay a solid foundation for future improvements.

Given the difficulties and frustrations we face, anger is understandable, but anger can be either constructive or destructive. I believe it should impel us to push hard for what we believe in, to acquire the knowledge needed to make proper judgments, and to proceed in ways with the greatest real world prospects of bringing our goals nearer rather than pushing them further away. Even when we feel that anger toward some of our elected representatives might be legitimate, we should consider carefully the consequences of punishing them in ways that replace them with others whose acts would be even more detrimental. The fate of a few hundred elected individuals is relatively inconsequential by itself, and so we should be careful when we hope to punish one of them out of exasperation that we are not also punishing millions of Americans who deserve to be helped rather than punished. Their welfare, in my view, deserves priority over even justifiable desires to relieve our frustrations through punitive actions.

With trepidation, I revisit the topic of our Afghanistan effort, worried that this will simply invite another round of familiar arguments. My own view is that our course there is probably the wisest among unwelcome choices. I respect the views of those who believe otherwise, and I expect that future events rather further arguing will determine the merits of these opposing positions.  

The American people will be watching with their own views, hopes, and anxieties. Many do not think we belong there. Six NATO troops, including three Americans, died yesterday in roadside bombing incidents, and so clearly not everyone over there welcomes our presence either. But how broad is that view among Afghans?

I don't know whether our Afghanistan effort will succeed or fail, but I cite below polling data reported in the Washington Post that deserves attention because it refutes extreme claims by opponents of our Afghan effort - claims that we will inevitably fail because Afghans as a people want us gone and support the insurgents who are trying to drive us out. If we fail, that is not likely to be the reason.

Here is the article:

Poll: 7 in 10 Afghans support US forces

Deb Riechmann, The Associated Press

Monday, January 11, 2010; 7:06 AM

KABUL -- Nearly seven in 10 Afghans support the presence of U.S. forces in their country, and 61 percent favor the military buildup of 37,000 U.S. and NATO reinforcements now deploying, according to a poll released Monday.

Support for U.S. and NATO forces, however, drops sharply in the south and east where the fighting is the most intense, the poll said.

Nationwide, 10 percent of Afghans support the Taliban, but the insurgents are backed by a higher percent of the population - 27 percent - in the country's southwest, the poll said.

The poll of a national random sample of 1,534 Afghan adults was conducted from Dec. 11 to Dec. 23 by ABC News, the BBC and ARD German TV, their fifth since 2005. The poll has an error margin of plus or minus 3 percentage points. Field work was done by the Afghan Center for Socio-Economic and Opinion Research in Kabul, a subsidiary of D3 Systems Inc. in Vienna, Va.

After steep declines in recent years, nearly seven in 10 Afghans also think their nation is headed in the right direction. That's up 30 percent since January 2009. The number of Afghans who expect their lives will be better a year from now also has jumped 20 percentage points from a year ago - to a new high of 71 percent, the poll said.

Moreover, 61 percent of the Afghans surveyed said they expect the next generation will have a better life - up 14 percent in the past 12 months, according to the poll.

However, Afghans' views about the direction the nation is headed are gloomier in high-conflict areas, such as Helmand province in the south, the heart of the Afghan poppy trade and the Taliban-led insurgency, the poll said.

The survey also said that blame is easing on the U.S. and donor nations.

Overall, 42 percent of Afghans blame the Taliban for the violence - up 27 percent from a year ago. Seventeen percent blame the U.S. and NATO, or the Afghan government or Afghan security forces - down 36 percent from a year ago.

To anyone who wishes to argue that these results do not prove we will accomplish our objectives in Afghanistan, I would say I agree. To those who draw this conclusion from the belief that most Afghans want us out of their country, I would suggest they reassess their position.

Finally, to reiterate a thought expressed at the beginning of this piece, I would like to suggest that in the absence of dramatic new evidence, we will gain little by repeating old arguments about the merits of our Afghanistan effort in general, but would find it useful to discuss the implications of the polling data.

Following the Christmas day attempt to blow up an airplane over Detroit, Janet Napolitano's claim that "the system worked" was politically disastrous and factually dubious - intelligence sufficient to prevent the would be terrorist from boarding the plane was available, but the system failed to utilize it.

Still, the system may not have failed as completely as generally concluded. The conventional view is that it was not the system that thwarted the terrorist's attempt but his own ineptitude. That view assumes that the two are unrelated. Perhaps they are not.

During the decades Al Qaeda has been plotting terror against us, they have focused almost exclusively on bombs and airplanes, although many other potential approaches might be available. There are undoubtedly a multitude of reasons for this restricted focus, but one is likely to be familiarity - if you learn how to use a tool and have many chances to practice, you are more likely to succeed than if you are trying to innovate. The concept is familiar to criminologists, who find that the routine "MO" (modus operandi) involved in a crime is a useful clue to the identity of the perpetrator.

The same concept lends credence to the value of strengthening defenses against methods terrorists have used in the past - in this case via better intelligence and more rigorous airport security. Doing this will not prevent the terrorists from seeking new ways to attack us, but it will reduce our risk from ways they have practiced to the point of reliability. In fact, it is likely that a successful terror attempt requires considerable skill, even if the methods are not sophisticated, and that there are many steps where something can go wrong. Getting a novel method to work on the first try is probably something of a long shot, even if it succeeded on 9/11. In that sense, our "system", by discouraging the use of established methods, worked to increase the probability of ineptitude. To employ a football metaphor, a team needing to gain three yards will be probably succeed more often if the defense has not acted to shut down a run up the middle, as opposed to a circumstance where that option is foreclosed, and the team must now try a trick play never previously attempted under game conditions. Certainly, fixing past mistakes won't eliminate new dangers, but its value in risk reduction should not be underestimated.

　

That is, if you're a polar bear.  Arctic temperatures are unseasonably warm.  Guess where all the cold went:

Arctic Oscillation In Negative Phase

 

When their backgrounds are investigated, it turns out that many regular TPM participants have a history of sociopathic behavior. 

The reason for this has been a mystery until recently, but a new study provides what appears to be a convincing explanation:

Sociopathic Behavior Study

Recent advice from an independent panel analyzing the benefits of mammography screening for breast cancer has ignited a furor of conflicting opinions. The panel suggested that recommendations for screening be limited to women between the ages of 50 and 74. Women from 40 to 49 were advised to consult their physicians so as to decide for or against screening based on their individual risks and preferences. Evidence for a screening benefit in women age 75 or older was absent, and biennial rather than annual screening was recommended for the 50-74 age group. No evidence was found for the benefits of breast self examination.

For reasons cited below, the panel's advice appears to represent a prudent and thoughtful response to available data, but this has done nothing to halt the intense and sometimes acrimonious debate within the media and the medical community.

The controversy has raged around the advice to avoid recommending routine mammography for women age 40-49, a reversal of previous standard policy. Contrary to some media reports, the panel did not advise against screening for this age group, but only against making this a routine practice rather than a matter of individual choice. The debate also took on political overtones, based on accusations that the altered recommendations were motivated by a desire to save money at the cost of women's health. Further fueling the intensity of debate were testimonials from many women whose cancers were detected by mammography and who are now cancer-free, claiming that mammography saved their lives. Since it is impossible to know how any of these women would have fared in the absence of mammography, their anecdotal evidence is uninformative and will not be addressed here further.

Does mammography save lives? It is striking how greatly the certainty of expressed opinions exceeds the certainty of evidence, but enough evidence exists to justify tentative conclusions. A number of randomized, controlled studies have shown modest reductions in death from breast cancer among women screened by mammography, with the reductions (typically about 20 percent) greatest within the 50-74 age bracket. Even within this group, however, the benefits are not dramatic - typically, more than one thousand women must be screened over 10 years to avert one breast cancer death. This benefit, which appears to be real, must be balanced against the downside risks. These include unnecessary anxiety among large numbers of women from the experience of being tested, the additional anxiety from repeat exams when an initial exam is inconclusive, and still further stress from false positives. In addition, false positives lead to unnecessary surgery or radiation, and even some mammographically detected breast cancers that are correctly diagnosed can result in unnecessary treatment, because a fraction of these appear to disappear spontaneously and would never have surfaced in the absence of a mammogram. Finally, mammography itself exposes women to radiation, although at a danger level too low to offset the gain resulting from cancer detection.

Although the above evidence tells us that mammography reduces a woman's risk of dying from breast cancer, it does not answer a larger question - if a woman routinely receives mammography screening, is she likely to live longer than if she doesn't?

Death from breast cancer in a screened population is known as "disease specific mortality". Death rates overall are referred to as "all cause mortality". Do reductions in disease-specific mortality translate into reductions in all-cause mortality?

The evidence is conflicting, but in aggregate suggests that over the entire age span contemplated for screening, the answer is no - women who are screened will not live longer, on a statistical average, than comparable women who are not screened. In contrast, within the 50-69 year old age bracket, reductions in breast cancer disease-specific mortality do appear to be accompanied by small reductions in all-cause mortality as well.

The overall benefit for women age 50 to 69, combined with a lack of clear evidence for an overall mortality reduction outside of that age bracket, supports the panel advice recommending routine screening starting only at age 50, with younger women encouraged to consult with their physicians before making a choice.

A relevant study quantifying some of these conclusions can be found at

http://findarticles.com/p/articles/mi_m0689/is_6_51/ai_87914467/